Holle Janeski, D.O., F. A.C.O.I.
March 12, 2015
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Sequence of events and progression of
disease
What happens when the body shuts down
When does care of a patient become nonbeneficial
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In 2000 the life
expectancy in our
patients is 80 for
women and 74 for
males
In the 1900’s life expectancy was
49 years old…sudden death
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In 2050 the life
expectancy will
increase to 84 for
women and 80 for men
Increasing life expectancy means
coping with serious chronic
illnesses…slow death
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Families struggle with managing pain and
symptoms
Coordination of care among multiple
providers and settings
Ensure that treatments reflect preferences
and benefits outweigh the harm
Achieve empathetic communication and care
Fostering well-being (spiritual concerns)
Maintain function
Support family and caregivers throughout
illness and bereavement
CANCER
CONGESTIVE HEART FAILURE
COPD
DEMENTIA
Cancer patients
experience a predictable
decline and are often
served by hospice in the
final weeks.
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CHF and COPD patients have impaired
function punctuated by unpredictable,
severe illness and rather sudden
death.
Rarely have hospice involved.
 Dementia
patients have prolonged
decline and often reside in
nursing homes.
 Rarely
utilize hospice care in the
nursing home due to financial
constraints for family.
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Loss of Appetite: Energy needs decline. The
patient may resist food of any kind…even
their favorite.
Near the end the dying person may be
physically unable to swallow
How to respond: Do not force feed.
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Excessive fatigue and sleep: the patient begins to
sleep the majority of the day and night.
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They may be difficult to rouse from sleep.
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Awareness of immediate surroundings decreases
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How to respond: Permit sleep. Assume,
however, that everything you say can be heard.
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Increased physical weakness: A decline in
food intake and lack of energy leads to less
energy, even for activities like lifting one's
head or shifting in bed. The person may even
have difficulty sipping from a straw
How to respond: Focus on keeping the person
comfortable.
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Mental confusion or disorientation: Organs
begin to fail, including the brain. The person
may not be aware of where he or she is or
who else is in the room, may speak or reply
less often, may respond to people who can't
be seen in the room by others.
How to respond: Remain calm and reassuring.
Speak to the person softly, and identify
yourself when you approach.
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Labored breathing: Breath intakes and
exhales become raggedy, irregular, and
labored.
Sometimes excessive secretions create loud,
gurgling inhalations and exhalations that
some people call a "death rattle."
How to respond: The stopping of breath or
loud rattle can be alarming to listeners, but
the dying person is unaware of this changed
breathing; focus on overall comfort.
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Social withdrawal: As the body shuts down,
the dying person may gradually lose interest
in those nearby.
A few days before receding socially for the
last time, the dying person sometimes
surprises loved ones with an unexpected
burst of alert, attentive behavior.
How to respond: Be aware that this is a
natural part of the dying process and not a
reflection of your relationship.
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Changes in urination: Little going in means
little coming out. Dropping blood pressure,
which is part of the dying process (and
therefore not treated at this point), also
contributes to the kidneys shutting down.
The concentrated urine is brownish, reddish,
or tea-colored.
How to respond: Hospice medical staff
sometimes decides that a catheter is
necessary.
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Swelling in the feet and ankles: As the kidneys
are less able to process bodily fluids, they can
accumulate and get deposited in areas of the
body away from the heart, in the feet and ankles
especially. These places, and sometimes also the
hands, face, or feet, take on a swollen, puffy
appearance.
How to respond: Usually no special treatment
(such as diuretics) is given when the swelling
seems directly related to the dying process. (The
swelling is the result of the natural death
process, not its cause.)
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Coolness in the tips of the fingers and toes: In
the hours or minutes before death, blood
circulation draws back from the periphery of the
body to help the vital organs. As this happens,
the extremities (hands, feet, fingers, toes)
become notably cooler. Nail beds may also look
more pale, or bluish.
How to respond: A warm blanket can keep the
person comfortable, or he or she may be
oblivious. The person may complain about the
weight of coverings on the legs, so keep them
loose.
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Mottled veins: Skin that had been uniformly
pale or ashen develops a distinctive pattern
of purplish/reddish/bluish mottling as one of
the later signs of death approaching. This is
the result of reduced blood circulation. It may
be seen first on the soles of the feet.
How to respond: No special steps need to be
taken.
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Food for thought…last sign of end of life:
Smoke or vapor from the mouth???
How to respond: Pray for the soul!!
Often called
“futile care”
Patient: Has fear of death
Family: “do everything
possible” and “spare no
expense” even if it is clear
that the patient will not
recover
Physician: “I’ll save this
patient”
Mechanical ventilation employed on a
patient in a permanent vegetative state.
Attempting CPR on a terminally ill
cancer patient whose death is imminent
and experiencing unremitting
pain/discomfort or is under heavy
sedation.
Tube-feeding in a patient with multiple
organ failure whose condition is
irreversible.
A situation where either the likelihood
of benefiting the patient is so small as
to be unrealistic or the quality of the
benefit gained is so minimal that the
healing goals of medicine are not
being achieved.
There is judgment in futility and it requires a
value decision. We must decide when to stop
“doing things to” patients and start “doing things
for” patients.
When a patient or family member insists on continuing
futile treatments, the health care team has no
obligation to provide such treatments.
Providing futile treatments often violates the health
care provider’s duty not to harm.
The use of futile treatments should be avoided
because it wastes society’s resources.
 Do not abandon the patient or the family.
Offer comfort and support to patients and
loved ones.
 Small acts: hold patient’s hand, moisten
lips, talking and listening to patient and
loved ones.
Rather than view the end of life as a medical
failure, health care professionals should
instead regard death as a planned-for and
natural event.
Rather than understanding the impending loss
of a loved one as an occasion to defy death,
family, clergy, and friends should instead help
patients and family to face death with courage
and dignity.
Questions???