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and caring in ways other than intrusive attempts at forced feeding or hydration
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Dying is not exclusively or even primarily a biomedical event It is an intimate personal experience with profound psychological, interpersonal, and existential meanings For many people at the end of life, the prospect of impending death stimulates a deep and urgent assessment of their identity, the quality of their relationships, and the meaning and purpose of their existence
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Requests from appropriately informed and competent patients or their surrogates for withdrawal of life-sustaining interventions must be respected In addition, clinicians may determine unilaterally that particular interventions are medically inappropriate eg, continuing renal dialysis in a patient dying of multiorgan failure In such cases, the clinician s intention to withdraw a specific intervention should be communicated to the patient and family If differences of opinion exist about the appropriateness of what is being done, the assistance of an institutional ethics committee should be sought Limitation of life support prior to death is an increasingly common practice in intensive care units The withdrawal of life-sustaining interventions such as mechanical ventilation must be approached carefully to avoid needless patient suffering and distress for those in attendance Clinicians should educate the patient and family about the expected course of events and the difficulty of determining the precise timing of death after withdrawal of support Sedative and analgesic agents should be administered to ensure patient comfort even at the risk of respiratory depression or hypotension Scopolamine (10 mcg/h subcutaneously or intravenously, or a 15-mg patch every 3 days) or atropine (1% ophthalmic solution, 1 or 2 drops sublingually as often as every hour) can be used for controlling airway secretions and the resultant death rattle A guideline for withdrawal of mechanical ventilation is provided in Table 5 8
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In 1969, Elisabeth K bler-Ross identified five psychological stages or patterns of emotions that patients at the end of life may experience: denial and isolation, anger, bargaining, depression, and acceptance Not every patient will experience all these emotions, and typically not in an orderly progression In addition to these five stages are the perpetual challenges of anxiety and fear of the unknown Simple information, listening, assurance, and support may help patients with these psychological challenges In fact, patients and families rank emotional support as one of the most important aspects of good end-of-life care Psychotherapy and group support may be beneficial as well Despite the significant emotional stress of facing death, clinical depression is not normal at the end of life and should be treated Cognitive and affective signs of depression (such as hopelessness) may help distinguish depression from the low energy and other vegetative signs common with end-stage illness Although traditional antidepressant treatments such as selective serotonin reuptake inhibitors are effective, more rapidly acting medications such as dextroamphetamine or methylphenidate may be particularly useful when the end of life is near or while waiting for other antidepressant medication to take effect
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Table 5 8 Guidelines for withdrawal of mechanical ventilation
1 Stop neuromuscular blocking agents 2 Administer opioids or sedatives to eliminate distress If not already sedated, begin with fentanyl 100 mcg (or morphine sulfate 10 mg) by intravenous bolus and infusion of fentanyl 100 mcg/h intravenously (or morphine sulfate 10 mg/h intravenously) Distress is indicated by RR > 24, nasal flaring, use of accessory muscles of respiration, HR increase > 20%, MAP increase > 20%, grimacing, clutching 3 Discontinue vasoactive agents and other agents unrelated to patient comfort, such as antibiotics, intravenous fluids, and diagnostic procedures 4 Decrease FiO2 to room air and PEEP to 0 cm H2O 5 Observe patient for distress If patient is distressed, increase opioids by repeating bolus dose and increasing hourly infusion rate by 50 mcg fentanyl (or 5 mg morphine sulfate),1 then return to observation If patient is not distressed, place on T piece and observe If patient continues without distress, extubate patient and continue to observe for distress
1 Ventilatory support may be increased until additional opioids have effect RR, respiratory rate; HR, heart rate; MAP, mean airway pressure; FiO2, fraction of inspired oxygen; PEEP, positive end-expiratory pressure Adapted, with permission, from San Francisco General Hospital Guidelines for Withdrawal of Mechanical Ventilation/Life Support
At the end of life, patients should be encouraged to discharge personal, professional, and business obligations This might include completing important work or personal projects, distributing possessions, writing a will, and making funeral and burial arrangements The prospect of death often prompts patients to examine the quality of their interpersonal relationships and to begin the process of saying goodbye (Table 5 9) Dying may intensify a patient s need to feel cared for by the doctor and the need for clinician empathy and compassion Concern about estranged relationships or unfinished business with sig-
Table 5 9 Five statements often necessary for the completion of important interpersonal relationships
(1) Forgive me (2) I forgive you (3) Thank you (4) I love you (5) Goodbye (An expression of regret) (An expression of acceptance) (An expression of gratitude) (An expression of affection) (Leave-taking)
Reprinted, with permission, from Byock I Dying Well: Peace and Possibilities at the End of Life New York: Riverhead Books, 1997
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