How is time to death calculated in terminally I’ll patients?
In: 510
Doctor here. It all depends on what they’re dying from. A lot of the mortality predictions come from cancer research – from large studies you can say that median survival is 3 years, ie if we took a hundred people in your situation, half would die before 3 years, the other half would live longer. If it’s a dialysis patient, you expect about a week after they stop dialysis. In my experience patients don’t ask as often as you’d think. Often it’s family members towards the end of life. I often use the “crystal ball” analogy. It’s common to say things like “long weeks to short months”. In the last stages of dying, it can be quite variable from long hours to weeks. Once someone stops eating and starts sleeping most of the day, you’re talking within days. Once they develop a pattern of breathing called Cheyn Stokes, it’s a day or two
It’s hard when someone is terminal and you know they could die within short hours, but the family doesn’t quite appreciate that and are talking about dropping the car off for servicing before they come in: you don’t want to be alarmist but you equally don’t want them to miss the passing of their loved one without the chance to see them again. The other hard situation is where the family press you for a more specific timeframe, eg do you think they’ll be here until auntie mavis arrives from overseas on Friday” or “should we get uncle bob to drive from interstate tonight?” I’ll say something like “we are really worried about your mum and how unwell she is. We really are dealing with an hour by hour process and there’s no guarantees”.
By far the hardest part is when it’s clear the person is dying, but the family aren’t ready or don’t understand the gravity. There’s a real tension between the patient’s status (i.e their symptom burden/suffering), the family’s hopes, the doctors’ insights and the nurses providing futile care that can be very emotionally burdensome for nurses. Maybe a palliative care physician can chime in, but I personally feel it’s not a dichotomous decisions to treat actively or to palliate. Sometimes the distinction is semantic and makes no practical difference. If the patient is suffering, I treat their pain/agitation/breathlessness/ nausea. It’s easy to cease medications that serve no purpose. Ceasing observation of vital signs or collecting blood tests are other intermediate steps. If the family wants to leave no stone unturned (or live with residual guilt), I can be swayed to continue IV antibiotics. It’s hard though when you know the treatment is futile and they will inevitably die – the nurses know that also and will urge me to “just tell the family we need to palliate” as if it were as easy as that. At that stage the doctor is making decisions that affect everyone’s wellbeing and it’s a hard balance to strike
Latest Answers