Abstract
Terminal secretions are one of five main physical symptoms managed in palliative care alongside pain, nausea, dyspnoea and restlessness or delirium. New Zealand s Te Ara Whakapiri (TAW) Palliative toolkit was first released in 2017 to assist prescribers manage palliative care symptoms when the Liverpool Care pathway was phased out. Two previous Cochrane reviews by Wee and Hillier (2008) and Wiley (2017) were unable to offer definitive guidance on the use of pharmacological treatments verses non-pharmacological interventions to manage terminal secretions.
The aim of this Integrative Literature Review (ILR) was to investigate current literature to understand the management of terminal secretions for patients at end-of-life. The research question was exploring the management of terminal secretions at end-of-life, what are the implications for clinical practice? An ILR was completed, and thematic analysis was undertaken utilising Braun and Clark s Reflexive Theory that identified concept coding and indexing themes followed by interpretation analysis.
The results from this ILR found that men and patients over the age of 70 years old were more likely to experience terminal secretions because of anatomy and physiological changes. The use of an assessment tool such as the Victoria Respiratory Congestion Scale (VRCS), to assess the efficacy of interventions, would be beneficial for prescribers and other health professionals. Identifying the type of secretions a patient is experiencing, relating to their underlying co-morbidities and anticholinergic drug burden index (DBI), is important to determine the best treatment pathway. Non-pharmacological interventions such as re-positioning in the lateral recumbent position and mouth cares remained first-line treatments and reduced the risk of side effects. Early and effective communication and education for the patients, families, carers and staff, regarding terminal secretions is important. Explaining that terminal secretions are not believed to be distressing for patients, would also help reduce the fear, some people experience, when faced with terminal secretions during a patient last days of life.
This ILR found that health professionals were needing guidance for the management of terminal secretions. The development of an intervention pathway, as part of the TAW palliative toolkit, would benefit health professionals in all patient settings for the management of this symptom. Using a standardised assessment tool like VRCS to assess the effectiveness of interventions would help ease confusion associated with continuing pharmacological interventions. Clear educations and communication for families and guidance for staff and prescribers would help to reduce the distress and anxiety associated with terminal secretion at end-of-life.