Chapter 219. Care of the Imminently Dying Patient

1. How do I know if a patient is dying?

2. What should I include in a family meeting?

3. What should I consider in the withdrawal of life-sustaining treatment?

There is substantial evidence that patients with advanced chronic illness often receive inappropriate or inadequate care, have poorly managed symptoms, experience spiritual distress and financial worries, and possess incomplete knowledge about illness progression. Hospitalized dying patients frequently receive aggressive care up to and including life-sustaining treatment and resuscitation, but inadequate preparation for potential death. Since approximately 50% of deaths occur in the hospital setting, substantial numbers of patients may experience increased suffering due to futile or iatrogenic interventions, needless delays to timely discharge, and insufficient patient and family inclusion in decisions about end-of-life care.

Recent government data show the aggregate costs of dying in the hospital amount to $20 billion. The average cost of an admission ending in death is three times that of a patient who is alive at discharge ($26,000 versus $94,00). Patients who had procedures (73%) were more likely to die than those who had none (27%). Twelve percent of those who died were admitted for an elective procedure, while 72% were admitted through the emergency department. Medicare insured 67% of all the patients who died in hospitals at a cost of more than $12 billion. Although more studies are needed to show whether this is too much or too little to spend, abundant evidence suggests that there is significant room for improvement in the area of end-of-life care.

An underlying diagnosis of metastatic cancer, end-stage renal or lung disease, severe liver disease, or congestive heart failure and a decline in performance status increase the likelihood of dying in the hospital. Other factors include prolonged length of stay without evident progress and a diagnosis of frailty in elderly patients. The dying process may begin with a gradual decline in a patient initially admitted with multiple comorbidities. The decline to death may occur more rapidly with a sudden cardiac event or respiratory failure. Sometimes invasive procedures such as the placement of a percutaneous feeding tube, stent, endoscopic retrograde cholangiopancreatography (ERCP), or bronchoscopy may precipitate the decline of a compromised, frail patient.

The dying process usually occurs over hours to weeks and should be suspected when certain signs are present (Tables 219-1 and 219-2).