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11. Dying: The Last Month
- Hong Kong University Press, HKU
- Chapter
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11 Dying: The Last Month RaymondSeeKitLO The Dying Phase Good comfort care for dying patients at the final stage of life is crucial, thoug h of cours e palliativ e car e doe s no t begi n onl y from th e countdow n o f th e patient's last month. Palliative care should commence right from th e momen t of the diagnosi s of any incurable illnes s that is expected t o deteriorat e wit h inexorable progression . I t i s essentia l t o ensur e earl y integratio n o f th e palliative car e component , wit h a smooth transitio n fro m a n activ e curativ e intent t o a palliative emphasis . Indeed , i t has been recentl y advocate d tha t palliative car e should begi n eve n at the pre-diagnostic phase , when cance r is suspected pendin g confirmation. 1 Regardles s a t which poin t o f th e diseas e trajectory palliativ e care is started, patients in th e last month o f life stil l fac e difficult problem s and new concerns and need our utmost care and attention . As a patient enters the dying phase, worsening physical, psychological, social, and spiritua l distres s ma y be presen t an d shoul d b e anticipate d b y healt h professionals an d care-givers . However, the dying phase may be abrupt and cannot always be predicte d by staff an d carers. 2 Sudden condition s e.g. , haemorrhage int o intracerebra l metastases, massive pulmonary embolism , and acute bleeding from advance d head an d nec k tumour s ar e onl y several problems amon g man y tha t coul d lead t o a rapid, unexpecte d declin e o f the patient . Further , diagnosin g th e dying phase can be more difficul t tha n i t appears to be. This is especially tru e in non-cance r conditions , whe n th e progres s o f th e diseas e i s less easil y predictable.2 For example , in advance d hear t failure o r pulmonary diseases , reversible causes such as arrhythmia, anaemia or infection ma y be present an d amenable t o correction . Notwithstandin g suc h difficult y an d challenges , experienced clinician s can still be accurate in identifying thos e patients in th e dying phase whose prognosis is going t o be poor, despit e optima l therapy . Recognition of clinical deterioration o f palliative care patients of the older age group especially requires skill and expertise.3 Symptoms in elderly people 152Raymond See KitLO are frequently non-specifi c an d atypical . For example , life-threatening sepsi s can presen t wit h just increasin g confusio n i n a n elderl y perso n wit h a background o f cognitive impairment. Symptoms of malignant hypercalcaemi a are ofte n non-specifi c an d ca n b e easil y overlooked . Malignan t cor d compression ma y not be immediately obvious in an elderly patient already deconditioned wit h le g weakness. Diagnosing th e final deterioratin g phas e i n the elderl y patient necessitates even mor e cautio n an d alertness . ComingtoTermswiththeDyingPhase In addition t o the various clinical challenges, other barriers exist in decision making in the diagnosis of the dying phase. Health-care professionals ma y be reluctant for variou s reasons.2 Different tea m member s may not always be i n consensus about a patient's condition and prognosis. Some may find it difficul t to le t go , an d continu e t o pursu e futil e interventions . Other s ma y b e concerned about ethical issues such as withholding and withdrawing treatment . There ma y als o b e som e wh o ar e uncomfortabl e communicatin g wit h th e patient an d famil y o n th e matte r o f death an d dying . These barriers ma y be especially difficult t o overcome in an acute care setting, where intensive effor t to search for a cure i s the usual aim . The sam e barriers would also be found i n the close relatives of our dyin g patients. If...