Prolonged dying phase handouts march 2012
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  • 1. Prolonged Dying Phase is licensed under aCreative Commons Attribution-ShareAlike 3.0 Unported License Christian Sinclair, MD, FAAHPM – ctsinclair@gmail.com @ctsinclair March 2012 - AAHPM Annual AssemblySlides available on Slideshare before during and after the conference http://www.slideshare.net/ctsinclairDisclosures: noneObjectives: Describe the challenge of prolonged dying from the perspective of patient and family Understand the difference between objective and subjective measurements of time and prognosis Describe how the perspective of time and prognosis influences suffering at the end of lifeWorking definition:Prolonged dying phase is identified when the dying process ofa terminal patient with minimal functionexceedsthe expected or true prognosisto the degree whichthe patient, family or health care teambegins to questionthe expected time frame.Physical symptoms and physical sufferingdo not need to be present for PDP,yetsuffering related to time and expectationsmay be experienced by all involved.Aspects of PDP • Patient is terminally ill • Care setting and tenor reflects terminal status • PPS ≤ 30% • May be identified by patient, family or staff • Usually acceptance; even welcoming of death • Suffering dependent on perception of time/ meaning as opposed to physical symptomsWhat PDP is not… • “We’re all dying…” – Denial/minimizing coping mechanisms • Lack of consensus of impending death • Not from first declaration of terminality/diagnosis • Not a side effect of medically hastened deaths • Depression Subjective vs. Objective PDP SUBJECTIVE OBJECTIVE • Prognosis dependent • Stochastic (random) – Errant prediction • Medical interventions • Communicated • Failed external outcome • Formulated • Organ transplant • Perceived • Special event – Multiple predictor (wide range) • Statistical deviation – Altered time passage • Prognosis independent – Stochastic (random) – Labeling – Acceptance – “Time bind” hypothesis – Altered time passage
  • 2. Time bind hypothesis (Hothschild 1997) – The fast pace of our lives makes us less patient with indefiniteor extended periods of timeUniversity of Wisconsin Donation after Cardiac Death Evaluation Tool (2003)