End-of-Life Care, the Imminently Dying Patient, and Bereavement
Recognizing dying
Look for profound weakness, bedbound status, reduced oral intake, decreased urine output, mottled extremities, Cheyne–Stokes respiration, and altered consciousness. These signs are expected and should be explained to families as part of the dying process, not as failures. The Palliative Performance Scale and clinical gestalt help; the surprise question can prompt hospice referral.
Comfort-focused care
Stop non-beneficial medications such as statins, antihypertensives, glucose-lowering agents, and routine laboratory testing. Continue analgesics, anxiolytics, antisecretory agents, and bowel and bladder comfort measures. For terminal secretions, reposition and use glycopyrrolate or scopolamine; suctioning is uncomfortable and usually ineffective. Treat terminal delirium with haloperidol; reserve benzodiazepines for withdrawal or severe agitation. Opioids titrated to symptoms are appropriate for dyspnea and pain, and families should be told the goal is comfort.
Hospice
The Medicare hospice benefit covers routine home care, continuous home care, general inpatient care, and respite care for patients with a prognosis of six months or less if the disease runs its usual course. Certification by two physicians is required at the start of care.
Bereavement
Grief is individual and culturally shaped. Risk factors for complicated grief include sudden or traumatic death, poor social support, prior losses, and caregiver burden. Prolonged grief disorder is diagnosed at 12 months with persistent yearning and functional impairment. Offer condolence contact and bereavement follow-up.
Worked example
A daughter asks whether stopping tube feeds 'starved' her father. Explain that in dying the body cannot use nutrition, that appetite loss is part of the process, and that mouth care and comfort are the priorities.