January 31, 2011

The Last Hours of Living: Practical Advice for Clinicians: Preparing for the Last Hours of Life

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

2. Preparing for the Last Hours of Life

During the last hours of their lives, most patients require continuous skilled care. This can be provided in any setting as long as the professional, family, and volunteer caregivers are appropriately prepared and supported throughout the process. The environment must allow family and friends access to their loved one around the clock without disturbing others and should be conducive to privacy and intimacy. Medications, equipment, and supplies need to be available in anticipation of problems, whether the patient is at home or in a healthcare institution. As the patient's condition and the family's ability to cope can change frequently, both must be reassessed regularly and the plan of care modified as needed. Changes in the patient's condition can occur suddenly and unexpectedly, so caregivers must be able to respond quickly. This is particularly important when the patient is at home, if unnecessary readmission is to be avoided.

If the last hours of a person's life are to be as positive as possible, advance preparation and education of professional, family, and volunteer caregivers are essential, whether the patient is at home, in an acute care or skilled nursing facility, a hospice or palliative care unit, prison, or other setting. Everyone who participates must be aware of the patient's health status, his or her goals for care (and the parents' goals if the patient is a child), advance directives, and proxy for decision making. They should also be knowledgeable about the potential time course, signs, and symptoms of the dying process, and their potential management.

Help families to understand that what they see may be very different from the patient's experience. If family members and caregivers feel confident, the experience can be a time of final gift giving. For example, when parents feel confident about providing for the needs of their dying child, their sense that they are practicing good parenting skills is reinforced. If they are left unprepared and unsupported, they may spend excessive energy worrying about how to handle the next event. If things do not go as hoped for, family members may live with frustration, worry, fear, or guilt that they did something wrong or caused the patient's death.

Establish in advance whether potential caregivers, including professionals who work in institutions, are skilled in caring for patients in the last hours of life. Do not assume that anyone, even a professional, knows how to perform basic tasks. Those who are inexperienced in this particular area will need specific training in areas such as body fluid precautions. Written materials can provide additional support to caregivers when experts are not present.

Although we often sense that death will either come quickly over minutes or be protracted over days to weeks, it is not possible to predict with precision when death will occur. Some patients may appear to wait for someone to visit, or for an important event such as a birthday or a special holiday, and then die soon afterward. Others experience unexplained improvements and live longer than expected. A few seem to decide to die and do so very quickly, sometimes within minutes. Although it is possible to give families or professional caregivers a general idea of how long the patient might live, always advise them about the inherent unpredictability of the moment of death.

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