The Last 48 Hours of Life

James L Hallenbeck, MDJames L Hallenbeck, MD

Assistant Professor of Medicine, Stanford UniversityAssistant Professor of Medicine, Stanford University

Director of Palliative Care Services, VA Palo Alto HCSDirector of Palliative Care Services, VA Palo Alto HCS

Topics to Discuss

Signs and Symptoms in Last 48 hoursSigns and Symptoms in Last 48 hours Coaching of FamilyCoaching of Family A physician’s checklistA physician’s checklist Death PronouncementDeath Pronouncement

Self-assessed Knowledge Rating Study Most physicians lack knowledge about the physical Most physicians lack knowledge about the physical

changes of dying changes of dying

On a scale of 1-5, the mean self-assessed knowledge On a scale of 1-5, the mean self-assessed knowledge

rating of interns on physical changes of dying was 1.70rating of interns on physical changes of dying was 1.70

The lowest score of 6 items rating clinical expertiseThe lowest score of 6 items rating clinical expertise

Hallenbeck and Bergen, 1999Hallenbeck and Bergen, 1999

N=27

J. Palliative Medicine

Signs of Impending Death

Respiratory Secretions (Death rattle) Respiratory Secretions (Death rattle) Median time PTD 23h (82h SD)Median time PTD 23h (82h SD)

Respirations with mandibular movementRespirations with mandibular movement Time PTD 2.5h (18h SD)Time PTD 2.5h (18h SD)

Cyanosis/mottlingCyanosis/mottling Time PTD 1.0h (11 SD)Time PTD 1.0h (11 SD)

Lack of radial pulseLack of radial pulse Time PTD 1.0h (4.2 SD)Time PTD 1.0h (4.2 SD) Morita 1998

N=100 Cancer pts.

Symptoms and Signs in the Last 24-48 Hours

• SymptomSymptom PercentPercent• Noisy, moist breathingNoisy, moist breathing 5656• Urinary incontinenceUrinary incontinence 3232• Urinary retentionUrinary retention 2121• PainPain 4242• Restlessness, agitationRestlessness, agitation 4242• DyspneaDyspnea 2222• Nausea, vomitingNausea, vomiting 1414• SweatingSweating 1414• Jerking, twitchingJerking, twitching 1212• ConfusionConfusion 0808

N = 200 cancer patients in hospiceN = 200 cancer patients in hospice Lichter and Hunt, 1990 Lichter and Hunt, 1990

Differences Between Cancer and Non-Cancer Diagnoses CancerCancer

Pain 40-100%Pain 40-100% Dyspnea 22-46%Dyspnea 22-46% More predictable More predictable

dying trajectorydying trajectory

Non-CancerNon-Cancer Pain ~ 42%Pain ~ 42% Dyspnea ~ 62%Dyspnea ~ 62% Less predictable Less predictable

dying trajectorydying trajectory

HungerHunger NurturingNurturing Other ways to Other ways to nurturenurture

ThirstThirst NurturingNurturing Mouth moistMouth moist

SpeechSpeech CommunicationCommunication Can still hear…Can still hear…

VisionVision Being seenBeing seen May be May be consciousconscious

HearingHearing Being heardBeing heard Can still feel…Can still feel…

TouchTouch Physical Physical presencepresence

Transition to Transition to ‘non-physical’ ‘non-physical’ relationshiprelationship

Sense/desire Family loss Coaching

Terminal Syndrome Characterized by Retained Secretions

Lack of coughLack of cough

Multi-system shut-downMulti-system shut-down

Not always associated with dyspneaNot always associated with dyspnea

Vigorous hydration may flood lungsVigorous hydration may flood lungs

Deep suctioning is generally ineffectiveDeep suctioning is generally ineffective

Role of IV and antibiotics is controversialRole of IV and antibiotics is controversial

Physician Checklist TreatmentTreatment

Switch essential medications to non-oral routeSwitch essential medications to non-oral route Stop unnecessary medications, procedures, monitoringStop unnecessary medications, procedures, monitoring

Evaluate for new symptomsEvaluate for new symptoms Pain, dyspnea, urinary retention, agitation, respiratory Pain, dyspnea, urinary retention, agitation, respiratory

secretionssecretions

Family: Contact, engage, educate, facilitate relationship Family: Contact, engage, educate, facilitate relationship with dying patient, consolewith dying patient, console

YourselfYourself Bear witnessBear witness

Death Pronouncement

Death – not a difficult diagnosisDeath – not a difficult diagnosis No need for “pupil exam, assessment for No need for “pupil exam, assessment for

pain”pain” Pronouncement – more than a set of Pronouncement – more than a set of

bureaucratic tasks – a cultural ritualbureaucratic tasks – a cultural ritual Rarely modeled by senior staff or attending Rarely modeled by senior staff or attending

physiciansphysicians Teachable skills existTeachable skills exist

Death Pronouncement Skills AnticipateAnticipate impending death and prepare family impending death and prepare family If called, inquire re circumstances If called, inquire re circumstances

family present/not, anticipated/notfamily present/not, anticipated/not If family present, assess ‘where they are’If family present, assess ‘where they are’

Already grieving or need ritual to believe Already grieving or need ritual to believe person has diedperson has died

‘‘Sacred silence’Sacred silence’ ConsoleConsole Next stepsNext steps Self-careSelf-care

Death Pronouncement by Phone

Avoid if possibleAvoid if possible Identify where recipient of news is Identify where recipient of news is

home, on freeway, alone or nothome, on freeway, alone or not Often, like bad news, ‘advance alert’Often, like bad news, ‘advance alert’ Slow recipient Slow recipient DOWN, DOWN, NOT – “you must come NOT – “you must come

right in away”right in away” Identify contact person at hospitalIdentify contact person at hospital

““Ask for Dr. … or Nurse …Ask for Dr. … or Nurse …

Summary

““Don’t worry, you will all die successfully!”Don’t worry, you will all die successfully!” Sogyal RinpocheSogyal Rinpoche

If there is a sacred moment in the life-cycle, other If there is a sacred moment in the life-cycle, other than a birth, it is a death than a birth, it is a death

As with a birth, families will long remember, how As with a birth, families will long remember, how a person died and how we helped or did nota person died and how we helped or did not

We need to re-learn how to coach patients and We need to re-learn how to coach patients and families through their last 24 hoursfamilies through their last 24 hours