The Last 48 Hours of Life

1. 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

2. Topics to Discuss • Signs and Symptoms in Last 48 hours • Coaching of Family • A physician’s checklist • Death Pronouncement

3. 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

4. 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

5. Symptoms and Signs in the Last 24-48 Hours • Symptom Percent • Noisy, moist breathing 56 • Urinary incontinence 32 • Urinary retention 21 • Pain 42 • Restlessness, agitation 42 • Dyspnea 22 • Nausea, vomiting 14 • Sweating 14 • Jerking, twitching 12 • Confusion 08 N = 200 cancer patients in hospice Lichter and Hunt, 1990

6. Cancer Pain 40-100% Dyspnea 22-46% More predictable dying trajectory Non-Cancer Pain ~ 42% Dyspnea ~ 62% Less predictable dying trajectory Differences Between Cancer and Non-Cancer Diagnoses

8. Sense/desire Family loss Coaching

9. 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

10. 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

11. 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

12. 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

13. 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 …

14. 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