Anger/Distress/Upset

Fever is a common symptom at the end of life. It can mean there is an infection, which often indicates an end-of-life pneumonia. But fever may also be associated with other causes, such as a cytokine-induced fever produced by a cancer, which is referred to as “tumour fever.”

The investigation and/or treatment of fever is based on life expectancy (is the patient imminently dying?), the patient's goals or wishes related to his or her care, and the degree of distress and discomfort associated with the fever.

Over the years, health care providers have debated whether to treat fever even in healthy patients. Is fever a response to an infection, or is it actually a part of the body’s way of ridding itself of an infection? It is now known that increasing body temperature by one to four degrees Celsius can impair micro-organism replication and enhance the macrophage killing of bacteria.

At the end of life, the question becomes whether the fever is making the patient uncomfortable. If the patient's condition has deteriorated beyond the need to determine the cause of fever, and the patient shows no signs of distress, there is no need to treat it. If the patient is still more alert and/or seems distressed by the fever, attempts should be made to keep him or her more comfortable. In either case, it is important to communicate with the patient to determine if he or she is uncomfortable. Also important is communicating with the family. Discuss their understanding of and expectations about fever management.

When a patient is having difficulty swallowing or is no longer able to swallow oral medications, the ease of administration and the risks of different agents should be weighed. Acetaminophen is safe in most patients and is the most common pharmacologic agent used to treat fever. However acetaminophen is not available to give parentally. It is available in tablets, caplets, liquid and suppositories. Using rectal suppositories may seem too invasive or cause increased discomfort for the patient and perhaps for family caregivers. Using suppositories may also place the patient at increased risk (for example, they may cause neutropenia in a patient not imminently dying). Other medications used to treat fever are the nonsteroidal anti-inflammatories, such as ibuprofen and naproxen. One of these agents, Ketorolac, can be given intravenously and is shown to be effective in fever control. However, these options have risks of gastrointestinal bleeding and renal impairment. Corticosteroids have been shown to have antipyretic and anti-inflammatory effects, but their risks may be somewhat higher. If fevers are recurrent, you may need to schedule medication to avoid significant swings in body temperature and related discomfort. As in all palliative care situations, you must weigh the benefits against the risks of treatment.

If suppositories are being used for fever management and the patient experiences increased pain when being moved or repositioned, you may need to consider other factors in addition to the above:

• Is there a role for short-acting analgesia (such as sublingual or intranasal fentanyl) for incident pain management before turning or providing care?
• Can suppository administration be timed with regular turning or repositioning?
  

Nonpharmacologic interventions include maintaining a comfortable ambient air temperature and air movement, providing cool cloths to the forehead, and ensuring linens are light and dry. Cool liquids or ice chips may be helpful for patients who are alert. Mouth and lip care is important for those who are not.

While aggressive cooling methods, such as a sponge bath with tepid water, ice packs or cooling blankets, and electric fans and air-conditioning, are effective in reducing fevers, they should be avoided because they tend to cause shivering, vasoconstriction, and often more discomfort.

The palliative care textbooks listed below provide general information on fever management and approaches to care.

References

Hanks G, Cherney NI, Christakis NA, Fallon M, Kaasa S, Portenoy RK, eds. Oxford Textbook of Palliative Medicine, 4th ed. New York, NY: Oxford University Press; 2010.

Ferrell BR, Coyle N, eds. Oxford Textbook of Palliative Nursing, 3rd ed. New York, NY: Oxford University Press; 2010.

Walsh TD, Caraceni AT, Fainsinger R, et al. Palliative Medicine: Expert Consult. Philadelphia, PA: Saunders Elsevier; 2009.