Prolonged Dying Phaseis licensed under a Creative Commons Attribution- ShareAlike 3.0 Unported License Christian Sinclair, MD, FAAHPM – ctsinclair@gmail.com @ctsinclair

March 2012 - AAHPM Annual Assembly

Slides 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 life

Working definition: Prolonged dying phase is identified when the dying process of a terminal patient with minimal function exceeds the expected or true prognosis to the degree which the patient, family or health care team begins to question the expected time frame. Physical symptoms and physical suffering do not need to be present for PDP, yet suffering related to time and expectations may 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 symptoms

What 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 PDPSUBJECTIVE

• Prognosis dependent– Errant prediction

• Communicated• Formulated• Perceived

– Multiple predictor (wide range)– Altered time passage

• Prognosis independent– Stochastic (random)– Labeling– Acceptance– “Time bind” hypothesis– Altered time passage

OBJECTIVE• Stochastic (random)• Medical interventions• Failed external outcome• Organ transplant• Special event• Statistical deviation

Time bind hypothesis (Hothschild 1997) – The fast pace of our lives makes us less patient with indefinite or extended periods of timeUniversity of Wisconsin Donation after Cardiac Death Evaluation Tool (2003)