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end of life

Also see impending death Epidemiology: - hospice is increasingly used at the end of life - this trend has not necessarily made death a more peaceful experience for patients or their families - frenzied moves during the last months of life - most medical care & death still occurs in an institution rather than at home [9] - end-of-life decisions in minorities tend to be family-centered [17] - hispanics more so than whites believe that the family rather than the patient should be informed of prognosis & should make end-of-life decisions for patient [17] - hispanic adults often confer with several extended family members in end-of-life discussion, but final decisions are usually made by one family member [17] - hispanics tend to choose life-sustaining treatments rather than refuse them [17] - black patients were more likely to overestimate their life expectancy & elect intensive end-of-life medical intervention than white patients - black nursing home residents are hospitalized during the last 30 days of life more frequenly than white residents (43 vs 32%) - patients with severe cognitive impairment, the difference is even larger (37 vs 22%) [34] - white nursing home residents are more likely than black residents to have do-not-hospitalize or do-not-resuscitate orders [34] - 1/3 of nursing home patients with atrial fibrillation continue to receive anticoagulation at the end-of-life [38] Clinical manifestations: - loss of appetite (almost all patients) - nearly all experience grief - associated with disease progression - patients retain ability for pleasure - grief occurs in waves - patients able to look forward to future - major depression in 1-53% - depression is never normal in dying patients [11] - pain is a risk factor [11] - depression is constant & unremitting - anhedonia - suicidal ideation - respiratory secretions, death rattle, tachypnea [12] - also see impending death Management: - discussions about death should be thought of as a process rather than a single event [10] - discontinue unnecessary intravenous fluids [12] - antidepressant for depression - grief does not need treatment (see clinical manifestations) - stimulant (dextroamphetamine, methylphenidate, pemoline) effective within 24-48 hours - antibiotics [42] - time-limited trial (2-3 days) of a new set of agents often helps everyone - doctors, patients, families - predetermined objective markers of progress (defervescence, oxygenation) - agreement on next steps if the trial is ineffective - use oral agents whenever possible - patients who cannot take oral agents due to frailty or dementia less likely to benefit from antibiotics - legitimate concerns of expense should not be reviewed in the patient's room - all focus should be on the individual patient [42] - opiates as needed for pain - no evidence of benefit for long-acting opiates over short- acting opiates - laxative + docusate for constipation - opiates for refractory dyspnea - atropine 1% (ophthalmic) administered sublingual 2 drops every 2 hours for terminal respiratory secretions (death rattle) [12] - in home palliative care reduces end-of-life emergency department visits & hospitalizations [12,31] - implementing standardized improvements in end-of-life care in acute hospitals beneficial per nursing, but not per family [35] - small meals of foods preferred by the patient [12] - enteral nutrition or parenteral nutrition does not improve survival [11] - music at the end of life may bring comfort [39] Notes: - CMS (Medicare) approves payment for voluntary end-of-life counseling [23] - a templated note in the electronic health record helps to organize end-of-life goals of care discussions [40] - aggressive end-of-life care does not improve quality of life or duration of life [11] - patients with hematologic malignancies often receive aggressive end-of-life care [16] - chemotherapy given near the end of life does not reduce mortality or improve quality of life o [22] - palliative care consultation for cancer patients at the end-of-life may reduce inappropriate antibiotic prescribing (also see antimicrobial stewardship) [41] - also see artificial hydration in terminally ill patients - end-of-life medical expenditures exceed costs of prior care & are likely to be unsustainable [6] - US hospitals vary widely on their use of resources for end of life care. - preventive medication use common in terminal cancer [37] - prevalence of pain increases rapidly in the last few months of life, regardless of the cause of death [3] - advanced dementia is consistently associated with severe disability in the last year of life [5] - hospitalization is a harbinger of disability [5] - end-of-life care discussions with patients with advanced cancer often come late in the course of the disease [7] - Medicare proposes reimbursing physicians for end-of-life discussions with patients [21] - guiding patient surrogates' end-of-life decision making is both appropriate & necessary [8] - higher ratings of satisfaction by families correlate with less-intensive end-of-life cancer care [24] - patients with ESRD, cardiopulmonary failure, less likely to receive palliative care consultation (44-50%) than those with cancer (74%) or dementia (61%); more likely to die in ICU than those with cancer (34%) or dementia (10%); less likely to have do-not-resuscitate orders (87% vs 94%) [30] No support for belief that cancer patients can delay their death for an important event. [2] Spiritual & existential concerns of patients at end-of-life 1) past a) value & meaning of person's life b) worth of relationships c) value of previous achievements d) painful memories or shame e) guilt about failures, unfulfilled aspirations 2) present a) diruption of personal integrity b) physical, psychologic, & social changes c) increased dependency d) meaning of person's life e) meaning of suffering 3) future a) impending separation b) hopelessness c) meaninglessness d) death 4) religion a) strength of faith b) a life lived without disgrace to the faith c) existence of afterlife

Related

artificial hydration in terminally ill patients death hospice palliative care

Specific

impending death

General

geriatric disorder; disease of old age; geriatric syndrome

References

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