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The Last 48 Hours of Life James L Hallenbeck, MD Assistant Professor of Medicine, Stanford University Director of Palliative Care Services, VA Palo Alto.

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Presentation on theme: "The Last 48 Hours of Life James L Hallenbeck, MD Assistant Professor of Medicine, Stanford University Director of Palliative Care Services, VA Palo Alto."— 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 Signs and Symptoms in Last 48 hours Coaching of Family Coaching of Family A physicians checklist A physicians checklist Death Pronouncement Death Pronouncement

3 Self-assessed Knowledge Rating Study Most physicians lack knowledge about the physical changes of dying 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 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 The lowest score of 6 items rating clinical expertise Hallenbeck and Bergen, 1999 Hallenbeck and Bergen, 1999 N=27 J. Palliative Medicine

4 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 movement Respirations with mandibular movement Time PTD 2.5h (18h SD) Time PTD 2.5h (18h SD) Cyanosis/mottling Cyanosis/mottling Time PTD 1.0h (11 SD) Time PTD 1.0h (11 SD) Lack of radial pulse Lack of radial pulse Time PTD 1.0h (4.2 SD) Time PTD 1.0h (4.2 SD) Morita 1998 N=100 Cancer pts.

5 Symptoms and Signs in the Last Hours Symptom Percent Symptom Percent Noisy, moist breathing56 Noisy, moist breathing56 Urinary incontinence32 Urinary incontinence32 Urinary retention21 Urinary retention21 Pain42 Pain42 Restlessness, agitation42 Restlessness, agitation42 Dyspnea22 Dyspnea22 Nausea, vomiting14 Nausea, vomiting14 Sweating14 Sweating14 Jerking, twitching12 Jerking, twitching12 Confusion08 Confusion08 N = 200 cancer patients in hospice N = 200 cancer patients in hospice Lichter and Hunt, 1990 Lichter and Hunt, 1990

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

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8 HungerNurturing Other ways to nurture ThirstNurturing Mouth moist SpeechCommunication Can still hear… Vision Being seen May be conscious Hearing Being heard Can still feel… Touch Physical presence Transition to non-physical relationship Sense/desireFamily lossCoaching

9 Terminal Syndrome Characterized by Retained Secretions Lack of cough Lack of cough Multi-system shut-down Multi-system shut-down Not always associated with dyspnea Not always associated with dyspnea Vigorous hydration may flood lungs Vigorous hydration may flood lungs Deep suctioning is generally ineffective Deep suctioning is generally ineffective Role of IV and antibiotics is controversial Role of IV and antibiotics is controversial

10 Physician Checklist Treatment Treatment Switch essential medications to non-oral route Switch essential medications to non-oral route Stop unnecessary medications, procedures, monitoring Stop unnecessary medications, procedures, monitoring Evaluate for new symptoms Evaluate for new symptoms Pain, dyspnea, urinary retention, agitation, respiratory secretions Pain, dyspnea, urinary retention, agitation, respiratory secretions Family: Contact, engage, educate, facilitate relationship with dying patient, console Family: Contact, engage, educate, facilitate relationship with dying patient, console Yourself Yourself Bear witness Bear witness

11 Death Pronouncement Death – not a difficult diagnosis Death – not a difficult diagnosis No need for pupil exam, assessment for pain No need for pupil exam, assessment for pain Pronouncement – more than a set of bureaucratic tasks – a cultural ritual Pronouncement – more than a set of bureaucratic tasks – a cultural ritual Rarely modeled by senior staff or attending physicians Rarely modeled by senior staff or attending physicians Teachable skills exist Teachable skills exist

12 Death Pronouncement Skills Anticipate impending death and prepare family Anticipate impending death and prepare family If called, inquire re circumstances If called, inquire re circumstances family present/not, anticipated/not family 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 person has died Already grieving or need ritual to believe person has died Sacred silence Sacred silence Console Console Next steps Next steps Self-care Self-care

13 Death Pronouncement by Phone Avoid if possible Avoid if possible Identify where recipient of news is Identify where recipient of news is home, on freeway, alone or not home, on freeway, alone or not Often, like bad news, advance alert Often, like bad news, advance alert Slow recipient DOWN, NOT – you must come right in away Slow recipient DOWN, NOT – you must come right in away Identify contact person at hospital Identify contact person at hospital Ask for Dr. … or Nurse … Ask for Dr. … or Nurse …

14 Summary Dont worry, you will all die successfully! Sogyal Rinpoche Dont 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 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 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 We need to re-learn how to coach patients and families through their last 24 hours


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