end of life

Introduction

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
• end-of-life decisions in minorities tend to be family-centered
  • 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
  • hispanic adults often confer with several extended family members in end-of-life discussion, but final decisions are usually made by one family member
• hispanics tend to choose life-sustaining treatments rather than refuse them
• 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%)
• white nursing home residents are more likely than black residents to have do-not-hospitalize or do-not-resuscitate orders
• 1/3 of nursing home patients with atrial fibrillation continue to receive anticoagulation at the end-of-life

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
  • pain is a risk factor
  • depression is constant & unremitting
  • anhedonia
  • suicidal ideation
• respiratory secretions, death rattle, tachypnea
• also see impending death

Management

• discussions about death should be thought of as a process rather than a single event
• discontinue unnecessary intravenous fluids
• antidepressant for depression
  • grief does not need treatment (see clinical manifestations)
  • stimulant (dextroamphetamine, methylphenidate, pemoline) effective within 24-48 hours
• antibiotics
  • 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
• 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)
• in home palliative care reduces end-of-life emergency department visits & hospitalizations
• implementing standardized improvements in end-of-life care in acute hospitals beneficial per nursing, but not per family
• small meals of foods preferred by the patient
• enteral nutrition or parenteral nutrition does not improve survival
• music at the end of life may bring comfort

Notes

• CMS (Medicare) approves payment for voluntary end-of-life counseling
• a templated note in the electronic health record helps to organize end-of-life goals of care discussions
• aggressive end-of-life care does not improve quality of life or duration of life
  • patients with hematologic malignancies often receive aggressive end-of-life care
  • chemotherapy given near the end of life does not reduce mortality or improve quality of life o
• palliative care consultation for cancer patients at the end-of-life may reduce inappropriate antibiotic prescribing (also see antimicrobial stewardship)
• also see artificial hydration in terminally ill patients
• end-of-life medical expenditures exceed costs of prior care & are likely to be unsustainable
• US hospitals vary widely on their use of resources for end of life care.
• preventive medication use common in terminal cancer
• prevalence of pain increases rapidly in the last few months of life, regardless of the cause of death
• advanced dementia is consistently associated with severe disability in the last year of life
• hospitalization is a harbinger of disability
• end-of-life care discussions with patients with advanced cancer often come late in the course of the disease
• Medicare proposes reimbursing physicians for end-of-life discussions with patients
• guiding patient surrogates' end-of-life decision making is both appropriate & necessary
• higher ratings of satisfaction by families correlate with less-intensive end-of-life cancer care
• 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%)

No support for belief that cancer patients can delay their death for an important event.

Spiritual & existential concerns of patients at end-of-life

• past
  • value & meaning of person's life
  • worth of relationships
  • value of previous achievements
  • painful memories or shame
  • guilt about failures, unfulfilled aspirations
• present
  • diruption of personal integrity
  • physical, psychologic, & social changes
  • increased dependency
  • meaning of person's life
  • meaning of suffering
• future
  • impending separation
  • hopelessness
  • meaninglessness
  • death
• religion
  • strength of faith
  • a life lived without disgrace to the faith
  • existence of afterlife

More general terms

• geriatric disorder; disease of old age; geriatric syndrome

More specific terms

• impending death

Additional terms

• artificial hydration in terminally ill patients
• death
• hospice
• palliative care