January 18, 2011

The Last Hours of Living: Practical Advice for Clinicians

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

1. Introduction to the Last Hours of Living

Clinical competence, willingness to educate, and calm and empathic reassurance are critical to helping patients and families during a loved one's last hours of living. Clinical issues that commonly arise in the last hours of living include the management of feeding and hydration, changes in consciousness, delirium, pain, breathlessness, and secretions. Management principles are the same whether the patient is at home or in a healthcare institution. However, death in an institution requires accommodations that may not be customary to assure privacy, cultural observances, and communication. In anticipation of the event, inform the family and other professionals about what to do and what to expect. Care does not end until the family has been supported with their grief reactions and those with complicated grief have been helped to get care.

Case Study: A.F. Is Dying at Home

A.F. is a 79-year-old woman with metastatic breast cancer who is in her own home, cared for by her daughter with the help of the home hospice program. She developed aspiration pneumonia, and was treated with oral antibiotics. Advance care planning indicates she does not want to go to the hospital under any circumstances, and oral antibiotics were an intermediate level of care. The patient and daughter agree that if she gets better, she may have some quality of time left. But if she doesn't, A.F. says she is ready to go. Her physician makes a joint home visit with the home hospice nurse in order to assess changes in mental status and because it sounds like her daughter panicked and considered calling 911.

Of all people who die, only a few (< 10%) die suddenly and unexpectedly. Most people (> 90%) die after a long period of illness, with gradual deterioration until an active dying phase at the end.[1] Care provided during those last hours and days can have profound effects, not just on the patient, but on all who participate. At the very end of life, there is no second chance to get it right.

Most clinicians have little or no formal training in managing the dying process or death. Many have neither watched someone die nor provided direct care during the last hours of life. Families usually have even less experience or knowledge about death and dying. Based on media dramatization and vivid imaginations, most people have developed an exaggerated sense of what dying and death are like. However, with appropriate management, it is possible to provide smooth passage and comfort for the patient and all those who watch.

1. Field MJ, Cassel CK, eds. Approaching Death: Improving Care at the End of Life. Washington, DC: National Academy Press; 1997:28-30

1 comment:

  1. Deaths due to secretions MUST be taken very seriously by physicians and nurses alike.

    In my little years of tropical medical practice, i have seen many recovering patients die becos of careless nursing care, especially as regards suctioning to remove secretions. This has been especially true in cases of tetanus and strokes - ischaemic and hemorrhagic.

    I don't wish to disdain nursing practice.

    All i am saying is that nurses in the tropics must improve on their practice, and attending physicians in the tropics also ought to be involved in how their patients are nursed to prevent unnecessary deaths.


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