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WikiDoc Resources for Death


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List of terms related to Death

In oncology, Death is defined as "Irreversible cessation of all bodily functions, manifested by absence of spontaneous breathing and total loss of cardiovascular and cerebral functions."[1]

The physician's perspective

A qualitative survey of internal medicine doctors in the United States found three sources of satisfaction from medical practice:

  1. realizing a fundamental change in perspective via an experience with a patient
  2. making a difference made in someone's life
  3. connecting with patients

The authors of the survey noted how often the meaningful events, such as connecting with patients, occurred at events, such as death, that normally suggest a failure of medical care.[2] The following research suggests factors associated with a meaningful death.

A qualitative study using focus groups that consisted of "physicians, nurses, social workers, chaplains, hospice volunteers, patients, and recently bereaved family members". The groups identified the following themes associated with a 'good death'.[3] The article is freely available and provides much more detail.

  1. Pain and Symptom Management. Patients want reassurance that symptoms, such as pain or shortness of breath that may occur at death, will be well treated.
  2. Clear Decision Making. According to the study, 'participants stated that fear of pain and inadequate symptom management could be reduced through communication and clear decision making with physicians. Patients felt empowered by participating in treatment decisions'.
  3. Preparation for Death. Patients wanted to know what to expect near death and to be able to plan for the events that would follow death.
  4. Completion. 'Completion includes not only faith issues but also life review, resolving conflicts, spending time with family and friends, and saying good-bye.'
  5. Contributing to Others. A family member noted, "I guess it was really poignant for me when a nurse or new resident came into his room, and the first thing he'd say would be, ‘Take care of your wife’ or ‘Take care of your husband. Spend time with your children.’ He wanted to make sure he imparted that there's a purpose for life."
  6. Affirmation of the Whole Person. 'They didn't come in and say, "I'm Doctor so and so." There wasn't any kind of separation or aloofness. They would sit right on his bed, hold his hand, talk about their families, his family, golf, and sports.'
  7. Distinctions in Perspectives of a Good Death

A separate study suggests that the patients' preferences will not be stable as death approaches and so the physician should consider re-evaluating these issues.[4]

End of life discussions

An observational study suggests that end-of-life discussions are an important component of the physician-patient relationship and are associated with better quality of life both for the patients and the patient's family after the patient's death.[5] Patients with 'high level of positive religious coping' may be more interested in prolonging life.[6]

A randomized controlled trial of communication between health care providers and family members at the time of death reported that the intervention decreased the burden of bereavement.[7] The intervention consisted of a brochure and family conference that focused on the following items that are remembered with the mnemonic value:

  • to Value and appreciate what the family members said
  • to Acknowledge the family members' emotions
  • to Listen
  • to ask questions that would allow the caregiver to Understand who the patient was as a person
  • to Elicit questions from the family members. Each investigator received a detailed description of the conference procedure

"Are you at peace?"

Although not mentioned in this study, other studies suggest most patients[8][9][10], patients would welcome discussion of spiritual or religious beliefs. This could be asked simply by:[11]

  • "Are you at peace"?

The discussion of being at peace can be expanded to[8]:

  • “at peace with God”
  • “at peace with my personal relationships”
  • “at peace with myself”

On saying good-bye

In an essay, 'On Saying Goodbye: Acknowledging the End of the Patient–Physician Relationship with Patients Who Are Near Death' suggestions are made to health care providers for saying good-bye to patients near death.[12] The quotes below are from the article. The article is freely available and provides much more detail.

  1. Choose an Appropriate Time and Place
  2. Acknowledge the End of Your Routine Contact and the Uncertainty about Future Contact The doctor could say, "You know, I'm not sure if we will see each other again in person, so while we are with each other now I want to say something about our relationship."
  3. Invite the Patient To Respond, and Use That Response as a Piece of Data about the Patient's State of Mind The authors suggest saying "Would that be okay?" or "how would you feel about that?"
  4. Frame the Goodbye as an Appreciation The authors suggest examples such as "I just wanted to say how much I've enjoyed you and how much I've appreciated your flexibility [or cooperation, good spirits, courage, honesty, directness, collaboration] and your good humor [or your insights, thoughtfulness, love for your family]."
  5. Give Space for the Patient to Reciprocate, and Respond Empathically to the Patient's Emotion If the patients becomes tearful, the doctor can provide silence to allow the patient to respond, or the doctor may ask about what the patient is feeling.
  6. Articulate an Ongoing Commitment to the Patient's Care Do not make the patient feel abandoned, "Of course you know I remain available to you and that you can still call me".
  7. Later, Reflect on Your Work with This Patient

Patients' wishes for end-of-life care may change over time.[13] For example, during hospitalization, patients may preference quality of life, but after discharge patients may preference survival over quality.[14]

Decision making can be assessed with the Aid to Capacity Evaluation (ACE).[15]

In a study in the United States, families and surrogates of critically ill patients did not want grave prognostic information withheld.[16]

Sedation at the end of life

Other difficult issues for physicians include providing sedation for a patient at death and discontinuing life support. Case reports detail these experiences from the physician's perspective.[17][18]

Withdrawing of life support

The experience for surviving family members may be better if life support is withdrawn, that its components be withdrawn sequentially rather than all at once. In addition, extubation of intubated patients before death is associated with more satisfaction.[19]

See also

External links


  1. Anonymous (2024), Death (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. Horowitz C, Suchman A, Branch W, Frankel R (2003). "What do doctors find meaningful about their work?". Ann Intern Med. 138 (9): 772–5. PMID 12729445.
  3. Steinhauser K, Clipp E, McNeilly M, Christakis N, McIntyre L, Tulsky J (2000). "In search of a good death: observations of patients, families, and providers". Ann Intern Med. 132 (10): 825–32. PMID 10819707.
  4. Fried TR, O'leary J, Van Ness P, Fraenkel L (2007). "Inconsistency over time in the preferences of older persons with advanced illness for life-sustaining treatment". Journal of the American Geriatrics Society. 55 (7): 1007–14. doi:10.1111/j.1532-5415.2007.01232.x. PMID 17608872.
  5. Wright, Alexi A. (2008-10-08). "Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment". JAMA. 300 (14): 1665–1673. doi:10.1001/jama.300.14.1665. Retrieved 2008-10-08. Unknown parameter |coauthors= ignored (help)
  6. Phelps AC, Maciejewski PK, Nilsson M; et al. (2009). "Religious coping and use of intensive life-prolonging care near death in patients with advanced cancer". JAMA. 301 (11): 1140–7. doi:10.1001/jama.2009.341. PMID 19293414. Unknown parameter |month= ignored (help)
  7. Lautrette A, Darmon M, Megarbane B, Joly LM, Chevret S, Adrie C et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med. 2007 February 1;356(5):469-78. PMID 17267907
  8. 8.0 8.1 Ehman JW, Ott BB, Short TH, Ciampa RC, Hansen-Flaschen J (1999). "Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill?". Arch. Intern. Med. 159 (15): 1803–6. PMID 10448785.
  9. MacLean CD, Susi B, Phifer N; et al. (2003). "Patient preference for physician discussion and practice of spirituality". J Gen Intern Med. 18 (1): 38–43. PMC 1494799. PMID 12534762. Unknown parameter |month= ignored (help)
  10. Post SG, Puchalski CM, Larson DB (2000). "Physicians and patient spirituality: professional boundaries, competency, and ethics". Ann. Intern. Med. 132 (7): 578–83. PMID 10744595. Unknown parameter |month= ignored (help)
  11. Steinhauser KE, Voils CI, Clipp EC, Bosworth HB, Christakis NA, Tulsky JA (2006). ""Are you at peace?": one item to probe spiritual concerns at the end of life". Arch. Intern. Med. 166 (1): 101–5. doi:10.1001/archinte.166.1.101. PMID 16401817. Unknown parameter |month= ignored (help)
  12. Back A, Arnold R, Tulsky J, Baile W, Fryer-Edwards K (2005). "On saying goodbye: acknowledging the end of the patient-physician relationship with patients who are near death". Ann Intern Med. 142 (8): 682–5. PMID 15838086.
  13. Wittink MN, Morales KH, Meoni LA; et al. (2008). "Stability of preferences for end-of-life treatment after 3 years of follow-up: the Johns Hopkins Precursors Study". Arch. Intern. Med. 168 (19): 2125–30. doi:10.1001/archinte.168.19.2125. PMID 18955642. Unknown parameter |month= ignored (help)
  14. Stevenson LW, Hellkamp AS, Leier CV; et al. (2008). "Changing preferences for survival after hospitalization with advanced heart failure". J. Am. Coll. Cardiol. 52 (21): 1702–8. doi:10.1016/j.jacc.2008.08.028. PMID 19007689. Unknown parameter |month= ignored (help)
  15. Sessums LL, Zembrzuska H, Jackson JL (2011). "Does this patient have medical decision-making capacity?". JAMA. 306 (4): 420–7. doi:10.1001/jama.2011.1023. PMID 21791691.
  16. Apatira L, Boyd EA, Malvar G; et al. (2008). "Hope, truth, and preparing for death: perspectives of surrogate decision makers". Ann. Intern. Med. 149 (12): 861–8. PMID 19075205. Unknown parameter |month= ignored (help)
  17. Edwards M, Tolle S (1992). "Disconnecting a ventilator at the request of a patient who knows he will then die: the doctor's anguish". Ann Intern Med. 117 (3): 254–6. PMID 1616221.
  18. Petty T (2000). "Technology transfer and continuity of care by a "consultant"". Ann Intern Med. 132 (7): 587–8. PMID 10744597.
  19. Gerstel E, Engelberg RA, Koepsell T, Curtis JR (2008). "Duration of withdrawal of life support in the intensive care unit and association with family satisfaction". Am. J. Respir. Crit. Care Med. 178 (8): 798–804. doi:10.1164/rccm.200711-1617OC. PMID 18703787. Unknown parameter |month= ignored (help)