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INTRODUCTION

In 2008, 2,473,000 people died in the United States; death rates are declining. Heart disease and cancer are the two leading causes of death and together account for nearly half of all deaths. About 70% of deaths occur in people who have a condition that is known to be leading to their death; thus, planning for terminal care is relevant and important. An increasing fraction of deaths are occurring in hospices or at home rather than in the hospital.

Optimal care depends on a comprehensive assessment of pt needs in all four domains affected by illness: physical, psychological, social, and spiritual. A variety of assessment tools are available to assist in the process.

Communication and continuous assessment of management goals are key components to addressing end-of-life care. Physicians must be clear about the likely outcome of the illness(es) and provide an anticipated schedule with goals and landmarks in the care process. When the goals of care have changed from cure to palliation, that transition must be clearly explained and defended. Seven steps are involved in establishing goals:

  1. Ensure that the medical information is as complete as possible and understood by all relevant parties.

  2. Explore the pt's goals while making sure the goals are achievable.

  3. Explain the options.

  4. Show empathy as the pt and the family adjust to changing expectations.

  5. Make a plan with realistic goals.

  6. Follow through with the plan.

  7. Review and revise the plan periodically as the pt's situation changes.

ADVANCE DIRECTIVES

About 70% of pts lack decision-making capacity in their final days. Advance directives define ahead of time the level of intervention the pt is willing to accept. Two types of legal documents can be used: the advance directive, in which specific instructions from the pt may be made known; and the durable attorney for health care, in which a person is designated as having the pt's authority to make health decisions on the pt's behalf. Forms are available free of charge from the National Hospice and Palliative Care Organization (www.nhpco.org). Physicians also should complete these forms for themselves.

PHYSICAL SYMPTOMS AND THEIR MANAGEMENT

The most common physical and psychological symptoms among terminally ill pts are shown in Table 10-1. Studies of pts with advanced cancer have shown that pts experience an average of 11.5 symptoms.

TABLE 10-1COMMON PHYSICAL AND PSYCHOLOGICAL SYMPTOMS OF TERMINALLY ILL PATIENTS

Pain

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