Reversible causes must be excluded before the diagnosis of dying is made. Hospital admission should be considered for patients with respiratory distress of unknown cause. When caring for a patient dying from suspected or confirmed COVID-19, continue to use standard principles of palliative care.

Death from COVID-19 occurs via the following mechanisms.
• Type 1 respiratory failure (low level of oxygen in the blood [hypoxemia] with either a normal [normocapnia] or low [hypocapnia] level of carbon dioxide, but not an increased level (hypercapnia).
• Acute respiratory distress syndrome or systemic shock from “cytokine storm” that resembles bacterial septic shock.

The most common end-of-life symptoms are: pyrexia, rigors, severe dyspnea, cough, delirium, and agitation. The terminal phase can be rapid, lasting just a few hours: these symptoms can develop rapidly and be very distressing. Rapid access to medication is vital and often involves larger doses than in “standard” palliative care practice.

The medications most expected to provide effective symptom control are:
• antipyretics for rigors and delirium
• opioids for dyspnea and cough
• benzodiazepines for agitation
• antipsychotics for delirium and agitation

Medication route
• If possible, insert a subcutaneous butterfly needle (or ideally a pediatric venflon if available) so that medications can be administered without multiple injections.
• The oral route may not be available in the dying phase, but oral morphine can be helpful if given early.
• Lorazepam, morphine, and oxycodone can be given via subcutaneous, oral, sublingual, and buccal; midazolam can be given via buccal.
• Viral shedding is thought to occur rectally, so the rectal route is best avoided.

Medication reasoning
• As nursing and medical staffing levels will be lower during the peak of the pandemic, the aim is to provide effective symptom control without relying on frequent medication administration.
• Larger than usual stat doses may be required for effective symptom control. The severe terminal anxiety and breathlessness that many patients experience may require higher doses of sedative medication in order to reduce conscious level more rapidly and deeply than in “traditional” palliative care practice.
• In the absence of staff to administer subcutaneous drugs frequently, the use of “standard” lower doses increases the risk of poor symptom control and unacceptable distress for patients and their families.

See reference for more information.

Adapted from COVID-19 Resource Hub. Guidance on the management of symptomatic patients dying from COVID-19. Internet. Available at https://elearning.rcgp.org.uk/pluginfile.php/149344/mod_resource/content/1/Covid%20eolc%20community%20symptom%20management%2027%2003%202020%20final.pdf.pdf Accessed on March 1, 2020.