Care of the Dying Patient and Their Family

Dr. PK Sachan, Professor and Head of the Department of Surgery, HIHT, Dehradun, India

  Friday, February 24^th, 4:00pm, HIHT

 There are new challenges to the oncology team.  How do we care for the terminally ill patient and best use palliative care versus the familiar curative care approach. 

 These challenges include:

1.     Medicalization of death—people rushing to the hospital and having unrealistic expectations for those terminally ill.

2.     Hospitals are run like a business—noisy, no place to discuss and reflect on these deeper issues surrounding dying.

3.     Lack of awareness and lack of education of staff—newly trained staff lack training in palliative medicine, management skills are poor

4.     Poor symptom control of pain—under or over control of pain symptoms, not dealing with side effects of management.

5.     Changing trajectory of disease—better health care giving rise to improved long term survival and how to handle the problems that arise.

6.     Difficult to give an accurate prognosis

7.     Communication gap between staff, patients and other disciplines in speaking among each other.

8.     Lack of planning due to poor information given and received from families and patients.

9.     Death is considered a taboo—

(Int J Clin Pract 2009.  63 (3):508-515.)

Planning the care of the terminally ill patient is important.  Discuss the prognosis properly.  Don’t make predictions.  Meet with others in the team who are the seniors for more information.  Don’t be extreme, nor overly optimistic.  Look at the statistics for each problem.  Explain these statistics and course of the disease to the family so they can make a good decision.  Explain the events that will happen and the best form of timely treatment.

There are barriers that inhibit advanced care planning.  Does the doctor lack curiosity—is the doctor more concerned with only diagnosis and medical/surgical treatment.  Has the doctor learned about the patient’s hopes, likes and dislikes and general life that has been lived and now will be ending?  How to best support this patient?  Does the doctor emphasize curing the disease or helping to heal the patient who has a terminal disease?  How does the doctor inform the children?  If the parent is dying, find out who in the family/village that is closest to this child.  What are the cultural and religious considerations of the patient and the family?

There are many considerations to palliative care:  relieve pain and symptoms, consider that dying is normal, do not hasten or delay the process, utilize proper support and integrate other services, use a team approach to coordinate and manage the program properly.

Patients want relief of their suffering.  Try to optimize their physical comfort, maintain proper management and prepare for their death.

There are multiple problems and systems that must be managed: Insomnia, fatigue, psychological problems, respiratory problems, bleeding and GI disorders

Consider sources of distress that come from the family and finances.  Be attentive to spiritual concerns and prepare for the final days (patient/family comfort and staff support).  Prepare to deal with grief and bereavement of all concerned.