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

Two Roads to Death: The Usual Trajectory

Decreasing Level of Consciousness

Most patients traverse the "usual road to death." Depending on the patient's illness, this trajectory may occur over hours or over many days. It is important to describe these changes and the probable, but unpredictable, time course to families. Dying patients experience increasing drowsiness, sleep most if not all of the time, and eventually become unarousable. Absence of eyelash reflexes on physical examination indicates a profound level of coma equivalent to full anesthesia.

Communication with the unconscious patient. Families will frequently find the inability to communicate with their loved one distressing. The last hours of life may be the time when they most want to communicate with their loved one. As many clinicians have observed, the degree of family distress seems to be inversely related to the extent to which advance planning and preparation occurred. The time spent preparing families is likely to be very worthwhile.

Although we do not know what unconscious patients can actually hear, extrapolation from operating room data and "near death" experiences suggests that at times their awareness may be greater than their ability to respond.[21,22]

Given our inability to assess a dying patient's comprehension and the distress that talking "over" the patient may cause, it is prudent to assume that the unconscious patient hears everything. Advise families and professional caregivers to talk to the patient as if he or she were conscious.

Encourage families to create an environment that is familiar and pleasant. Surround the patient with the people, children, pets, objects, music, and sounds that he or she would like. Include the patient in everyday conversations. Encourage family members to say the things they need to say. At times, it may seem that a patient may be waiting for "permission" to die. A family member may bring this up to a clinician. If this is the case, encourage family members to give the patient permission to "let go" and die in a manner that feels most comfortable. The physician, nurse, social worker, chaplain, or other caregivers might suggest to family members other words like:

  • "I love you. I will miss you. I will never forget you. Please do what you need to do when you are ready."

  • "Mommy and Daddy love you. We will miss you, but we will be okay."

As touch can heighten communication, encourage family members to show affection in ways they are used to. Let them know that it is okay to lie beside the patient in privacy to maintain as much intimacy as they feel comfortable with.

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