Presentation is loading. Please wait.

Presentation is loading. Please wait.

The Last 48 Hours of Life James L Hallenbeck, MD

Similar presentations

Presentation on theme: "The Last 48 Hours of Life James L Hallenbeck, MD"— Presentation transcript:

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
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 Signs of Impending Death
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 Restlessness, agitation 42 Dyspnea Nausea, vomiting 14 Sweating Jerking, twitching 12 Confusion N = 200 cancer patients in hospice Lichter and Hunt, 1990

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


8 Sense/desire Family loss Coaching Hunger Nurturing Other ways to nurture Thirst Mouth moist Speech Communication Can still hear… Vision Being seen May be conscious Hearing Being heard Can still feel… Touch Physical presence Transition to ‘non-physical’ relationship

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

Download ppt "The Last 48 Hours of Life James L Hallenbeck, MD"

Similar presentations

Ads by Google