A Dignified Death
What is a dignified death?
We all only get one death. Surgeons can help to ensure that when the time comes their patients experience a dignified death, in line with their wishes, preferences and beliefs, just as we would wish for ourselves or our loved ones.
For patients that may be nearing the end of their life, decisions should be made early as to whether or not to undergo surgical or other interventions. These decisions should be made by the patient in conjunction with their healthcare team. The appropriateness of high intensity treatments, escalation of treatment and admission to intensive therapy wards should be discussed. The dying person’s wishes must take priority and should be regularly reviewed and revised.
The patient’s wishes should be clearly documented so that all members of the healthcare team are aware of them and care is well co-ordinated. Each patient’s care should be individualised and delivered with dignity and compassion; it should include consideration of nutrition, hydration, symptom control and psychological, social and spiritual support.
Once a patient has died, their bereaved friends and family should be provided with support appropriate to their needs.
Adapted from: National Palliative and End of Life Care Partnership’s Ambitions for Palliative and End of Life Care: A National Framework for Local Action 2015–2020; and Leadership Alliance for the Care of Dying People’s One Chance to Get it Right.
Definition and recognition of the end of life
Defining "end of life"
There can be confusion about the term ‘end of life care’. Patients in the last 12 months of life meet the common definition for ‘end of life’, although the term is often used on the ward to denote care in the final days of one’s life.
The scope of this guidance includes both:
• Care for people who are likely to die within 12 months
• Care for people in the final days only - the imminently dying
Clarifying terms can be important, especially in conversations with patients and families. Nevertheless, both possible death in the coming months and weeks and imminent death are often very difficult to predict. In some people conditions which will end their life begin many years before the end, whereas for others end of life care may start only in the preceding seconds, minutes or hours before death. Preparation for death will clearly differ between an individual who has been given a terminal diagnosis where a chronic course is expected and a patient presenting with an acute unsalvageable catastrophe.
Recognition of the "end of life"
Recognising that a patient is approaching the end of their life can be difficult and not just for surgeons; the patient themselves may not realise their situation and may need to be made aware of it in a compassionate way. This recognition is important to allow patients to plan the final stages of their life, including appropriate decisions about their treatment.
Surgeons may use the surprise question as guidance when considering whether a patient may be nearing the end of life, as pioneered by the Gold Standards Framework Proactive Identification Guidance.
“Would you be surprised if this patient were to die in the next few months, weeks, days?” is a useful starting point.
Good Medical Practice recommends the following range of situations to guide when end of life care should be considered:
a) Advanced, progressive, incurable conditions
b) General frailty and co-existing conditions that mean death is expected within 12 months
c) Existing conditions where there is a risk of dying from a sudden acute crisis in that condition
d) Life-threatening acute conditions caused by sudden catastrophic events
Surgeons should be familiar with the specific clinical indicators that patients are likely to be in their last year of life, available from the Proactive Identification Guidance or the Supportive and Palliative Care Indicators Tool for cancer, organ failure and frailty/dementia, to guide the discussions that they have with patients or their supporters about care.