Health Articles

The last moments of life can have a lasting effect on family, friends, and caregivers. The patient should be in an area that is peaceful and quiet and ensures physical comfort. Some patients close to death may develop noisy bronchial congestion or palatal relaxation, known as the death rattle. If this distresses the family, 0.4 mg of scopolamine or atropine can dry up the patient’s secretions and reduce the noise. Also, patients may develop CNS irritability, including agitation and restlessness, which can be relieved with a sedative.
Any stains or tubes on the bed should be covered, and odors should be masked. The family should be encouraged to maintain physical contact, such as holding hands, with the patient. Support personnel such as clergy or friends should be encouraged to be present, if the patient and family desire. If feasible and desired by the patient and family, cultural, spiritual, or ethnic rites of passage should be performed.

Grieving is a normal process that usually begins before an anticipated death. For the patient, it often starts with denial caused by fears about a loss of control, separation, and an uncertain future, as well as a fear of suffering. The staff can help patients accept the prognosis by listening to their concerns, helping them understand that they can remain in control, explaining what the future probably holds, and assuring them that their pain will be controlled.
The family may also need support in expressing grief. Any member of the health care team who has come to know the patient and family may help them through this process and direct them to professional services if needed. Physicians and others responsible for the care of dying persons need to develop regular procedures that ensure follow-up of grieving family members.

Approaching death is most stressful when it is unexpected or when interpersonal conflicts keep patient and family from snaring their last moments together. Such conflicts can lead to excessive guilt or an inability to grieve among survivors and can cause anguish for the patient. A family member who is taking care of a dying patient at home may also experience physical and emotional stress. The patient may have an altered body image and a loss of self-esteem, fears of abandonment and separation, anxieties, and feelings of hopelessness. Usually, stress in dying patients and families is best treated with compassion, information, counseling, and even time-limited psychotherapy. Sedatives should be used sparingly and only briefly.
When a partner in a marriage dies, the survivor may be overwhelmed by making decisions about legal or financial matters or managing the household. With an elderly couple, the death of one partner may reveal cognitive impairment in the survivor that the deceased spouse had compensated for. Stress is even greater if no support is extended by friends or other family members. Physicians should identify such high-risk situations so they can mobilize the resources needed to prevent undue suffering and dysfunction.
Effective care for the dying usually involves a team because no one caregiver can provide 24-h availability and several disciplines must be consulted to provide all skills and perspectives needed to help the patient. Palliative-care or hospice teams anticipate potential problems and make appropriate arrangements, such as obtaining supplies or narcotics in an emergency. With death impending, an experienced person can comfort the family and may prevent an inappropriate call to the emergency medical system brought on by panic. Dying patients often have spiritual needs that should be recognized, acknowledged, and with the help of one or several team members, addressed as part of the care plan.
Not everyone is at ease with dying patients, but those who choose to work with them find rewards in providing support to the family and comfort to the patient. Nurses who work in a hospice setting do not seem to experience the same degree of burnout that frequently occurs in settings such as oncology or intensive care units. However, staff members may become so involved with the patient or family that they grieve with them. This stressful involvement can be mitigated by a nurturing work environment or a staff support group that meets regularly to share responses to dying patients and their families. Physicians and others who work in less supportive environments may need to form similar support groups and find sources of guidance.

Most dying patients experience some depression. One patient may have many regrets about his life, while another may be preoccupied with legal, social, or financial problems. Providing psychologic support and allowing the patient to express concerns and feelings is the best and simplest course of action. Helping the patient and family settle any unresolved matters may decrease the level of anxiety. A skilled social worker, physician, or nurse can help with conflicts that distance the patient from family members.
Antidepressants should be reserved for patients who have persistent, clinically significant depression. Such patients may be helped by a low dose of an antidepressant once a day at bedtime. For anxiety, a sedating tricyclic should be used and supplemented as needed with another appropriate sedating agent. In the last weeks of life, a sedating antidepressant sometimes provides restful sleep while lifting the patient’s depression. Given the circumstance, the usual concerns about possible cardiac and neurologic effects are attenuated. Doxepin and trazodone may provide sedation with milder anticholinergic effects than ami-triptyline.
Withdrawn patients and those with vegetative signs may be helped by methylphenidate 5 to 10 mg once a day adjusted to individual response. This drug has a rapid onset and fewer adverse effects than most antidepressants; however, it may precipitate agitation.