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.
The U.S. Government National Cancer Institute advises that the presence of some of the following signs may indicate that death is approaching:
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.
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.
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.
^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