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The Patient's Story

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Mr R was a 74-year-old widower diagnosed as having cholangiocarcinoma. Three months later, a stent was placed to prevent biliary obstruction. He was reportedly in good health for 6 months, but thereafter, Mr R became progressively jaundiced and weaker. Within 9 months of his diagnosis, he was using a wheelchair. In clinic, his oncologist referred him to home hospice. Two days after hospice admission, Mr R became acutely ill with a fever (temperature to 39°C) and gasping respirations. His family brought him to the hospital. He was intubated, admitted to the intensive care unit (ICU), and given antibiotics and vigorous hydration. Blood cultures grew Escherichia coli. A palliative care consultation was obtained. A family conference was held, and the team recommended a transition to comfort care. The family agreed. Mr R was transferred to a palliative care unit bed. Although the family thought that Mr R's death was imminent, he lived for a week. He initially rallied and was able to recognize and greet visitors. During the next days, he became less alert and eventually was unresponsive. By day 7 of his hospitalization, he was receiving 2 mg of morphine every 4 hours intravenously for possible pain and dyspnea and lorazepam for agitation. Atropine eye drops were administered sublingually for retained respiratory secretions. His family remained at his bedside during his final days. On the day of his death, his morphine dose was doubled because of an increased respiratory rate, suggestive of possible underlying pain or dyspnea. At 10 pm, he was given a continuous morphine infusion and his family went home. He died at 11:47 pm. His family was called and returned to the hospital. They stayed with Mr R until 6:30 am. A week later, the palliative care consulting attending physician made a follow-up telephone call to the patient's daughter to offer condolences.

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Perspectives

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Shortly after Mr R's death, a Perspectives editor separately interviewed Mr R's daughter and the attending physician on the palliative care consultation team.

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This case may remind clinicians of many dying patients for whom they have provided care. Still, there is much that can be learned. This article addresses issues that commonly arise in the care of actively dying patients—prognostication, physical changes at the end of life and related treatment, family coaching, death pronouncement, inquiries about autopsy, and postdeath follow-up. Consideration of the very different perspectives of the daughter and the physician, as they struggle to understand Mr R's death, is also instructive. For most patients, active dying, a rapidly evolving process just preceding death, will be recognized hours to days earlier; sudden deaths by trauma or illness are the exceptions, not the rule. With each death, families and friends grieve the loss of their loved one. Clinicians come to recognize limitations in their powers to cure illness and must also grieve. We all are reminded of our own ...

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