J Korean Med Assoc.  2009 Jul;52(7):697-704. 10.5124/jkma.2009.52.7.697.

The Last Hours of Living: Practical Advice for Clinicians

• Kim JH
• Choi YS

• KMID: 2188030
• DOI: http://doi.org/10.5124/jkma.2009.52.7.697

Abstract

Caring for a patient dying is a hardship not only for the health care professionals, but also for the direct family members. Everyone wants to die in peace. However, inevitable problems accompanied by pain, dyspnea, moist breathing, nausea and vomiting, restlessness jerking and twitching were commonly noted in the last phase of life. Terminal patients also experience increasing weakness and immobility, loss of interest in food and drink, difficulty in swallowing, and drowsiness during the last hours of life. Control of symptoms and family support are extremely important, and the actual nature of the primary illness takes less importance. This is a time when levels of anxiety, stress, and emotion can be high for patients, families, and other caregivers. Thus, it is important for the healthcare team to adopt sensitive and systematic approach to patients including documentation and communication of end-of-life issues. Hospice is the most ideal program for this purpose.

Keyword

The last hours of living; Dying patient; Communication; Hospice

MeSH Terms

Anxiety
Caregivers
Deglutition
Delivery of Health Care
Dyspnea
Hospices
Humans
Nausea
Patient Care Team
Psychomotor Agitation
Respiration
Sleep Stages
Vomiting

Reference

1. Thompsona G, Chochinov H. Dignity-based approaches in the care of terminally ill patients. Curr Opin Support Palliat Care. 2008. 2:49–53.

2. National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for quality palliative care, executive summary. J Palliat Med. 2004. 7:611–627.

3. Sullivan AM, Lakoma MD, Matsuyama RK, Rosenblatt L, Arnold RM, Block SD. Diagnosing and discussing imminent death in the hospital: a secondary analysis of physician interviews. J Palliat Med. 2007. 10:882–893.

4. Brandt HE, Ooms ME, Deliens L, van der Wal G, Ribbe MW. The last two days of life of nursing home patients a nationwide study on causes of death and burdensome symptoms in The Netherlands. Palliat Med. 2006. 20:533–540.

5. Koh SJ, Lee KS, Hong YS, Yoo YS, Park HJ. Clinical Change of Terminally Ill Cancer Patients at the End-of-life Time. Korean J Hosp Palliat Care. 2008. 11:99–105.

6. Doyle-Brown M. The transitional phase: the closing journey for patients and family caregivers. Am J Hosp Palliat Care. 2000. 17:354–357.

7. Knauft E, Nielsen EL, Engelberg RA, Patrick DL, Curtis JR. Barriers and facilitators to end-of-life care communication for patients with COPD. Chest. 2005. 127:2188–2196.

8. Paul JM. Death-Talks: Transformative Learning for Physicians. Am J Hosp Palliat Care. 2008. 25:271–277.

9. Pitorak EF. Care at the time of death. Am J Nurs. 2003. 103:42–52. quiz 3.

10. Abrahm Janet I. A physician's guide to Pain and Symptom Management in Cancer Patients. 2005. 2nd ed. The John's Hopkins University Press.

11. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA. 1999. 282:1365–1370.

12. American College of Physicians. Parenteral nutrition in patients receiving cancer chemotherapy. Ann Intern Med. 1989. 110:734–736.

13. McCann RM, Hall WJ, Groth-Juncker A. Comfort care for terminally ill patients. The appropriate use of nutrition and hydration. JAMA. 1994. 272:1263–1266.

14. Ferris FD, von Gunten CF, Emanuel LL. Competency in endof-life care: last hours of life. J Palliat Med. 2003. 6:605–613.

15. Lawlor PG, Gagnon B, Mancini IL, Pereira JL, Hanson J, Suarez-Almazor ME, Bruera ED. Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. Arch Intern Med. 2000. 160:786–794.

16. White C, McCann MA, Jackson N. First do no harm. Terminal restlessness or drug-induced delirium. J Palliat Med. 2007. 10:345–351.

17. Brajtman S, Higuchi K, McPherson C. Caring for patients with terminal delirium: palliative care unit and home care nurses' experiences. Int J Palliat Nurs. 2006. 12:150–156.

18. de Graeff A, Dean M. Palliative sedation therapy in the last weeks of life: a literature review and recommendations for standards. J Palliat Med. 2007. 10:67–85.

19. Lonergan E, Britton AM, Luxenberg J, Wyller T. Antipsychotics for delirium. Cochrane Database Syst Rev. 2007. CD005594.

20. Stirling LC, Kurowska A, Tookman A. The use of phenobarbitone in the management of agitation and seizures at the end of life. J Pain Symptom Manage. 1999. 17:363–368.

21. Caraceni A, Simonetti F. Palliating delirium in patients with cancer. Lancet Oncol. 2009. 10:164–172.

22. Thomas JR, von Gunten CF. Clinical management of dyspnoea. Lancet Oncol. 2002. 3:223–228.

23. Del Fabbro E, Dalal S, Bruera E. Symptom control in palliative care-Part III: dyspnea and delirium. J Palliat Med. 2006. 9:422–436.

24. Bruera E, Sala R, Spruyt O, Palmer JL, Zhang T, Willey J. Nebulized versus subcutaneous morphine for patients with cancer dyspnea: a preliminary study. J Pain Symptom Manage. 2005. 29:613–618.

25. Navigante AH, Cerchietti LC, Castro MA, Lutteral MA, Cabalar ME. Midazolam as adjunct therapy to morphine in the alleviation of severe dyspnea perception in patients with advanced cancer. J Pain Symptom Manage. 2006. 31:38–47.

26. Grond S, Zech D, Schug SA, Lynch J, Lehmann KA. Validation of World Health Organization guidelines for cancer pain relief during the last days and hours of life. J Pain Symptom Manage. 1991. 6:411–422.

27. Cancer Pain Management Guideline. Ministry for health, welfare and family affair. 2008. 3rd ed. www.cancer.go.kr.

28. Hagen NA, Fisher K, Stiles C. Sublingual methadone for the management of cancer-related breakthrough pain: a pilot study. J Palliat Med. 2007. 10:331–337.

29. Bennett MI. Death rattle: an audit of hyoscine (scopolamine) use and review of management. J Pain Symptom Manage. 1996. 12:229–233.

30. Morita T, Tsunoda J, Inoue S, Chihara S. Risk factors for death rattle in terminally ill cancer patients: a prospective exploratory study. Palliat Med. 2000. 14:19–23.

31. Wildiers H, Menten J. Death rattle: prevalence, prevention and treatment. J Pain Symptom Manage. 2002. 23:310–317.

32. Wee BL, Coleman PG, Hillier R, Holgate SH. The sound of death rattle I: are relatives distressed by hearing this sound? Palliat Med. 2006. 20:171–175.

33. Wee BL, Coleman PG, Hillier R, Holgate SH. The sound of death rattle II: how do relatives interpret the sound? Palliat Med. 2006. 20:177–181.

34. Wee B, Hillier R. Interventions for noisy breathing in patients near to death. Cochrane Database Syst Rev. 2008. CD005177.

35. Back IN, Jenkins K, Blower A, Beckhelling J. A study comparing hyoscine hydrobromide and glycopyrrolate in the treatment of death rattle. Palliat Med. 2001. 15:329–336.

36. Hugel H, Ellershaw J, Gambles M. Respiratory tract secretions in the dying patient: a comparison between glycopyrronium and hyoscine hydrobromide. J Palliat Med. 2006. 9:279–284.

37. Likar R, Rupacher E, Kager H, Molnar M, Pipam W, Sittl R. [Efficacy of glycopyrronium bromide and scopolamine hydrobromide in patients with death rattle: a randomized controlled study]. Wien Klin Wochenschr. 2008. 120:679–683.

38. Bickel K, Arnold RM. Death rattle and oral secretions--second edition #109. J Palliat Med. 2008. 11:1040–1041.

39. Ganzini L, Goy ER, Miller LL, Harvath TA, Jackson A, Delorit MA. Nurses' experiences with hospice patients who refuse food and fluids to hasten death. N Engl J Med. 2003. 349:359–365.

40. Georges JJ, Onwuteaka-Philipsen BD, van der Heide Heide, van der Wal G, van der Maas PJ. Symptoms, treatment and "dying peacefully" in terminally ill cancer patients: a prospective study. Support Care Cancer. 2005. 13:160–168.

41. Smith JL. Schonwetter RS, editor. The Process of Dying and Managing the Death Event. Hospice and Palliative Medicine: Core Curriculum and Review Syllabus. American Academy of Hospice and Palliative Medicine. 1999. Iowa: Kendall/Hunt Publishing Company;159–166.