Key Clinical Questions
What are the signs that death is approaching?
How does the clinician decide what medications are still needed at the end of life?
How does the clinician address end-of-life concerns?
Caring for dying patients is an integral role of hospitalists; recent data show that approximately 25% of medicare beneficiaries die in hospitals. This chapter will focus on the imminently dying patient with an expected life expectancy in the range of a few weeks or less. In the United States, the most common causes of dying include heart disease, cancer, and chronic lower respiratory disease, followed by accidents, stroke, and Alzheimer’s disease. The mere thought of dying can invoke great distress, and it is a natural response that people often try to disregard the universal inevitability of death. Not confronting end-of-life risks compounds suffering: unwanted medical interventions, impaired family bereavement, and unfulfilled life closure tasks. Physical, emotional, spiritual, and existential suffering are all possible, though not guaranteed. Health care providers need to remain sensitive to the many ways that patients and families may suffer near end of life.
Any illness that cannot be cured and contributes to a short life expectancy is a terminal illness. Most, though not all, stage IV cancers are terminal. Heart failure, chronic obstructive pulmonary disease, Alzheimer’s dementia progress from chronic to terminal illness, although these are less commonly thought of as terminal illnesses compared to cancers.
The dying process may be categorized as “acute” due to a sudden event, “chronic” due to progressive disease and/or acute exacerbations of chronic disease, or “acute-on-chronic” due to a catastrophic complication of the chronic illness. Terminal illness generally creates a negative trend in functional abilities over time with an “active dying” phase that spans a few days to a week. Active dying in the final days includes withdrawing from the world and shutting down of body organ functions. Sometimes an additional acute process complicates the signs which otherwise would have pointed to a longer, though limited, prognosis. The presence of several characteristics dying signs and symptoms mark a transition to “active” or “imminently dying” (see Table 217-1). These may be witnessed in the final minutes, hours, or days of life. Acute dying processes are less predictable; clinicians may suddenly bear witness to active dying with minimal notice during a sudden terminal event.
TABLE 217-1Common Signs Associated with the Dying Process |Favorite Table|Download (.pdf) TABLE 217-1 Common Signs Associated with the Dying Process
|Dying Patients Typically Have a Constellation of These Symptoms, Not Just One |
|Sign ||Comments |
|Anorexia ||Nearly universal in final days |
|Increasing weakness and debility || |
|Sleeping most of the day || |
|Decreasing urine output || |
|More starring, withdrawing from the world || |
|Worsening dysphagia || |
|Near-death awareness ||Eg, seeing or interacting with deceased friends/family |
|Transient clinical improvement, a “rally” ||Eg, family reports unexpected “really good day” |
|Confusion, disorientation, ...|