* This is the Professional Version. *
The Dying Patient
Dying patients can have needs that differ from those of other patients. So that their needs can be met, dying patients must first be identified. Before death, patients tend to follow
* This is the Professional Version. *
The Dying Patient
Dying patients can have needs that differ from those of other patients. So that their needs can be met, dying patients must first be identified. Before death, patients tend to follow 1 of 3 general trajectories of functional decline:
A limited period of steadily progressive functional decline (eg, typical of progressive cancer)
A prolonged indefinite period of severe dysfunction that may not be steadily progressive (eg, typical of severe dementia, disabling stroke, and severe frailty)
Function that decreases irregularly, caused by periodic and sometimes unpredictable acute exacerbations of the underlying disorder (eg, typical of heart failure or COPD)
With the first trajectory (eg, in progressive cancer), the course of disease and time of death tend to be more predictable than with the other trajectories. For example, with prolonged dysfunction (eg, severe dementia), death may occur suddenly because of an infection such as pneumonia. With irregularly progressive dysfunction (eg, heart failure), people who do not appear near death may die suddenly during an acute exacerbation. As a result, although knowing the trajectory of functional decline can help, it is still often difficult to estimate with any precision when death will occur. Thus, clinicians are advised to consider patients that fulfill both of the following criteria as potentially dying patients, recognizing that these criteria may be overly inclusive:
If a patient is recognized as potentially dying, the clinician should
Communicate the likely course of disease, including an estimation of the length of survival, to the patient, and, if the patient chooses, to family, friends, or both
Discuss and clarify the goals of care (eg, palliation, cure)
Arrange for desired palliative and hospice care
Plan what to do when death is imminent
Help address financial, legal, and ethical concerns
Help patients and caregivers deal with stress
Patients should be involved in decision making as much as they can. If patients lack capacity to make health care decisions (see Capacity (Competence) and Incapacity) and have a durable power of attorney for health care, the person appointed by that document makes health care decisions. If patients have no authorized surrogate, health care practitioners usually rely on the next of kin or even a close friend to gain insight into what the patient's wishes would be. However, the exact scope of authority and the priority of permissible surrogates vary by state. In states where default surrogate decision makers are authorized, the typical order of priority is the patient's
If more than one person has the same priority (eg, several adult children), consensus is preferred, but some states allow health care practitioners to rely on a majority decision.
A common mistake is to assume that patients and caregivers understand the course of disease or recognize when death is imminent; they need to be told specifically. When possible, a range of likely survival durations should be given, perhaps advising people to "hope for the best but plan for the worst." Educating patients early provides them time to address spiritual and psychosocial concerns and to deliberate and make reasoned decisions about priorities for their care. Priorities can differ when facing death. For example, some people value prolongation of life, even if it causes discomfort, costs money, or burdens family. Other people identify specific goals, such as maintaining function and independence, or relieving symptoms, such as pain. Some people are most concerned with seeking forgiveness, reconciling, or providing for a loved one.
Advance care plans should be documented and readily accessible to other health care providers (eg, emergency department) to offer the best chance of achieving the patient's desired care. State-authorized Portable Orders and Physician Orders for Life-Sustaining Treatment (POLST) are widely used and should be easily accessible in the home and in the medical record to direct emergency medical personnel regarding what medical care to give and to forgo. Decisions about specific treatments can be helpful. For example, CPR and transport to a hospital are usually not desirable if death is imminent; in contrast, certain aggressive treatments (eg, blood transfusions, chemotherapy) may be desired to relieve symptoms even if death is inevitable.
Palliative care aims to improve quality of life by helping relieve bothersome physical symptoms and psychosocial and spiritual distress. Palliative care is not incompatible with many curative treatments and can, in fact, be provided at the same time. For example, the palliative aspect of care emphasizes treatment of pain or delirium for a patient with liver failure who may be on a liver transplant list. However, to say that a patient's care has changed from curative to supportive or from treatment to palliation is an oversimplification of a complex decision process. Most patients need a customized mix of treatment to correct, prevent, and mitigate the effects of various illnesses and disabilities.
Clinicians should initiate palliative care as soon as patients are identified as seriously i