care, the patient would experience fewer intolerable symptoms, physical or emotional, and would not choose death over these symptoms. palliative care would also ensure that patients receive proper information about their disease prognosis as not to make decisions about pas without complete and careful consideration. medical care many aspects of medical care are different for terminal patients compared to patients in the hospital for other reasons. doctor–patient relationships doctor–patient relationship are crucial in any medical setting, and especially so for terminal patients. there must be an inherent trust in the doctor to provide the best possible care for the patient. in the case of terminal illness, there is often ambiguity in communication with the patient about his/her condition. while terminal condition prognosis is often a grave matter, doctors do not wish to quash all hope, for it could unnecessarily harm the patient's mental state and have unintended consequences. however, being overly optimistic about outcomes can leave patients and families devastated when negative results arise, as is often the case with terminal illness. mortality predictions often, a patient is considered terminally ill when his or her estimated life expectancy is six months or less, under the assumption that the disease will run its normal course based on previous data from other patients. the six-month standard is arbitrary, and best available estimates of longevity may be incorrect. though a given patient may properly be considered terminal, this is not a guarantee that the patient will die within six months. similarly, a patient with a slowly progressing disease, such as aids, may not be considered terminally ill if the best estimate of longevity is greater than six months. however, this does not guarantee that the patient will not die unexpectedly early. in general, physicians slightly overestimate the survival time of terminally ill cancer patients, so that, for example, a person who is expected to live for about six weeks would likely die around four weeks. a recent systematic review on palliative patients in general, rather than specifically cancer patients, states the following: "accuracy of categorical estimates in this systematic review ranged from 23% up to 78% and continuous estimates over-predicted actual survival by, potentially, a factor of two." there was no evidence that any specific type of clinician was better at making these predictions. healthcare spending healthcare during the last year of life is costly, especially for patients who used hospital services often during end-of-life. in fact, according to langton et al., there were "exponential increases in service use and costs as death approached." many dying terminal patients are also brought to the emergency department (ed) at the end of life when treatment is no longer beneficial, raising costs and using limited space in the ed. while there are often claims about "disproportionate" spending of money and resources on end-of-life patients, data have not proven this type of correlation. the cost of healthcare for end-of-life patients is 13% of annual healthcare spending in the u.s. however, of the group of patients with the highest healthcare spending, end-of-life patients only made up 11% of these people, meaning the most expensive spending is not made up mostly of terminal patients. many recent studies have shown that palliative care and hospice options as an alternative are much less expensive for end-of-life patients. psychological impact coping with impending death is a hard topic to digest universally. patients may experience grief, fear, loneliness, depression, and anxiety among many other possible responses. terminal illness can also lend patients to become more prone to psychological illness such as depression and anxiety disorders. insomnia is a common symptom of these. it is important for loved ones to show their support for the patient during these times and to listen to his or her concerns. people who are terminally ill may not always come to accept their impending death. for example, a person who finds strength in denial may never reach a point of acceptance or accommodation and may react negatively to any statement that threatens this defense mechanism. impact on patient depression is relatively common among terminal patients, and the prevalence increases as patients become sicker. depression causes quality of life to go down, and a sizable portion of patients who request assisted suicide are depressed. these negative emotions may be heightened by lack of sleep and pain as well. depression can be treated with antidepressants and/or therapy, but doctors often do not realize the extent of terminal patients' depression. because depression is common among terminal patients, the american college of physicians recommends regular assessments for depression for this population and appropriate prescription of antidepressants. anxiety disorders are also relatively common for terminal patients as they face their mortality. patients may feel distressed when thinking about what the future may hold, especially when considering the future of their families as well. it is important to note, however, that some palliative medications may facilitate anxiety. coping for patients caregivers may listen to the concerns of terminal patients to help them reflect on their emotions. different forms of psychotherapy and psychosocial intervention, which can be offered with palliative care, may also help patients think about and overcome their feelings. according to block, "most terminally ill patients benefit from an approach that combines emotional support, flexibility, appreciation of the patient's strengths, a warm and genuine relationship with the therapist, elements of life-review, and exploration of fears and concerns." impact on family terminal patients' families often also suffer psychological consequences. if not well equipped to face the reality of their loved one's illness, family members may develop depressive symptoms and even have increased mortality. taking care of sick family members may also cause stress, grief, and worry. additionally, financial burden from medical treatment may be a source of stress. parents of terminally ill children also face additional challenges in addition to mental health stressors including difficulty balancing caregiving and maintaining employment. many report feeling as if they have to "do it all" by balancing caring for their chronically ill child, limiting absence from work, and supporting their family members. children of terminally ill parents often experience a role reversal in which they become the caretakers of their adult parents. in taking on the burden of caring for their sick parent and assuming the responsibilities they can no longer accomplish, many children also experience significant declines in academic performance. coping for family discussing the anticipated loss and planning for the future may help family members accept and prepare for the patient's death. interventions may also be offered for anticipatory grief. in the case of more serious consequences such as depression, a more serious intervention or therapy is recommended. upon the death of someone who is terminally ill, many family members that served as caregivers are likely to experience declines in their mental health. grief counseling and grief therapy may also be recommended for family members after a loved one's death. grief counseling and grief therapy may also be recommended for family members after a loved one's death. dying when dying, patients often worry about their quality of life towards the end, including emotional and physical suffering. in order for families and doctors to understand clearly what the patient wants for themselves, it is recommended that patients, doctors, and families all convene and discuss the patient's decisions before the patient becomes unable to decide. advance directives at the end of life, especially when patients are unable to make decisions on their own regarding treatment, it is often up to family members and doctors to decide what they believe the patients would have wanted regarding their deaths, which is often a heavy burden and hard for family members to predict. an estimated 25% of american adults have an advance directive, meaning the majority of americans leave these decisions to be made by family, which can lead to conflict and guilt. although it may be a difficult subject to broach, it is important to discuss the patient's plans for how far to continue treatment should they become unable to decide. this must be done while the patient is still able to make the decisions, and takes the form of an advance directive. the advance directive should be updated regularly as the patient's condition changes so as to reflect the patient's wishes. some of the decisions that advance directives may address include receiving fluids and nutrition support, getting blood transfusions, receiving antibiotics, resuscitation (if the heart stops beating), and intubation (if the patient stops breathing). having an advance directive can improve end-of-life care. it is highly recommended by many research studies and meta-analyses for patients to discuss and create an advance directive with their doctors and families. do-not-resuscitate main article: do not resuscitate one of the options of care that patients may discuss with their families and medical providers is the do-not-resuscitate (dnr) order. this means that if the patient's heart stops, cpr and other methods to bring back heartbeat would not be performed. this is the patient's choice to make and can depend on a variety of reasons, whether based on personal beliefs or medical concerns. dnr orders can be medically and legally binding depending on the applicable jurisdiction. decisions like these should be indicated in the advance directive so that the patient's wishes can be carried out to improve end-of-life care. symptoms near death a variety of symptoms become more apparent when a patient is nearing death. recognizing these symptoms and knowing what will come may help family members prepare. during the final few weeks, symptoms will vary largely depending on the patient's disease. during the final hours, patients usually will reject food and water and will also sleep more, choosing not to interact with those around them. their bodies may behave more irregularly, with changes in breathing, sometimes with longer pauses between breaths, irregular heart rate, low blood pressure, and coldness in the extremities. it is important to note, however, that symptoms will vary per patient. good death patients, healthcare workers, and recently bereaved family members often describe a "good death" in terms of effective choices made in a few areas: assurance of effective pain and symptom management. education about death and its aftermath, especially as it relates to decision-making. completion of any significant goals, such as resolving past conflicts. in the last hours of life, palliative sedation may be recommended by a doctor or requested by the patient to ease the symptoms of death until they die. palliative sedation is not intended to prolong life or hasten death; it is merely meant to relieve symptoms.