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


March 24, 2015

In This Article

Dying in Institutions

The preceding discussion is relevant to patients dying in any setting (eg, at home, in hospitals, in nursing homes, in other extended care facilities, in prisons, etc.). However, there are particular challenges to ensuring a comfortable death in an institution where the culture is not focused on end-of-life care.[57]

When death is imminent, it is appropriate for patients to remain with familiar caregivers rather than being transferred to another facility. An exception occurs when a patient's symptom management cannot be achieved in a certain setting; in that case, the patient might need to be transferred to another setting with a higher level of care. For example, a patient residing in a nursing home who needs continuous infusion of an opioid and a benzodiazepine that the nursing facility does not feel comfortable or staffed to provide might need to be transferred to a palliative care unit or an acute care hospital.

Institutions can help by making the environment as home-like as possible. Try to place the patient in a private room where family can remain continuously with the patient if they so choose and be undisturbed. The clinician will want to talk with the professional staff and encourage continuity of care plans across nursing shifts and changes in house staff.

Priorities and care plans at the end of life often differ considerably from priorities and plans focusing on life prolongation and cure. It can be challenging for physicians, nurses, and other healthcare professionals to incorporate both kinds of care in a busy hospital or skilled nursing facility. For this reason, specialized palliative care units where patients and families can be assured of the environment and the skilled care that they need have been developed in many institutions.[58,59,60]

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