Drug management of terminal symptoms in advanced cancer patients

This review addresses recent research into drug management of terminal major symptoms such as breathlessness, terminal delirium and death rattle.

High quality evidence on pharmacotherapy at the end of life is lacking. For delirium currently available data demonstrate no clear advantage of use of atypical antipsychotics. The roles of donepezil and modafinil in management of delirium are yet to be assessed. Regarding dyspnoea, one randomized trial demonstrated that midazolam, in combination treatment, may enhance the effect of morphine on terminal dyspnoea. A recent study suggested that glycopyrronium is at least as effective as hyoscine hydrobromide in dealing with death rattle. Finally, a randomized, placebo-controlled, double-blind trial evaluating dextromethorphan identified no significant improvement in pain management in combined treatment with morphine.

Conducting well designed trials in the setting of terminal cancer is complex and ethically questionable. Most data retrieved are based mainly on clinical experience. Further high quality research is required to inform clinical recommendations regarding terminal care.