Junior Doctor Tips - Death & Dying
About 65% of people die in hospitals in the UK and, as the population continues to age, the total number is expected to rise. Caring for the dying/terminally ill is stressful for all those involved in their care, including Junior Doctors. Evidence suggests Doctors and healthcare workers come to terms with mortality at a much younger age than most people.
The Five Elements of Good End-of-Life Care
Communication
Breaking Bad News - this is a difficult but essential aspect of healthcare. Contrary to popular opinion, people remember how bad news was given to them. While every situation demands a unique approach, here are some helpful tips:
Seek Guidance: If you're uncertain about how to start, consult with the patient's nurse. Ask nurses what they think the patient knows before seeing the patient and take a nurse with you to the bedside.
Privacy: Whenever possible, take the patient to a private room to discuss bad news.
Tissues and Time: Ensure you have tissues handy and allocate sufficient time for the conversation.
Listen Actively: Ask open-ended questions like "What do you know so far?" and assess how much information the patient wants.
Honesty: Be truthful and direct in your communication. People usually want more information than doctors give them.
Avoid Medical Jargon: Speak in plain language and avoid using medical terminology.
Provide Written Information: Consider giving the patient written information and diagrams to explain their condition.
Chunk Information: Break down information into manageable chunks and encourage the patient to ask questions.
Support for Relatives: Find out if the patient wants you to break the news to their relatives and ensure the patient has given consent for you to discuss the details with family members.
Follow-up: Make follow-up appointments with senior members of the team if necessary.
Inform the Nursing Staff: Communicate what you've discussed with the patient to the nursing staff, as they can provide further information and support.
Utilise Additional Resources: Consider involving other professionals like chaplains, palliative care teams, or support groups when needed.
Ongoing Communication with Dying Patients:
Regularly visit the patient's bedside to check in on their well-being and answer any questions.
Pay attention to functional symptoms like headaches and insomnia, reassuring patients and ensuring there are no underlying medical causes.
Maintain continuity of care, even when staff changes occur.
Adapt your communication to the patient's emotional state, considering the stages of dying proposed by Elisabeth Kubler-Ross: denial, anger, bargaining, depression, and acceptance.
Be prepared for difficult behavior from dying patients, offering acceptance and understanding even in challenging situations.
Encourage open discussions about dying, as patients often appreciate having someone they can talk to frankly.
Ask five important questions to help patients express themselves and address their concerns.
2. Pain Control
Pain is one of the most feared aspects of dying for patients. You can make a significant difference in alleviating their pain:
Involve the pain management team and seek senior advice early.
Understand that patients may not always admit to being in pain, so look for physiological signs such as tachycardia, hypertension, sweating, and pupil dilation.
Reassure patients that severe pain can be effectively controlled.
3. Symptom Control
For comprehensive guidance on symptom control in terminal care, consult the British National Formulary (BNF) under "Terminal care" in the index. Your hospital may also have local policies for prescribing in terminal care, and you can seek advice from the palliative care team when needed.
4. Prescribing for the Dying
Following the discontinuation of the Liverpool Care Pathway, there is increased focus on providing compassionate care for the dying. The key principles remain the same: maximise patient comfort while avoiding excessive medical intervention.
Simplify drug regimens, prescribing only medications that offer clear benefits.
Ensure continuous analgesia, and consider patient-controlled analgesia.
Discuss options like syringe drivers and patches for patients who can no longer swallow.
Collaborate with the pain team, anaesthetists, and pharmacists for optimal pain management.
Consider fluid management and, if appropriate, discuss the possibility of withdrawing intravenous fluids with seniors and relatives.
5. Support for the Dying and for Healthcare Providers
Providing care to dying patients can be emotionally challenging. It's essential to take care of yourself and seek support when needed.
Utilise available resources such as hospice services, chaplains, and bereavement officers.
Recognise the impact of caring for dying patients on your emotional well-being and seek opportunities for self-reflection.
Maintain clear documentation of patient care and communication.
Death and What to Do When a Patient Dies
If a patient passes away, it's crucial to handle the situation with care and efficiency, providing support to both the patient's family and healthcare professionals.
Confirmation of death:
View the body.
Confirm death by checking for fixed and dilated pupils, no spontaneous respiratory effort, no breath sounds for 2 minutes, no central pulses for 2 minutes, and no heart sounds for 2 minutes. Record these findings for 5 minutes in total.
Document your actions and sign your name clearly with your bleep number.
Note the date and time of death confirmation.
Record the possible cause(s) of death.
Check for pacemakers or radioactive implants and make arrangements for their removal if the patient is to be cremated.
Inform the patient's general practitioner (GP) about the death and provide a discharge summary.
Telling Relatives About the Patient's Death
Inform relatives that their loved one is close to death whenever possible.
Establish the patient's designated "next of kin" and communicate with them.
Offer a private and supportive environment for relatives to process their grief.
Discuss important decisions such as cremation or burial and the potential need for a post-mortem examination.
Religious Practices on Death
Understanding religious or cultural customs related to death is essential to facilitate respectful and appropriate care for patients and their families. Different religions have varying practices:
Buddhism, Christianity, Confucianism: No specific arrangements.
Hinduism: Cremation.
Islam: Burial within 24 hours.
Judaism: Avoid leaving the body alone.
Sikhism: Avoid moving the body; cremation.
Conclusion
In summary, providing compassionate terminal care involves effective communication, pain and symptom control, appropriate prescribing, and support for both patients and healthcare providers. Understanding and respecting cultural and religious practices related to death is also essential. While caring for dying patients is challenging, your dedication and empathy can make a significant difference during this critical stage of life.
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