The Last 24 Hours of Life
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Transcript The Last 24 Hours of Life
The Last 48 Hours of Life
James L Hallenbeck, MD
Assistant Professor of Medicine, Stanford University
Director of Palliative Care Services, VA Palo Alto HCS
Topics to Discuss
Signs and Symptoms in Last 48 hours
Coaching of Family
A physician’s checklist
Death Pronouncement
Self-assessed Knowledge Rating
Study
N=27
Most physicians lack knowledge about the
physical changes of dying
On a scale of 1-5, the mean self-assessed
knowledge rating of interns on physical changes
of dying was 1.70
The lowest score of 6 items rating clinical
expertise
Hallenbeck and Bergen, 1999
J. Palliative Medicine
N=100 Cancer pts.
Signs of Impending Death
Respiratory Secretions (Death rattle)
Median time PTD 23h (82h SD)
Respirations with mandibular movement
Time PTD 2.5h (18h SD)
Cyanosis/mottling
Time PTD 1.0h (11 SD)
Lack of radial pulse
Time PTD 1.0h (4.2 SD)
Morita 1998
Symptoms and Signs
in the Last 24-48 Hours
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Symptom
Noisy, moist breathing
Urinary incontinence
Urinary retention
Pain
Restlessness, agitation
Dyspnea
Nausea, vomiting
Sweating
Jerking, twitching
Confusion
Percent
56
32
21
42
42
22
14
14
12
08
N = 200 cancer patients in hospice
Lichter and Hunt, 1990
Differences Between Cancer and
Non-Cancer Diagnoses
Cancer
Pain 40-100%
Dyspnea 22-46%
More predictable
dying trajectory
Non-Cancer
Pain ~ 42%
Dyspnea ~ 62%
Less predictable
dying trajectory
Sense/desire
Family loss
Coaching
Hunger
Nurturing
Other ways to
nurture
Mouth moist
Thirst
Nurturing
Speech
Communication Can still hear…
Vision
Being seen
Hearing
Being heard
Touch
Physical
presence
May be
conscious
Can still feel…
Transition to
‘non-physical’
relationship
Terminal Syndrome
Characterized by Retained
Secretions
Lack of cough
Multi-system shut-down
Not always associated with dyspnea
Vigorous hydration may flood lungs
Deep suctioning is generally ineffective
Role of IV and antibiotics is controversial
Physician Checklist
Treatment
Switch essential medications to non-oral route
Stop unnecessary medications, procedures, monitoring
Evaluate for new symptoms
Pain, dyspnea, urinary retention, agitation, respiratory
secretions
Family: Contact, engage, educate, facilitate relationship
with dying patient, console
Yourself
Bear witness
Death Pronouncement
Death – not a difficult diagnosis
No need for “pupil exam, assessment for
pain”
Pronouncement – more than a set of
bureaucratic tasks – a cultural ritual
Rarely modeled by senior staff or attending
physicians
Teachable skills exist
Death Pronouncement Skills
Anticipate impending death and prepare family
If called, inquire re circumstances
family present/not, anticipated/not
If family present, assess ‘where they are’
Already grieving or need ritual to believe
person has died
‘Sacred silence’
Console
Next steps
Self-care
Death Pronouncement by Phone
Avoid if possible
Identify where recipient of news is
home, on freeway, alone or not
Often, like bad news, ‘advance alert’
Slow recipient DOWN, NOT – “you must come
right in away”
Identify contact person at hospital
“Ask for Dr. … or Nurse …
Summary
“Don’t worry, you will all die successfully!”
Sogyal Rinpoche
If there is a sacred moment in the life-cycle, other
than a birth, it is a death
As with a birth, families will long remember, how
a person died and how we helped or did not
We need to re-learn how to coach patients and
families through their last 24 hours