“He’s taken longer to die than a horse”BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4590 (Published 11 September 2015) Cite this as: BMJ 2015;351:h4590
- Fay Murray-Brown, specialty trainee year 4, palliative medicine, Hospiscare, Exeter, UK
A 70 year old dairy farmer was admitted acutely with bronchopneumonia two months after a diagnosis of glioblastoma, for which he received palliative radiotherapy.
Unfortunately, despite maximal antibiotic treatment, he deteriorated and his condition was considered irreversible. The medical team told his family that as he was unlikely to survive, all active treatments should be stopped. Over the next three days he was mostly awake and, although confused, was communicating with his family. On day 5 he became unconscious and was transferred to the local hospice.
Once there, his wife described his symptoms and signs in animal terms. She helped manage their farm and kept horses. She regularly conversed with vets and had a good understanding of animal physiology. She described his recent respiratory distress as “double breathing.” Horses have delicate lungs and are sensitive to dusts and pollens. Long term exposure to these irritants can cause chronic obstructive pulmonary disease. Symptoms can be so severe that the horse has to take a double exhalation to push the air out of its lungs.1 His wife assumed his respiratory distress was double breathing, interpreted this as a grave sign, and agreed with the medical team’s decision to stop treatment. However, she was concerned that he took much longer to die than her animals would and thought that he had been “starved to death.” Little is known about the dying process in horses, as most are euthanased when they become too old or unwell for recovery. Online posts describe horses being found dead in fields or dying naturally over several hours.2 It is therefore understandable that the patient’s wife might assume the process in humans to be similarly short. She did not see anyone offer him food or drink, and when asked if she had done so in the last five days she said, “But no-one told me I could.” He died peacefully 24 hours after hospice admission.
In 2012 there was outcry in the media over the Liverpool care pathway for the dying patient, suggesting it led to malnutrition, dehydration, and premature death. An external review advised that it should be phased out and replaced with a “personalised end of life care plan.”3 The Leadership Alliance for the Care of Dying People has since outlined five priorities for care of the dying person, all based on communication with the patient and their families. It states that “even if it has been determined that someone may be dying, health and care staff must continue to offer them food and drink.”4 In this patient’s case, although the medical team told the family that he was dying, they did not say that he could still eat and drink for comfort. It highlights the importance of communicating not only what dying patients can’t do or have, but also what can be provided. It also underlines the importance of exploring each family’s understanding of the dying process, as their employment or life experiences may be unique. Oral food and fluids must not be viewed as treatments but as comfort measures that should, if possible, be enjoyed by all.
Cite this as: BMJ 2015;351:h4590
Patient consent obtained from spouse after patient’s death.