Professor D. Robin Taylor The diagnosis of dying Professor D. Robin Taylor

The diagnosis of dying Progressive pathological process(es), malignant or non-malignant, affecting one or more major organs whose course is unlikely to be influenced by maximal medical therapy AND Progressively declining quality of life such that impact of disease (on ADLs) is relatively unaffected by medical interventions, but is amenable to palliative treatments Death is envisaged as inevitable within hours, days or 6-12 months

The diagnosis of dying: other aspects Establishes appropriate truthfulness in the minds of patients, their families and health care professionals. Hope is not extinguished. The diagnosis of dying does not imply abandonment. Futile and burdensome treatments are avoided: - no meaningful benefit - adverse effects - wasteful of resources - illusions of potential recovery Appropriate palliative treatments are given The next of kin are cared for more appropriately

2-5 years but death often seems “unexpected” Diagnosing dying – when? Function Death High Low Frequent admissions, self-care becomes difficult, quality of life deteriorates 2-5 years but death often seems “unexpected” Time Acute exacerbations or complications Unsatisfact stories, phoning OOH, waiting about on trolleys, no benefits, much less support and info at home Delamothe In BMJ last weekend : nobody thinks we have this half right we do not this half right

Ceiling of treatment: respiratory Assuming that other immediately reversible problems have been Addressed (e.g. pneumothorax), management of the patient’s acute respiratory distress SHOULD ALWAYS INCLUDE SYMPTOM RELIEF e.g. low flow oxygen, opiates, haloperidol, benzodiazepine. Thereafter, the patient’s ACUTE MANAGEMENT MAY INCLUDE THE FOLLOWING: (Circle YES or NO. Changes can be at any time later if necessary). ARTERIAL BLOOD GAS ANALYSIS YES / NO ANTIBIOTICS YES / NO PREDNISOLONE YES / NO NON-INVASIVE VENTILATION (BiPAP) YES / NO TRANFER TO HIGH DEPENDENCY UNIT YES / NO ICU / POSSIBLE MECHANICAL VENTILATION YES / NO CPR IN THE EVENT OF CARDIO-RESPIRATORY ARREST YES / NO Active consideration should be given to the need for spiritual care.