michaelsharrington (Hridayam)

In palliative care, the main focus is comfort-care for both the patient and their families. Paying close attention to physical symptoms such as pain, nausea, loss of appetite and confusion. Consideration is given to the emotional and spiritual concerns of patients and families and ensuring that care is respectful and supportive of patient dignity, social, religious or spiritual priorities and cultural needs of patients and families. 

Palliative care often involves a team approach that may include volunteers, social workers and spiritual leaders in addition to medical staff, quality of life and helping with symptoms. Palliative care can help patients understand their choices for medical treatment. The organized services available through palliative care may be helpful to any older person having a lot of general discomfort and disability very late in life.

Often there is a palliative care consultation team, a multidisciplinary team that works with the patient, family, and the patient’s other doctors to provide medical, social, emotional, and practical support. The team is made up of palliative care specialist doctors and nurses, and includes others such as social workers, nutritionists, the planning of green burials, and chaplain consideration, etc. In palliative care, you do not have to give up treatment that might cure a serious illness. Palliative care can be provided along with curative treatment and may begin at the time of diagnosis. 

Over time, if the doctor or the palliative care team believes ongoing treatment is no longer helping, there are two possibilities. Palliative care could transition to hospice care if the doctor believes the person is likely to die within 6 months (see What does the hospice 6-month requirement mean?). Or, the palliative care team could continue to help with increasing emphasis on comfort care.

Senior or elder care, where the client/patient simply needs more assistance but does not necessarily-have a defined illness or disease process leading to impending death can go on for several decades or several months.

The final two phases of palliative care are also considered ‘end-of-life care’ are Pre-dying and dying and they often overlap. Much depends on the specific nature of the disease or terminal illness, the metabolic profile of the individual patient, along with signs and symptoms that are present.

The Pre-dying phase can lasts approximately two weeks. 

Signs of the pre-active phase of dying: increased restlessness, confusion, agitation, inability to stay content in one position and insisting on changing positions frequently (exhausting family and caregivers), withdrawal from active participation in social activities, increased periods of sleep, lethargy, decreased intake of food and liquids, beginning to show periods of pausing in the breathing (apnea) whether awake or sleeping, patient reports seeing persons who had already died, patient states that he or she is dying, patient requests family visit to settle “unfinished business” and tie up “loose ends”- inability to heal or recover from wounds or infections, increased swelling (edema) of either the extremities or the entire body. The Active dying phase lasts on average, about three days.

Signs of the Active Phase of Dying phase include: inability to arouse patient at all (coma) or, ability to only arouse patient with great effort but patient quickly returns to severely unresponsive state (semi-coma), severe agitation in patient, hallucinations, acting “crazy” and not in patient’s normal manner or personality, much longer periods of pausing in the breathing (apnea), dramatic changes in the breathing pattern including apnea, but also including very rapid breathing or cyclic changes in the patterns of breathing (such as slow progressing to very fast and then slow again, or shallow progressing to very deep breathing while also changing rate of breathing to very fast and then slow), other very abnormal breathing patterns, severely increased respiratory congestion or fluid buildup in lungs, inability to swallow any fluids at all (not taking any food by mouth voluntarily as well), patient states that he or she is going to die, patient breathing through wide open mouth continuously and no longer can speak even if awake, urinary or bowel incontinence in a patient who was not incontinent before, marked decrease in urine output and darkening color of urine or very abnormal colors (such as red or brown), blood pressure dropping dramatically from patient’s normal blood pressure range (more than a 20 or 30 point drop), systolic blood pressure below 70, diastolic blood pressure below 50 patient’s extremities (such as hands, arms, feet and legs) feel very cold to touch, patient complains that his or her legs/feet are numb and cannot be felt at all, cyanosis, or a bluish or purple coloring to the patients arms and legs, especially the feet, knees, and hands), patient’s body is held in rigid unchanging position, jaw drop; and the patient’s jaw is no longer held straight and may drop to the side their head is lying towards.

 Physician-assisted suicide is an option in some cases and has been available in selected states and countries for decades, the typical scenario is probably different from what you imagine or fear. The good news is that vulnerable patients do not appear to be pressured to take this option. Instead, the typical patient has cancer, is older, white, well-educated, and does not have extreme pain. He has lost independence and quality of life, fears increased pain, and prefers to choose the timing of his exit.

Great strides have been made in improving end-of-life care through palliative care and hospice programs, but sometimes it’s just not enough. Many elderly and chronically ill patients in America die in pain, and many nursing homes are understaffed. Chronic and life-limiting illness can also make a person feel like they have lost all control of their lives. The body isn’t doing what it should and there’s no way to stop it. Physician-assisted suicide (PAS) may feel like a way to regain some of that control. If they can’t control the illness, they can at least control how they die. The quality of life is the driving force behind patients seeking PAS. Loss of autonomy, or not being able to care for oneself and make one’s own decisions, is reported in 90 percent of cases of PAS in Oregon. Closely following are the loss of one’s dignity and the loss of being able to participate in enjoyable activities. It goes without saying that physical suffering greatly diminishes the quality of life as well. For those who are suffering in their final days of life, death can be a welcome event. They may feel that it will permanently relieve their suffering and alleviate the burden on their loved ones. Physician-assisted suicide may seem like the best option for them and their families.

Physician-Assisted Suicide Statistics. In U.S. jurisdictions where legal, the percentage of physician-assisted deaths were 0.1 percent to 0.2 percent of all deaths, while in the Netherlands it is 1.8 percent to 2.9 percent of all deaths.U.S.Physician-assisted suicide is legal in five states as of 2017: Oregon, Washington, Montana, Colorado, Vermont, and California. It has been legal in Oregon since 1997 and the Oregon Health Authority produces a yearly report on PAS. The reasons patients gave when requesting PAS in Oregon has been consistent in reports for 20 years:    90 percent reported a decreasing ability to participate in activities that made life enjoyable    90 percent reported loss of autonomy    65 percent reported loss of dignityMore

Oregon statistics include:    

Less than two-thirds of Oregon patients who receive a prescription for PAS die from ingesting the medications. That number has remained consistent over two decades. The number each year receiving the prescription is small, although growing, increasing from under 100 per year through 2010 to over 200 per year in 2015 and 2016.    Only 1,127 patients died from physician-assisted suicide in Oregon from 1997 through 2016 while 1,749 prescriptions were written.    90 percent of Oregon PAS patients died at home and 88 percent of them were enrolled in a hospice program.    Physician-assisted suicide accounts for 37.2 per 10,000 deaths in Oregon, the number doubling since 2010.    

Less than 1 percent of physicians in Oregon and Washington write a prescription for PAS each year.Canada: Physician-assisted suicide was legalized in Quebec in 2016 and nationally in June 2016.The Netherlands:    Physician-assisted suicide is legal under strict circumstances.    The right to choose physician-assisted suicide remains highly favored.    60 percent of Dutch physicians have granted requests for PAS.Belgium: Legalized euthanasia in 2002.Luxembourg: Legalized euthanasia and assisted suicide in 2009.U.K.: Physician-assisted suicide is illegal. 

The current movement there is to focus on palliative care, not euthanasia. Elsewhere in the World: Physician-assisted suicide is legal under strictly defined regulations in Colombia, and Japan.    

IT IS IMPORTANT TO CONSIDER:

As the incoming life (newborn) often needs 20 hours sleep a night, the outgoing life (dying person) may also thrive on more silence as well. At some point it behooves us to let the dying person lead. They have lost many of the obstacles or veils that obscure the subtle realm and possess a direct line to the spiritual and timeless dimension that is often not easily accessible for others. The dying person is bathing on the cusp of form and formlessness, dancing in the recesses of Spirit.      

Often family members and friends see a dying person’s eyes open, and realize it is a rare opportunity. They want to fill the space with words, conversation, or loud energies. Wait. Wait some more. Bask in the silent interlude. If words need come, let the dying initiate conversation. Trust your intuition here. Yes, they might be in pain or have immediate issues that require attention.        

If something important needs to be said, at first, let the silent heart speak it without words. Of course, just like in ‘regular life’ gibberish and non-sequiturs may come out of the dying person’s mouth but also incredible insights and delights from the great beyond. The dying person is communing with the Maker, in intimate contact with Essence. A loved one who is dying provides us with a great opportunity to deepen in eternal presence.