Maintaining an adequate Decadron dose during this period allows the caregivers to keep the patient comfortable and high-functioning for as long as possible.

As the signs indicate that a previous dose is no longer adequate, requesting an increase can bring about improvements often within 48 hours. Typically, when there are a number of symptoms, very small increases accomplish nothing. For instance, the patient who, at 10 mg/day, is now sleeping most of the day away, complaining of headaches, and quickly losing function on the affected side of the body, may see no improvement at all if the dose is taken to 12 mg/day, but may see dramatic change at 18-20 mg/day. It's important to realize that when symptoms break through at the current dose, this dose may have been inadequate for some time---days to weeks---so there may be some "catching up" to do, so to speak.

Most doctors will approve a request to elevate the Decadron dose in the end-stage period; often, they appreciate an update from the family in 2-3 days so that further decisions on dosing can be made then, if necessary. Sometimes, the physician isn't terribly experienced in steroid management and may feel uncomfortable with doses he or she views as "high." The doctor treating one patient I have known was very reluctant to raise the dose above 12 mg/day, believing that this was extreme. It's not. Many end-stage patients require doses of 12-32 mg/day in order to achieve comfort and maintain some level of function and interaction with the family. This particular family called to request that the dose be raised to 20 mg/day "just to see." Their loved one, a man in his late 60s with gbm, was at that point sleeping nearly 23 hours a day and awake for only minutes at a time. The doctor approved of the dose only after a lot of persuasion from the patient's daughter. A week later, the patient was asking for assistance in coming downstairs for a meal, and when a friend came by with whom he used to play racquetball, he said he'd like to go to the club for a game! They weren't sure what to do, but the friend, who was a physician, said that he'd keep a close eye on him, so off he went, with his pajamas perhaps slightly passable as exercise pants, and had a wonderful afternoon with his buddy. At the time the family phoned the doctor, the patient was perhaps in his final week of life. The increase of Decadron reduced the swelling and managed to buy the family some time. The patient lost his fight about two months later and was able to witness a daughter's wedding, there in the bedroom, in the week before his passing. This is an excellent example of how steroid management can be used to buy high-quality time.

One friend with gbm, whose renowned neuro-oncologist continued to be his physician (by phone) during the hospice period, was taking 60 mg/day of Decadron as his headaches became quite severe. This is probably the extreme, but it supports that every patient is an individual, and that it's the person, not the numeral of the dosage, that matters. It would be unusual, however, for an end-stage patient to have no need for the steroid.