CPD ARTICLES

 

How to approach patients and families at the end of life

 

 

Maggie De Swardt^I; Rene Krause^I; Louis S. Jenkins^{II, III, IV}

^IDepartment of Family, Community and Emergency Care, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
^IIDepartment of Family and Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
^IIIPrimary Health Care Directorate, Department of Family, Community and Emergency Care, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
^IVDepartment of Family and Emergency Medicine, Western Cape Department of Health, George Hospital, George, South Africa

Correspondence

 

 

---

ABSTRACT

Healthcare practitioners are regularly faced with treating patients at the end of their life, and this can be very daunting. This article hopes to help the practitioner have an approach to managing end-of-life care that makes it less distressing. The symptoms at the end-of-life include delirium and/or agitation, breathing changes, skin changes, sleeping more, decrease in need for food and drink, incontinence, and increased secretions. These symptoms are discussed and practical ways of management are given. The article further discusses how to approach the difficult conversation with the family and gives guidance as to what needs to be discussed. A number of tips are discussed on how to prepare the family to handle a death at home. It is essential to look at coping mechanisms and selfcare for practitioners dealing with end-of-life care as the death of a patient not only affects the family but also the practitioner.

Keywords: palliative care; end-of-life; multi-professional teams; symptoms; difficult conversation.

---

 

 

Introduction

Healthcare practitioners are faced with situations where a patient in their care is experiencing the last few days of their life. This time during the end of life may be experienced with apprehension and anxiety by everyone involved in the dying person's life if one is not prepared. Various palliative care resources and hospice support structures are available to provide support, help and understanding during this time.^1,2 While palliative medicine is now a well-established discipline, many healthcare practitioners remain uncertain or untrained on how to approach patients and their families at the end-of-life. Healthcare practitioners need skills in communication, especially how to break bad news and contain a patient and family, to manage common symptoms, offer psychosocial and spiritual support, incorporate community resources, and how to be aware of their own responses in dealing with suffering and death.³ The Health Professions Council of South Africa (HPCSA) published a useful booklet called 'Ethical Guidelines on Palliative Care', which helps healthcare practitioners understand how personal and professional values and ethical principles influence end-of-life care.⁴

Context is very important and highly variable in South Africa. Increasingly, people with advanced diseases are preferring to die at home.^5,6 Home visits are not typically conducted by most healthcare practitioners, which is a skill in itself. Some patients end up in hospices, hospital wards, community health centres or tuberculosis (TB) hospitals at the end of their lives. Young people with diseases such as TB or acquired immunodeficiency syndrome (AIDS), and sometimes children with advanced terminal diseases, are a reality in South Africa. Understanding the roles of every member of the multi-professional palliative care team, community health workers, and family members is paramount. Listening with empathy and shared decision-making with the family and carers are crucial. Taking time, being comfortable with uncertainty and allowing periods of silence, are all part of the process.³

 

Symptoms at the end-of-life

Various symptoms appear during this time. Not all symptoms mentioned here appear at the same time and some may never appear at all. All the symptoms described indicate that the body is preparing itself for the final stage of life (see Table 1).^7,8,9 In general, unnecessary investigations and invasive interventions should be avoided, medications should be rationalised, and changing baseline organ functions should be considered.

 

Having the difficult conversation with the family

The discussion with the family starts early in the palliative phase and does not happen just before dying. The sooner the patient gets opportunity to express his or her wishes to the family, the better and easier the practitioner can navigate the last part of the journey of life with the family. Before speaking to the family, ensure you are speaking to the correct family members. The patient is the best person to identify who should be spoken to. If the patient is unable to communicate, ensure you are speaking to the next of kin as indicated in the records. Prepare for the meeting by ensuring you and the whole treating team are informed and agree that the patient is nearing the end of life and are in agreement about the future care. Ensure all conversations are held in a quiet private space. Decisions about whether the patient should be included in the conversation should be determined by the patient's wishes and physical and emotional state.² As far as possible, maintain patient autonomy, also depending on how they engaged with their health and the health system in the past.

Start the conversation with formal introductions and affirming confidentiality. Open the conversation by asking the family what they understand about what is happening to the person. Their understanding of the person's condition and their emotional response will determine what must be said, the extent and, the level of emotional support that is required. If they are not aware of the seriousness of the patient's condition a breaking bad news conversation should be followed.¹⁰ Many times, families are aware of the seriousness of the patient's condition and your response to their narrative should be to affirm the emotional response to their understanding of the patient's condition. If the family are aware that the patient is very sick but has not realised that the patient is dying, the doctor must provide a warning shot and inform the family that the patient is dying (unfortunately, sadly I have to inform you that I am worried that Mr X is at the end of his life or dying). Using the words 'I am worried' softens the conversation. Then ensure you follow this with silence and enough time to contain the family's emotions. Most families will enquire 'how long' and at this point you can inform them that no doctor knows the exact time for certain but from what is currently happening you will estimate short days, weeks, among others. Do not give a number and again inform the family that you may be wrong. However, if the family have certain tasks to be completed, for example, another family who wants to visit, or cultural and religious rituals that can be done before life ends, encourage them to rather do this earlier than later. Be sensitive to cultural practices like fetching the soul if the person does not pass away in his or her family home. Ask the family if they are ready to have a further discussion or whether they want to first have time to be alone.¹⁰

The next part of the conversation is planning the end-of-life care. This conversation should follow an ask, listen, tell and respond to the emotions format. Ask about what is important to the patient and family. Ask about worries and concerns. Inform them about what care is currently in place, for example, pain relief and comfort care measures. Enquire about the place of care and whether they want to take the patient home. If the family wishes to take the patient home, do an appropriate community referral, education about what to expect and what to do when the patient passes away. Ensure any vulnerable family members have been identified and adequate psycho-social care and bereavement care is in place, for example, elderly spouses or young children. Enquire about spiritual care and link to the family's own or hospital spiritual resources. Offer to link the family to bereavement support. Ensure the family have easy access to the patient and that all relevant family members have been informed.¹¹

After the conversation, have enough time for questions and share with them how to get in contact with your team for follow-up conversations. Document the conversation.¹⁰

 

Tips on how to prepare the family for a death at home

• The family member(s) may need someone to be with them. Think about who that would be and keep their telephone number on hand.

• Explain to the family the signs of death: no breathing, no pulse and/or heartbeat; loss of control of bladder and bowel; no response; eyes become dull and glazed, might be half open and dries out; jaw relaxes and mouth slightly open; body becomes cold, skin colour changes and body will eventually become stiff.

• After the passing of the patient the family can phone the ambulance, who will do the death declaration and then they can contact the undertaker.

• The family need to have the patient's ID document or passport available for the ambulance and undertaker.

There is no need to call the ambulance or undertaker immediately. It is often helpful for the family to have time with the person who has died before the undertaker arrives.

Patients who choose to die in hospital, need a slightly different approach (not covered in this article).

 

Be aware of your own feelings and coping mechanisms

Rituals like a minute of silence after the death of a patient to ground yourself and staff involved, lighting a candle, saying a prayer or having a memory wall can be very helpful, as it is normal to be affected by a patient's death. In difficult cases, a debrief session with the family and also all staff involved afterwards and even counselling or just talking about it, can also make a big difference. Take care of your own mental health and seek advice or help if not coping. There may be a sense of relief with the family or practitioner that the suffering of the patient is over, which in turn may invoke a sense of guilt. The death of a patient often affects the family and even the physician many months later. Be aware of this.

 

Conclusion

Palliative care at the end-of-life needs specific skills to address the various patient symptoms and relational family and personal dynamics. Hopefully, this brief article will contribute to the growing body of excellent resources available.

 

Acknowledgements

The authors acknowledge PALPRAC South Africa who kindly gave permission to use material on their website. The authors also acknowledge the many healthcare workers who offer good palliative care to patients in our communities and health facilities.

Competing interests

The authors declare that they have no financial or personal incentives that may have inappropriately influenced them in writing this article.

Authors' contributions

L.S.J. conceptualised the article. M.d.S., R.K. and L.S.J. provided inputs to subsequent drafts. All authors scrutinised and approved the final manuscript.

Ethical considerations

This article followed all ethical standards for research without direct contact with human or animal subjects.

Funding information

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

Data sharing is not applicable to this article, as no new data were created or analysed in this study.

Disclaimer

The views expressed in the submitted article are those of the authors and not an official position of an institution or funder, and the publisher.

 

References

1. Association of Palliative Care Centres of South Africa [homepage on the Internet]. [cited 2024 Jan 24]. Available from: https://apcc.org.za        [ Links ]

2. PALPRAC. A guide to caring for someone in their last days to hours of life [homepage on the Internet]. [cited 2024 Jan 24]. Available from: https://palprac.org/wp-content/uploads/2020/04/PALPRAC-A-guide-to-caring-for-someone-who-is-in-their-last-days_hours-of-life-1.pdf        [ Links ]

3. National Health System. What you can do to practically care for someone who is in their last days and hours of life [homepage on the Internet]. [cited 2024 Jan 24]. Available from: https://helixcentre.com/_content-img/projects/eolc-toolkit/Practical-Care-For-Dying-Person-Toolkit.pdf        [ Links ]

4. Ethical Guidelines on Palliative Care. HPCSA Booklet 17 (2019) [homepage on the Internet]. [cited 2024 Mar 08]. Available from: https://www.hpcsa-blogs.co.za/wp-content/uploads/2019/09/HPCSA-Booklet-17-Ethics-Guidelines-on-Pallative-Care.pdf        [ Links ]

5. Cai J, Zhang L, Guerriere D, Coyte PC. Congruence between preferred and actual place of death for those in receipt of home-based palliative care. J Palliat Med. 2020;23(11):1460-1467. https://doi.org/10.1089/jpm.2019.0582        [ Links ]

6. Roberts B, Robertson M, Ojukwu EI, Wu DS. Home based palliative care: Known benefits and future directions. Curr Geriatr Rep. 2021;10(4):141-147. https://doi.org/10.1007/s13670-021-00372-8        [ Links ]

7. Hospice Palliative Care Association of South Africa. Clinical Guidelines 2012 [homepage on the Internet]. [cited 2024 Jan 24]. Available from: https://apcc.org.za/wp-content/uploads/2020/04/HPCA_Clinical_guidelines_2012-1.pdfAPCC        [ Links ]

8. Hospice United Kingdom. What to expect when someone is in the last few days of life [homepage on the Internet]. [cited 2024 Jan 24]. Available from: https://www.hospiceuk.org/information-and-support/death-and-dying-what-expect/last-few-days        [ Links ]

9. Wilcock A, Howard P, Charlesworth S, editors. Palliative Care Formulary. London: Pharmaceutical Press; 2020.         [ Links ]

10. Rosenzweig MQ. Breaking bad news: A guide for effective and empathetic communication. Nurse Pract. 2012;37(2):1-4. https://doi.org/10.1097/01.NPR.0000408626.24599.9e        [ Links ]

11. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES - A six-step protocol for delivering bad news: Application to the patient with cancer. Oncologist. 2000;5(1):302-311. https://doi.org/10.1634/theoncologist.5-4-302        [ Links ]

 

 

Correspondence:
Louis Jenkins
Louis.Jenkins@westerncape.gov.za

Received: 27 Jan. 2024
Accepted: 11 Mar. 2024
Published: 24 Apr. 2024