Question

How do you know when a person is approaching the last hours/days of his or her life? what tools can assist in diagnosing dying?

Answer 1

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In order to care for dying patients it is essential to “diagnose dying” (figure).7 However, diagnosing dying is often a complex process. In a hospital setting, where the culture is often focused on “cure,” continuation of invasive procedures, investigations, and treatments may be pursued at the expense of the comfort of the patient. There is sometimes a reluctance to make the diagnosis of dying if any hope of improvement exists and even more so if no definitive diagnosis has been made. When recovery is uncertain it is better to discuss this rather than giving false hope to the patient and family. This is generally perceived as a strength in the doctor-patient relationship and helps to build trust.

Recognising the key signs and symptoms is an important clinical skill in diagnosing dying. The dying phase for cancer patients can sometimes be precipitous—for example, massive haemorrhage—but is usually preceded by a gradual deterioration in functional status. In cancer patients, the following signs are often associated with the dying phase:

The patient becomes bedbound

The patient is semicomatose

The patient is able to take only sips of fluid

The patient is no longer able to take oral drugs.

This predictability of the dying phase is not always as clear in other chronic incurable diseases. Patients with heart failure highlight some of the complexities of diagnosing dying. Heart failure is the most common single cause of death in many hospital medical wards. The palliative care needs of these patients have, until recently, been largely ignored. However, the national service framework for coronary heart disease specifically requires cardiologists and others involved in the management of patients with heart failure to work with palliative care staff to use or adapt palliative care practices for their needs (see quotes on bmj.com).8

Care of the dying patient

Healthcare professionals are sometimes reluctant to diagnose dying, as they have not been trained to care for dying patients and therefore feel helpless. One example of this is the practice of transferring the patient to a side room and withdrawing from the patient and family, a strategy that has been used for many years, particularly in hospitals. However, this is the very moment when the hospice model of “intensive palliative care” should come into action, providing physical, psychological, social, and spiritual care for the patient and the relatives (box ​(boxB2)

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