The Last 48 Hours of Life
James L Hallenbeck, MD
Assistant Professor of Medicine, Stanford University
Director of Palliative Care Services, VA Palo Alto HCS
Topics to Discuss
Signs and Symptoms in Last 48 hours
 Coaching of Family
 A physician’s checklist
 Death Pronouncement
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Self-assessed Knowledge Rating
Study
N=27
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Most physicians lack knowledge about the
physical changes of dying
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On a scale of 1-5, the mean self-assessed
knowledge rating of interns on physical changes
of dying was 1.70
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The lowest score of 6 items rating clinical
expertise
Hallenbeck and Bergen, 1999
J. Palliative Medicine
N=100 Cancer pts.
Signs of Impending Death
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Respiratory Secretions (Death rattle)
 Median time PTD 23h (82h SD)
Respirations with mandibular movement
 Time PTD 2.5h (18h SD)
Cyanosis/mottling
 Time PTD 1.0h (11 SD)
Lack of radial pulse
 Time PTD 1.0h (4.2 SD)
Morita 1998
Symptoms and Signs
in the Last 24-48 Hours
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Symptom
Noisy, moist breathing
Urinary incontinence
Urinary retention
Pain
Restlessness, agitation
Dyspnea
Nausea, vomiting
Sweating
Jerking, twitching
Confusion
Percent
56
32
21
42
42
22
14
14
12
08
N = 200 cancer patients in hospice
Lichter and Hunt, 1990
Differences Between Cancer and
Non-Cancer Diagnoses

Cancer
 Pain 40-100%
 Dyspnea 22-46%
 More predictable
dying trajectory

Non-Cancer
 Pain ~ 42%
 Dyspnea ~ 62%
 Less predictable
dying trajectory
Sense/desire
Family loss
Coaching
Hunger
Nurturing
Other ways to
nurture
Mouth moist
Thirst
Nurturing
Speech
Communication Can still hear…
Vision
Being seen
Hearing
Being heard
Touch
Physical
presence
May be
conscious
Can still feel…
Transition to
‘non-physical’
relationship
Terminal Syndrome
Characterized by Retained
Secretions
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Lack of cough

Multi-system shut-down
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Not always associated with dyspnea
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Vigorous hydration may flood lungs
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Deep suctioning is generally ineffective
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Role of IV and antibiotics is controversial
Physician Checklist
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Treatment
 Switch essential medications to non-oral route
 Stop unnecessary medications, procedures, monitoring
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Evaluate for new symptoms
 Pain, dyspnea, urinary retention, agitation, respiratory
secretions
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Family: Contact, engage, educate, facilitate relationship
with dying patient, console

Yourself
 Bear witness
Death Pronouncement
Death – not a difficult diagnosis
 No need for “pupil exam, assessment for
pain”
 Pronouncement – more than a set of
bureaucratic tasks – a cultural ritual
 Rarely modeled by senior staff or attending
physicians
 Teachable skills exist
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Death Pronouncement Skills
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Anticipate impending death and prepare family
If called, inquire re circumstances
 family present/not, anticipated/not
If family present, assess ‘where they are’
 Already grieving or need ritual to believe
person has died
‘Sacred silence’
Console
Next steps
Self-care
Death Pronouncement by Phone
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Avoid if possible
Identify where recipient of news is
 home, on freeway, alone or not
Often, like bad news, ‘advance alert’
Slow recipient DOWN, NOT – “you must come
right in away”
Identify contact person at hospital
 “Ask for Dr. … or Nurse …
Summary
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“Don’t worry, you will all die successfully!”
Sogyal Rinpoche
If there is a sacred moment in the life-cycle, other
than a birth, it is a death
As with a birth, families will long remember, how
a person died and how we helped or did not
We need to re-learn how to coach patients and
families through their last 24 hours