Competent Novice

Caring for a dying patient in hospital

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2174 (Published 17 April 2013)
Cite this as: BMJ 2013;346:f2174

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  1. Katherine E Sleeman, clinical lecturer in palliative medicine1,
  2. Emily Collis, consultant in palliative medicine2
  1. 1King’s College London, Cicely Saunders Institute, Department of Palliative Care Policy and Rehabilitation, London SE5 9PJ, UK
  2. 2Pembridge Palliative Care Centre, Central London Community Healthcare Trust, St Charles’s Hospital, London W10 6DZ, UK
  1. Correspondence to: K E Sleeman katherine.sleeman{at}kcl.ac.uk

Recognising the dying phase shifts focus of care from disease management to the patient’s priorities and symptoms

Key points

  • Junior doctors are often required to care for dying patients

  • Early recognition of dying facilitates meeting patients’ and relatives’ preferences for end of life care

  • Communication is the cornerstone of good end of life care

  • The principles of end of life prescribing are: to stop non-essential drugs; convert essential drugs to the subcutaneous route; and use anticipatory prescribing

Every year, more than half a million people die in the United Kingdom, and over half of these deaths occur in hospital. Junior doctors are often required to care for dying patients,1 and assessment and management of these patients are essential skills.2 3 4

The importance of good end of life care, both for the patient and for their family, is increasingly recognised. However, many people dying in hospital continue to have unmet needs, and, in the UK more than half of complaints referred to the Healthcare Commission (the Care Quality Commission’s predecessor) concerned the care of dying people.5 Acquisition of the basic skills required to care for people who are dying can improve the patient’s and their family’s experience of death, as well as the safety, efficiency, and satisfaction of the junior doctor’s work.

Recognising dying

Doctors are notoriously poor at prognosticating, and recognising that a person is dying is a skill that develops over time. In the patient who is close to death, clinical signs such as reduced consciousness level, respiratory changes (for example, Cheyne-Stokes breathing), and cardiovascular changes (for example, peripheral vasoconstriction) are common. For the patient and his or her family to have time to express their preferences for end of life care, however, recognition of dying must occur earlier.

The last weeks of life for most people are characterised …

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