This is a question that comes to me as an end-of-life care nurse practitioner every single week, without fail. However, it isn’t just weekly, it’s every day. Some days I might get called to a patient who is recognised to be dying, however, before I get there, they have taken that last important but final breath. The reason we do it so late - life and medicine is uncertain.
How can our acute care hospitals recognise dying earlier? I sometimes feel like this is the million-dollar question. Perhaps instead what we should be asking instead of how do we recognise dying earlier, is “how can we recognise when treatments may not reverse this situation” or better still “is this treatment in line with the end-of-life wishes of this patient?”
Acute care hospitals have a default setting – 'Fix it'. If you have ever had the misfortune of spending time as a patient in an acute care hospital, you were probably very happy with the default setting. However, it is not for everyone or every situation.
The problem is that sometimes it’s hard not to fix everything, our patients want you to cure them, and relieve them of their ills. Their families want you to cure them because they are not ready to consider any other way of life that might not include that central person. Our health care professionals do not want their patients to die.
The 'Surprise Question' has long been used to consider if a patient may be nearing the end of their life, “would you be surprised if this person was to die in the next 12 months?”.  In our acute care hospitals, perhaps it would be more apt to ask, “would you be surprised if this person was to die during this admission?” if the answer is no…you need to start constructing conversations about some pretty serious and challenging issues.
Perhaps we need a cultural shift. Based on McWhineys modelling.  If we asked about the history of the patient not in a medical diagnosis of the disease led model, but in a combined disease- illness based model “what does this illness mean to you?”, “how does this illness affect your life?”, “what if we told you, you won’t get better function with this treatment, but will likely need increased care?”
Are these the questions we should be asking alongside our disease-specific questions? Social assessments are rapid in the medical assessment model, if we asked more about the person with the disease, instead of the disease of the person, perhaps we could start to recognise dying just a little bit earlier.
- Moss AH, Ganjoo J, Sharma S, Gansor J, Senft S, Weaner B, Dalton C, MacKay K, Pellegrino B, Anantharaman P, Schmidt R. Utility of the "surprise" question to identify dialysis patients with high mortality. Clin J Am Soc Nephrol. 2008 Sep;3(5):1379-84. doi: 10.2215/CJN.00940208. Epub 2008 Jul 2.
- McWhinney IR. Changing models: the impact of Kuhn's theory on medicine. Fam Pract. 1984 Mar;1(1):3-8. doi: 10.1093/fampra/1.1.3
Jeanette Lacey, End of Life Care Nurse Practitioner, Hunter New England LHD
This blog is part of a series of blogs commissioned by End-of-Life Essentials to support health professionals in providing end-of-life care. You can find more information on the End-of-Life Essentials website.