Care of the dying patient

Ten-step guide	Tips/examples
Establish a proper setting	Quiet, appropriate parties invited, pagers turned off.
Introductions	“Can you tell me something about your mom?”
Assess patient/family understanding	“What have the doctors told you about your mom’s condition?”
Medical review/summary	Start with a warning shot. Give small pieces of information. Avoid jargon. “I’m afraid I have some bad news. Your mom is dying.”
Silence/reactions	“I wish we had better treatments for her disease.” “I can only imagine how disappointed you must be.” “You’ve been so devoted and loving to your mom.”
Discuss prognosis	Assess the amount of information desired. Present prognostic data using ranges.
Assess goals	Not prolonging the dying process, a peaceful death, being surrounded by family? “If your mom could talk to us right now, what would she tell us is most important to her?”
Present broad options	“Based on what we’ve discussed and what you’ve told me about your mom, I recommend that we refocus our efforts on maximizing her comfort and not prolong her dying process.”
Translate goals into care plan	“Maintaining your mom on life support does not seem consistent with what her wishes would be, therefore I’m recommending that we liberate her from the machine and allow her to have a natural death.”
Document	Write DNR orders, discontinue and add appropriate therapies, give a new care plan.

Source: Adapted from Weissman DE. “The Family Goal Setting Conference” and “Communication Phrases Near the End of Life” pocket cards from Medical College of Wisconsin.

Critical management

Withdrawal of ventilator support or “liberation from the ventilator”: a common step preceding death in the ICU.
- Preparation:
  - Ensure that “Do not resuscitate” (DNR)/“Do not intubate” (DNI) orders and paperwork are completed.
  - Ensure that the spiritual needs of patient and family are met, which may include completion of important religious rituals.
  - Chaplaincy or even physician instruction regarding end-of-life communication that expresses gratitude and forgiveness can be a helpful tool in allowing patients and families to achieve peace and closure (Table 67.2).
  - Discontinue unnecessary laboratory testing and therapies that are not supporting goals, such as artificial nutrition and hydration, vasopressors, and antibiotics.
- Premedication:
  - Glycopyrrolate 0.2 mg every 6 hours to minimize respiratory secretions.
- Procedure:
  - Turn off monitors as alarms will be distracting and the patient’s visible signs of discomfort, rather than vital signs, should guide management.
  - The ETT can be easily removed after cuff deflation.
  - Adequate analgesia and sedative medications should be available, either through continuous drips that can be titrated for symptom control or in prefilled syringes that be delivered as IV pushes at the bedside.
  - Dosing instructions: for patients already on opiate and benzodiazepine infusions, bolus doses used for dyspnea should be approximately double the hourly infusion rate (i.e., if fentanyl is infusing at 100 micrograms/hour, the patient should receive 200-microgram boluses every 10–15 minutes until comfort is achieved).
  - Oxygen does not need to be administered as it might prolong the patient’s dying process, and opiates can adequately palliate dyspnea.
  - Goal: no signs of respiratory distress and/or dyspnea, which would include gasping, accessory muscle use, or labored breathing.
- Prognosis:
  - If desired, families should be informed regarding the estimated survival time once ventilator support is discontinued, as this allows for adequate preparation and planning. Prognostic estimates should be communicated as time frames: minutes to hours, hours to days, or days to weeks.
  - Once ventilator support is removed, the median time to survival is just under an hour, though some patients may survive for days. Predictors of shorter survival include such variables as multi-organ failure, use of vasopressors, and brain death.
Other symptom considerations
- Terminal delirium:
  - This is common and easily treatable with antipsychotics.
  - Haldol 0.5–2 mg IV every 6 hours is an adequate dosing regimen for most patients.
- Pain:
  - Pain is common in critically ill patients.
  - Dying patients are often sedated and/or unable to communicate, so nonverbal cues such as grimacing, moaning, and restlessness should be used.
  - Opiates are the mainstay treatment. Dilaudid is preferred over morphine in patients with renal or liver failure.
Other considerations
- Transferring patients to the palliative care unit or inpatient hospice:
  - Hospitals are increasingly incorporating palliative care and hospice units into their institutions. These can be ideal settings for transitions from LST to comfort-focused care.
- Improving the family’s experience:
  - Families rate factors such as “preparation for death”; timely, compassionate communication; care maintaining comfort, dignity, and personhood; open access and proximity of the family to the patient; interdisciplinary care; and bereavement support as highly important in the setting of a dying patient.
  - Surprisingly, families of patients who have died rather than survived in the ICU show higher satisfaction with the care delivered.