In medicine, nursing and the allied health professions, end-of-life care refers to health care, not only of patients in the final hours or days of their lives, but more broadly care of all those with a terminal illness or terminal condition that has become advanced, progressive and incurable.
End-of-life care requires a range of decisions, including questions of palliative care, patients' right to self-determination (of treatment, life), medical experimentation, the ethics and efficacy of extraordinary or hazardous medical interventions, and the ethics and efficacy even of continued routine medical interventions. In addition, end-of-life often touches upon rationing and the allocation of resources in hospitals and national medical systems. Such decisions are informed both by technical, medical considerations, economic factors as well as bioethics. In addition, end-of-life treatments are subject to considerations of patient autonomy. "Ultimately, it is still up to patients and their families to determine when to pursue aggressive treatment or withdraw Life support ."
Estimates show that about 27% of Medicare's annual $327 billion budget ($88 billion) in 2006 goes to care for patients in their final year of life. It represents 22% of all medical spending in the United States, 18% of all non-Medicare spending, and 25 percent of all Medicaid spending for the poor.
The Congress of the USA had hoped that the 1991 Patient Self Determination Act together with the 1986 Hospice Care Entitlement that is reimbursed by Medicare would greatly reduce expensive end-of-life care in Intensive Care and Critical Units of US Acute Care Hospitals when elderly/disabled terminal patients on Medicare would freely choose to shorten their lives to shorten their suffering from terminal illnesses and die in their own personal residences or in nursing-home residences. However, since the physicians and for-profit clinics were not placed under the provisions of the 1991 PSDA and the states didn't implement the goals of the 1991 PSDA in state laws, the Hospice Entitlement paid for out of the Medicare Purse has failed to achieve the savings anticipated in the 1991 PSDA.
End of life care has been identified by the UK Department of Health as an area where quality of care has previously been "very variable", and which has not had a high profile in the NHS and social care. To address this, a national end of life care programme was established in 2004 to identify and propagate best practice, and a national strategy document published in 2008. The Scottish Government has also published a national strategy.
In 2006 just over half a million people died in England, about 99% of them adults over the age of 18, and almost two-thirds adults over the age of 75. About three-quarters of deaths could be considered "predictable" and followed a period of chronic illness – for example heart disease, cancer, stroke or dementia. In all, 58% of deaths occurred in an NHS hospital, 18% at home, 17% in residential care homes (most commonly people over the age of 85), and about 4% in hospices. However a majority of people would prefer to die at home or in a hospice, and according to one survey less than 5% would rather die in hospital. A key aim of the strategy therefore is to reduce the needs for dying patients to have to go to hospital and/or to have to stay there; and to improve provision for support and palliative care in the community to make this possible. One study estimated that 40% of the patients who had died in hospital had not had medical needs which required them to be there.
Care in the final days and hours of life
Signs that death may be near
- Drowsiness, increased sleep, and/or unresponsiveness (caused by changes in the patient's metabolism).
- Confusion about time, place, and/or identity of loved ones; restlessness; visions of people and places that are not present; pulling at bed linens or clothing (caused in part by changes in the patient's metabolism).
- Decreased socialization and withdrawal (caused by decreased oxygen to the brain, decreased blood flow, and mental preparation for dying).
- Decreased need for food and fluids, and loss of appetite (caused by the body's need to conserve energy and its decreasing ability to use food and fluids properly).
- Loss of bladder or bowel control (caused by the relaxing of muscles in the pelvic area).
- Darkened urine or decreased amount of urine (caused by slowing of kidney function and/or decreased fluid intake).
- Skin becoming cool to the touch, particularly the hands and feet; skin may become bluish in color, especially on the underside of the body (caused by decreased circulation to the extremities).
- Rattling or gurgling sounds while breathing, which may be loud (death rattle); breathing that is irregular and shallow; decreased number of breaths per minute; breathing that alternates between rapid and slow (caused by congestion from decreased fluid consumption, a buildup of waste products in the body, and/or a decrease in circulation to the organs).
- Turning of the head toward a light source (caused by decreasing vision).
- Increased difficulty controlling pain (caused by progression of the disease).
- Involuntary movements (called myoclonus), changes in heart rate, and loss of reflexes in the legs and arms are additional signs that the end of life is near.
The following are some of the most common potential problems that can arise in the last days and hours of a patient's life:
- Pain -Suffering from uncontrolled pain is a significant fear of those at end of life.
- Typically controlled using morphine or diamorphine; or other opioids.
- Delirium, terminal anguish, restlessness (e.g. thrashing, plucking, or twitching). Typically controlled using midazolam, or other benzodiazepines. Symptoms may also sometimes be alleviated by rehydration, which may reduce the effects of some toxic drug metabolites.
- Respiratory Tract Secretions
- Saliva and other fluids can accumulate in the oropharynx and upper airways when patients become too weak to clear their throats, leading to a characteristic gurgling or rattle-like sound ("death rattle"). While apparently not painful for the patient, the association of the symptom with impending death can create fear and uncertainty for those at the bedside. The secretions may be controlled using drugs such as scopolamine (hyoscine), glycopyrronium, or atropine. Rattle may not be controllable if caused by deeper fluid accumulation in the bronchi or the lungs, such as occurs with pneumonia or some tumours.
- Nausea and vomiting
- Typically controlled using cyclizine; or other anti-emetics.
- Dyspnea (breathlessness)
- Typically controlled using morphine or diamorphine
Typical care plans, such as those based on the Liverpool Care Pathway for dying patients, pre-authorise staff to address such symptoms as soon as they are needed, without needing to take time to seek further authorisation. Subcutaneous injections are one preferred means of delivery when it has become difficult for patients to swallow or to take pills orally; and if repeated medication is needed, a syringe driver (called an infusion pump in the US) is often likely to be used, to deliver a steady low dose of medication.
Another means of medication delivery, available for use when the oral route is compromised, is a specialized catheter designed to provide comfortable and discreet administration of ongoing medications via the rectal route. The catheter was developed to make rectal access more practical and provide a way to deliver and retain liquid formulations in the distal rectum so that health practitioners can leverage the established benefits of rectal administration. Its small flexible silicone shaft allows the device to be placed safely and remain comfortably in the rectum for repeated administration of medications or liquids. The catheter has a small lumen, allowing for small flush volumes to get medication to the rectum. Small volumes of medications (under 15ml) improve comfort by not stimulating the defecation response of the rectum, and can increase the overall absorption of a given dose by decreasing pooling of medication and migration of medication into more proximal areas of the rectum where absorption can be less effective.
- Naila Francis - Dr. Lauren Jodi Van Scoy Poses Critical Questions About Death in First Book - PhillyBlurbs.com - The Intelligencer, July 10/11, 2011.
- Donald R Hoover, Stephen Crystal, Rizie Kumar, Usha Sambamoorthi, and Joel C Cantor (December 1, 2002). "Medical Expenditures during the Last Year of Life: Findings from the 1992–1996 Medica0000re Current Beneficiary Survey". Health Service Research 37 (6): 1625–1642. doi:10.1111/1475-6773.01113. PMC 1464043. PMID 12546289.
Last-year-of-life expenses constituted 22 percent of all medical, 26 percent of Medicare, 18 percent of all non-Medicare expenditures, and 25 percent of Medicaid expenditures.
- Julie Appleby. Debate surrounds end-of-life health care costs. USA Today, July 10/11, 2011.
- Hoover, D. R.; Crystal, S.; Kumar, R.; Sambamoorthi, U.; Cantor, J. C. (2002). "Medical Expenditures during the Last Year of Life: Findings from the 1992–1996 Medicare Current Beneficiary Survey". Health Services Research 37 (6): 1625–1642. doi:10.1111/1475-6773.01113. PMC 1464043. PMID 12546289.
- NHS National End of Life Care Programme, official website
- End of Life Care Strategy: Promoting high quality care for all adults at the end of life, UK Department of Health, July 2008.
- Q&A: End of life care, BBC News, 26 November 2008
- 'Better' end of life care pledge, BBC News, 21 August 2008
- Living and Dying Well: A national action plan for palliative and end of life care in Scotland, Scottish Government, 2 October 2008
- Scots end-of-life plan launched as part of innovative palliative care strategy, Nursing Times, 14 October 2008.
- End of life care: 1. The current place and quality of end of life care, House of Commons Public Accounts Committee, 30 March 2009, paragraphs 1-3.
See also End of life care strategy, UK Department of Health, July 2008, paragraphs 1.1 and 1.7-1.14 (pages 26-27); and End of Life care, UK National Audit Office Comptroller and Auditor General's report, 26 November 2008, paragraphs 2.2-2.5 (page 15)
- End of Life care, UK National Audit Office Comptroller and Auditor General's report, 26 November 2008, paragraph 21 (page 7) and supporting study
- The Quality of Death: Ranking end-of-life care across the world, Economist Intelligence Unit, July 2010
- Quality of death, Lien Foundation, July 2010
- United States Tied for 9th Place in Economist Intelligence Unit's First Ever Global 'Quality of Death' Index, Lien Foundation press release
- UK comes top on end of life care - report, BBC News, 15 July 2010
- NCI Factsheet: End-of-Life Care: Questions and Answers, 30 October 2002. Some material here has been adapted verbatim from the factsheet, which is identified as being in the public domain as a creation of federal government employees (NCI Web policies: Copyright and registered trademarks).
- This list is based on the principal heading prompts in the Liverpool Care Pathway standard documentation template. A more detailed discussion of common symptoms and potential mitigation options can be found in the U.S. National Cancer Institute's PDQ Last Days of Life: Symptom management.
- Canadian Nurses Association. "Position Statement: Providing Care at The End of Life", 2008, p.3
- LCP Sample hospital template, Marie Curie Palliative Care Institute, Liverpool. Version 11 - November 2005
- NCI PDQ: Last Days of Life: Symptom management, United States National Cancer Institute, Revised 9 March 2009
- De Boer AG, Moolenaar F, de Leede LG, Breimer DD. (1982) "Rectal drug administration: clinical pharmacokinetic considerations." Clin Pharmacokinetics. 7(4):285-311
- Moolenaar F, Koning B, Huizinga T. (1979) "Biopharmaceutics of rectal administration of drugs in man. Absorption rate and bioavailability of phenobarbital and its sodium salt from rectal dosage forms." International Journal of Pharmacaceutics, 4:99-109
- End of Life Issues. MedlinePlus.
- EndLink - Resource for End of Life Care Education, Robert H. Lurie Comprehensive Cancer Center, Northwestern University
- End of life care, NHS Choices
- End of Life Care Strategy - promoting high quality care for all adults at the end of life, UK Department of Health, Publications policy and guidance
- Ellershaw John, Ward Chris (2003). "Care of the dying patient: the last hours or days of life". British Medical Journal 326: 30–34. doi:10.1136/bmj.326.7379.30.
- Polly Mazanec, Julia Bartel (2002), Symptoms and Symptom Management, in Robert Kastenbaum (ed), Macmillan Encyclopedia of Death and Dying. New York: Macmillan Reference USA. ISBN 0-02-865689-X
- End Of Life: The Facts, Marie Curie Cancer Care
- End of life care in adults, Map of Medicine, updated 29 October 2010
- End-of-Life Decisions from the Institute for Good Medicine at the Pennsylvania Medical Society
- Survivorship A to Z: End-Of-Life
- Before I Die: Medical Care and Personal Choices. Produced by Thirteen/WNET, premiered on Public Broadcasting Service April 22, 1997. The program explores the medical, ethical, and social issues surrounding end-of-life care in America today.
- Palliative Care Policy Center (PCPC), formerly Center for Palliative Care Studies. Includes RAND Health white paper on Living Well at the End of Life: Adapting Health Care to Serious Chronic Illness in Old Age. plus other resources.
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