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