special subjects
The Dying Patient
Advance Planning for Imminent Death
Planning for symptom relief as well as receiving patient and family support can help people deal with the most difficult parts of dying. When death is expected to occur at home, a hospice team typically provides drugs (a comfort kit) with instructions for how to use them to quickly suppress symptoms, such as pain or dyspnea. Family members should be told about changes that are likely during the dying process, including confusion, somnolence, irregular or noisy breathing, cool extremities, and purplish skin color. Planning can also help avert unnecessary, distressing hospital visits at the end of life. Family members should rehearse whom to call (eg, physician, hospice nurse, clergy) and know whom not to call (eg, ambulance service). Witnessing the last moments of a person's life can have a powerful, lasting effect on family, friends, and caregivers. The patient should be in an area that is peaceful, quiet, and physically comfortable. Clinicians should encourage family to maintain physical contact with the patient, such as holding hands. Hospice providers should inquire about and make accommodation for spiritual, cultural, ethnic, or personal rites of passage desired by the patient and family members. Families also often need help with burial or cremation services and arranging payment for them; social workers can provide information and advice. Regardless of setting (eg, home, hospital, nursing home, inpatient or home hospice), religious practices may affect care of the body after death and should be discussed in advance with the patient, family, or both. Decisions about organ donation and autopsy are usually best made before death because that is usually a less stressful time than immediately after death. 