How to Diagnose Dying

SMACCJune 26, 2015

Ashley Shreves, MDAssistant Professor

Department of Emergency MedicineBrookdale Department of Geriatrics and Palliative Medicine

Icahn School of Medicine at Mt. Sinai

Atul Gawande “Letting Go”

Identifying “the dying”

• It’s hard

• Somewhat subjective

• Not always possible

• Obvious in retrospect

Why does it matter?

• Patient goals/priorities change

• Treatment

– Less effective

– burdens >> benefits

• Resource utilization

Case

• 80 y/o m

• Cardiac arrest

• EMS: picked up from dialysis

• ED: ACLS 10 min – get ROSC

• Yay!

Patterns of Dying

Lunney JAMA 2003

Terminal Illness

• Cancer

• Lengthy disease, sharp decline

• Measure of function?– Time in bed

• Associated symptoms– Anorexia, weakness, pain, dyspnea

Is she dying?

• 60 y/o f– Metastatic breast CA– Worsening dyspnea

• Need more info– Function?– Dyspnea history – reversible?

Organ Failure

• COPD, CHF

• Common

• Intermittent crises

• Surprising recoveries

• Clues– Repeated admits– Higher levels of care

Is he dying?

• 70 y/o m, COPD, 2 L home O2– 5 admits/past year for COPD exacerbations– Moderate respiratory distress– On BIPAP…may need intubation

• Need more info– Function?– Still independent? QOL?

• Past experience/GOALS matter bc prognostication tough

Frailty

• Dementia

• Slow decline, profound disability

• Complications define EOL

• Clues – Infections– Eating problems

Is she dying?

• 90 y/o f– Dementia, bedbound, minimal verbal– UTI x 2 in past 3 months– Fever, PNA

• Yes – Recurrent infections + AD = months– Can extend but NOT improve life

Sudden Death

• Not chronically ill

• 10-15% US population

• EM thinks all deaths

Is he dying?

• 40 y/o m, healthy, collapsed on tennis court– Found V fib, CPR/shocked x 3– Massive STEMI

• Maybe– “Dying” when all resuscitative efforts stop

• Time to death seconds-minutes

My case

• Cachectic elderly male• NH– Dementia, ESRD, CHF– Not eating or walking lately

• Which trajectory?

• Palliative extubation/died in ED

In summary…

• Seek trajectories (context)– Ask about function– Look at old chart

• Allows qualitative prognostication

• More appropriate medical plan