The Last Hours of Living: Practical Advice for Clinicians

Linda L. Emanuel, MD, PhD; Frank D. Ferris, MD; Charles F. von Gunten, MD, PhD; Joshua M. Hauser, MD; Jamie H. Von Roenn, MD

Disclosures

March 24, 2015

In This Article

Introduction to the Last Hours of Living

Clinical competence, willingness to educate, and calm and empathic reassurance are critical to helping patients and families during a loved one's last hours and days of living. Clinical issues that commonly arise in the last hours of living include the management of nutrition and hydration, changes in consciousness, delirium, pain, breathlessness, and secretions. Management principles are the same whether the patient is at home or in a healthcare institution. However, death in an institution requires accommodations that may not be customary to ensure privacy, cultural observances, and communication. In anticipation of the event, inform the family and other professionals about what to do and what to expect. Care does not end until the family has been supported with their grief reactions and those with complicated grief have been helped to get care.

Case Study: A.F. Is Dying at Home

A.F. is a 79-year-old woman with metastatic breast cancer who is in her own home, cared for by her daughter with the help of a home hospice program. She recently developed aspiration pneumonia and was treated with oral antibiotics. Advance care planning indicates that she does not want to go to the hospital under any circumstances, and she wants a trial of oral antibiotics to see whether her pneumonia could be treated. The patient and daughter agree that if she improves, she may have some quality time left. But if she doesn't, A.F. says that she is "ready to go." Her physician makes a joint home visit with the home hospice nurse to assess changes in mental status and provide support to the patient and family.

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Of all people who die, only a small minority (<10%) die suddenly and unexpectedly. Most people (>90%) die after a long period of illness, with gradual deterioration preceding an active dying phase at the end.[1] Care provided during those last hours and days can have profound effects, not just on the patient but on all who participate, including both family and professional caregivers. At the very end of life, there is no second chance to get it right.

Many clinicians have little or no formal training in managing the dying process or death. Families usually have even less experience or knowledge about death and dying. From media dramatizations and vivid imaginations, most people have developed an exaggerated sense of what dying and death are like. Media portrayals of the outcomes of resuscitation have, for example, been shown to be overly optimistic compared with actual data.[2] With appropriate management, it is possible to provide smooth passage and comfort for patients and their loved ones.

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