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Palliative care: The last hours and days of life

Authors
F Amos Bailey, MD
Stephanie M Harman, MD, FACP
Section Editors
Eduardo Bruera, MD
Robert M Arnold, MD
Deputy Editor
Diane MF Savarese, MD

INTRODUCTION

Patients in the last days/hours of life often have unrelieved physical suffering, as well as significant emotional, spiritual, and social distress. Recognizing that a person is entering the imminently dying or terminal phase of their illness is critical to appropriate care planning, with a shift to comfort care. Defining when this phase begins is not always straightforward. Patients at the end of life are frequently not recognized as dying. As a result, suffering may not be properly appreciated or managed, and the patient’s overall condition may even be exacerbated by the continuation of standard medical care.  

The modern hospice movement was established partly in response to the poor quality of care of the dying patient. Hospice is a health care delivery system under which support and services are provided to a patient with a terminal illness when curative or life-prolonging therapy is no longer indicated, and the focus is on comfort rather than cure. Hospice care focuses on the management of pain and other symptoms while addressing other forms of distress such as spiritual distress, psychosocial stressors, and existential angst. Given their excellence in care during the last days and hours of life, hospice programs can help individuals have a “good death” and lead to higher family satisfaction with the quality of care the patient receives. (See "Hospice: Philosophy of care and appropriate utilization in the United States".)

Palliative care is an interdisciplinary medical specialty that focuses on preventing and relieving suffering as well as supporting the best possible quality of life for patients and their families facing serious illness. While all care that is delivered by hospice can be considered palliative care, not all palliative care delivered is in hospice. Palliative care can be appropriately offered to patients at any time along the trajectory of any type of serious life-threatening illness, even concurrent with restorative, life-prolonging therapies. (See "Benefits, services, and models of subspecialty palliative care" and "Hospice: Philosophy of care and appropriate utilization in the United States".)

Despite the benefits of palliative and hospice care, many patients in the terminal stages of a serious life-threatening illness die in settings where they do not receive care designed to address suffering in the last hours of life. Providing care to actively dying patients presents unique challenges for the clinician. Patients in their final days require careful symptom management, and families need support and coaching as death approaches. Care does not end with the death of the patient but continues through death pronouncement, family notification of the death, and bereavement support.

This topic review will cover management of patients with a terminal disease who are in the final days to hours of life. The comprehensive patient assessment and symptom assessment for palliative care patients, as well as an overview of managing pain and common non-pain symptoms in palliative care patients and issues surrounding stopping enteral and parenteral nutrition and hydration and ventilatory support are addressed in detail elsewhere. (See "Overview of comprehensive patient assessment in palliative care" and "Approach to symptom assessment in palliative care" and "Pain assessment and management in the last weeks of life" and "Overview of managing common non-pain symptoms in palliative care" and "Stopping artificial nutrition and hydration at the end of life" and "Withholding and withdrawing ventilatory support in adults in the intensive care unit" and "Palliative care delivery in the home".)

                                        

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Literature review current through: Nov 2016. | This topic last updated: Fri Nov 11 00:00:00 GMT 2016.
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