When Symptoms become Vital Signs…. Fetch your End-of-Life Care Crash Cart

Dear Editor,

As Tagore poignantly expressed, ‘Death is not extinguishing the light; it is only putting out the lamp because the dawn has come’.^[1] This timeless perspective invites us to reframe our approach to dying – not as a failure of medicine, but as a natural and meaningful part of life’s journey.

By gradually moving beyond the traditional biomedical model – which often emphasises cure alone – we have an opportunity to transform hospitals into healing environments where quality of life, dignity and comfort are prioritised in the terminal phase.^[2] Shifting the focus from aggressive physiological monitoring to attentive monitoring for the discomforting symptoms and signs of distress allows us to better meet the physical, emotional and spiritual needs of patients and their families during this profound time.

Yet, this shift in perspective remains elusive within the healthcare community, particularly in acute care settings, where most patients with chronic, life-limiting illnesses spend their final days.^[3,4] Encouragingly, the 2023 Supreme Court of India judgment, which granted legal validity to advance medical directives and simplified the process of withholding or withdrawing life-sustaining treatment, marks a crucial milestone in the country’s end-of-life care landscape.^[5] With this legal clarity, hospital-based endof-life care is likely to increase, necessitating a parallel strengthening of institutional preparedness, healthcare provider education and the availability of essential resources.

Once the dying phase is identified, this must be followed by proactive assessment and management of symptoms by a multidisciplinary team. During this phase, healthcare providers must anticipate distress, rather than wait for patients or families to report symptoms. Literature describes over 55 symptoms that may manifest at the end of life, many of which are underrecognised and poorly managed, particularly in imminently dying patients.^[6] Common distressing issues include pain, anorexia-cachexia, delirium, nausea, vomiting, dyspnoea, constipation and asthenia, among others.^[6]

The hospital’s end-of-life care (EOLC) policy must contain an EOLC symptom monitoring chart. An example that is being used in our hospital is attached, as shown in Figure 1.

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Figure 1:

End-of-life care monitoring. IV: Intravenous.

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We propose the implementation of an ‘End-of-Life Care (EOLC) Crash Cart’ [Table 1], a structured and easily accessible resource that includes anticipatory prescriptions and essential pharmacological agents tailored to manage the most common and distressing symptoms in the terminal phase of illness.^[7,8] The cart should be easily available for ready use once a patient is on end-of-life care (just like an Emergency Crash cart for Code Blue). The cart may be individualised through team discussions whenever required. Its availability would ensure timely symptom control, minimise unnecessary delays in medication administration and foster a sense of preparedness within the care team.

Such a system can significantly enhance the confidence and clinical autonomy of nurses and other frontline healthcare providers, enabling them to respond swiftly and appropriately to evolving symptom burdens. Empowering the team in this way not only improves patient comfort but also reduces the moral distress associated with witnessing suffering that could otherwise be mitigated. However, this pharmacological readiness must be complemented by non-pharmacological interventions grounded in communication, compassion and collaborative care.