March 22, 2011

The Last Hours of Living: Practical Advice for Clinicians: Summary of Take-Home Lessons

MedscapeCME - Linda Emanuel, MD, PhD; Frank D. Ferris, MD; Charles F. von Gunten, MD, PhD; Jamie H. von Roenn, MD

8. Summary of Take-Home Lessons

Clinical competence, willingness to educate and calm, and empathic reassurance are critical to helping patients and families in the last hours of living. For most dying patients, predictable physiologic changes occur. Management principles are the same at home or in a healthcare institution. However, death in an institution requires accommodations that include ensuring privacy, cultural observances, and communication that may not be customary.

In anticipation of the event, it helps to inform the family and other professionals about what to do and what to expect, including matters such as when rigor mortis sets in, and how to call the funeral home, say goodbye, and move the body. Care does not end until the clinician has helped the family with their grief reactions and helped those with complicated grief to get care. Care at the end of life is an important responsibility for every health professional, and there is a body of knowledge to guide care.[2,65,66]

In summary, keep these key points in mind:
  1. There is only one chance to get management of the last hours right.
  2. Patients in the last hours of life usually need skilled care around the clock. The environment must allow family and friends ready access to their loved one in a setting that is conducive to privacy and intimacy.
  3. Advance preparation and education of professional, family, and volunteer caregivers are essential. They should also be knowledgeable about the potential time course, signs and symptoms of the dying process, and their potential management. The physician or nurse needs to help family members understand that what they see may be very different from what the patient is experiencing.
  4. The physiologic changes of dying are complex. To control each symptom effectively, clinicians need to have an understanding of its cause, underlying pathophysiology, and the appropriate pharmacology to use.
  5. When death is imminent, fatigue is an expected part of the dying process and should not be treated medically in most cases.
  6. Most patients lose their appetite and reduce food intake long before they reach the last hours of their lives. Anorexia may be protective, and the resulting ketosis can lead to a greater sense of well-being and diminish pain.
  7. Most patients also reduce their fluid intake, or stop drinking entirely, long before they die. Dehydration in the last hours of living does not cause distress and may stimulate endorphin release that adds to the patient's sense of well-being.
  8. Moisture should be maintained in mucosal membranes with meticulous oral, lip, nasal, and conjunctival hygiene and lubrication.
  9. Most patients experience increasing drowsiness and sleep much of the time, eventually becoming unarousable. Absence of eyelash reflexes indicates a profound level of coma equivalent to full anesthesia.
  10. It should be assumed that the unconscious patient hears everything.
  11. Moaning, groaning, and grimacing accompanying agitation and restlessness are frequently misinterpreted as pain. Terminal delirium may be occurring. Although a trial of opioids may be beneficial in the unconscious patient who is difficult to assess, benzodiazepines or sedating neuroleptics may be needed to manage terminal delirium. Benzodiazepines may cause paradoxical exciting effects; these patients require neuroleptic medications to control their delirium.
  12. Diminished hepatic function and renal perfusion may change the pharmacology of chronically administered medications.
  13. Secretions from the tracheobronchial tree frequently accumulate. Scopolamine or glycopyrrolate will effectively reduce the production of saliva and other secretions.
  14. Dying in an institution presents particular challenges. Priorities and care plans at the very end of life differ from those priorities and plans focused on life prolongation and cure.
  15. Planning discussions should cover personal, cultural, and religious traditions, rites, and rituals that may dictate how prayers are to be conducted, how a person's body is to be handled after death, and when and how the body can be moved.
  16. When an expected death occurs, the focus of care shifts to the family and those who provided care.
  17. Acute grief reactions should be addressed, especially when the body is moved.
Pearls and Pitfalls

Pearls for quality care include:
  1. Use only essential medications. Stop routine dosing and continue to offer opioids as needed. Accumulating serum concentrations of active drug and metabolites may lead to toxicity and terminal delirium.
  2. Know the signs of the dying process.
  3. Make a partnership with the patient and the family caregiver(s); draw them into the interdisciplinary team and foster their active participation in the care plan.
Common pitfalls include:
  1. Maintaining parenteral fluids. Continuing fluids may have adverse effects that are not commonly considered.
  2. Oropharyngeal suctioning. While suctioning is likely to be ineffective at clearing secretions, it may be very effective at stimulating a gag, cough, or vomiting.
  3. Removing the body insensitively or too soon. This can be more distressing for families than the moment of death.
REFERENCES
65. Ellershaw J, Ward C. Care of the dying patient: the last hours or days of life. BMJ. 2003;326:30-34.
66. Ferris FD, von Gunten CF, Emanuel LL. Competency in end of life care: The last hours of living. J Palliat Med. 2003;6:605-613. Abstract

The EPEC™-O curriculum was initially produced by the EPEC Project™ at Northwestern University’s Feinberg School of Medicine, with major funding provided by the National Cancer Institute and supplemental funding provided by the Lance Armstrong Foundation.

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