Dying patients may have needs that are different from those of other patients. So that their needs can be met, dying patients must first be recognized. Before death, follow patients usually 1 of 3 usual course of the function order:

(Dying and death in children and advance directives.) Dying patients may have needs that are different from those of other patients. So that their needs can be met, dying patients must first be recognized. Before death, follow patients usually 1 of 3 usual course of the function order: A limited period steadily progressive functional decline (. Eg typical for progressive cancer) A longer indefinitely by serious malfunctions that are not constant progression (eg. typically caused in severe dementia, unable machendem stroke and severe frailty) function that decreases irregularly urch periodic and sometimes unpredictable acute exacerbations of underlying disease (eg. B. typical (for heart failure or COPD) in the first waveform z. B. for progressive cancer) the course of the disease and the time of death seem to be more predictable than the other tracks. With prolonged dysfunction, for example (eg. As severe dementia), death can occur due to infection suddenly such. As by pneumonia. At irregular progressive dysfunction (z. B. heart failure), people who do not appear suddenly ableben dying during an acute exacerbation can. As a result, when you know that the onset form of functional decline can also be helpful, it is still often difficult to accurately estimate when death will occur. So doctors are advised to consider patients who meet the following two criteria as potentially dying patients, noticing that these criteria can be excessive included: presence of diseases that are serious and likely to deteriorate death within one year, would the doctors not surprisingly, if a patient is detected as dying, the doctor should the probable course of the disease over the Patineten communicate, including an assessment of the length of survival and, if the patient agrees to discuss to the family, friends or twin goals of care and clear (for example, stress relief, healing) Desired palliative and hospice care clarify planning what to do when death is imminent behandlen symptoms Help, to address financial, legal and ethical aspects of patient care and Persona help deal with stress patients should be involved in decision making, so far it is possible for them. If patients are unable to make health care decisions in a position (capacity (competence), and disability) have and a durable power of attorney for health care, appointed in this document person should make the decisions in question. When patients have no authorized representative, doctors usually leave to the next of kin or a close friend. Communication and clarification of objectives A common mistake is to assume that patients and caregivers understand the progression of the disease or detect when death is imminent; it must be explicitly told. If possible, an approximate survival time should be specified and people might fall, “hoping for the best but prepare for the worst.” educate patients early, allowing them to address mental and psychosocial concerns and to advise and make thoughtful decisions about the priorities of their care. Priorities may be different in the face of death. For example, some people attach importance to the prolongation of life, even if it causes discomfort, costs money or the family burden. Other people set forth specific goals, such as the preservation of function and independence or the alleviation of symptoms, such as pain. For some people, the search for forgiveness, reconciliation, or taking care of a loved one is most important. Submitted Care plans should be documented and readily available to other health care providers (eg. As emergency room) to have the best chance to achieve the patient’s desired care to offer. State authorized instructions and the doctor’s instructions for life-sustaining treatment (POLSTPortable Orders waiving resuscitation (VaW- arrangement) and medical instructions for life-sustaining treatments) are widely used and should be readily available in the apartment and sien also noted in the patient record to the medical emergency personnel should be done in terms of when it comes to medical care and renounces what to give information. Decisions on the specific treatments can be helpful. For example, CPR and transport are not desirable in a hospital usually when death is imminent; however, certain aggressive therapies (such as blood transfusions, chemotherapy) may be desirable in order to alleviate the symptoms, even if death is inevitable. Palliative care and hospice palliative care The palliative care aims to improve the quality of life by facilitating annoying physical symptoms and psychosocial and emotional stress. Palliative care is compatible with many medical treatments and can be made available, in fact, at the same time. For example, the palliative aspect of care can emphasize the treatment of pain or delirium in a patient with liver failure, which can be on a liver transplant list. On the other hand, the statement that the care of one patient has changed from Curative for supportive or by treatment to palliative, an oversimplification of a complex decision process. Most patients require an individual Behandlungsmix to correct the effects of various diseases and disabilities, to prevent and mitigate. Physicians should initiate palliative care when patients are classified as seriously ill and v. a., when they are sick enough to die. A palliative care can be provided by individual physicians, interdisciplinary teams and hospice programs. The individual Palliative care is specialized in the detection and treatment of pain and other troublesome symptoms. Interdisciplinary palliative teams are made up of different professionals (eg. B., doctors, nurses, social workers, counselors) together, who work with family doctors and specialists of the patient in order to reduce physical, psychosocial and mental stress. Tips and risks they pull palliative care for all potentially dying patient into consideration, even for those that pursue aggressive or curative therapies. Hospice Hospice is a program of care and support for people who are very likely to die in a few months. The hospice care focuses on comfort and significance, not a cure. Among the services providing physical care, counseling, medications, durable medical equipment and consumables may include. In some countries, like the US, the hospice service is v. a. available at home; in other countries, such as England, hospice services are mainly in residential facilities. In the typical hospice care, the family members are the primary caregivers, often with additional help from welfare centers and volunteers. The hospice staff is available 24 hours a day every day. The hospice staff is specially trained. The hospice team usually consists of the personal doctor of the patient, the hospice physician or medical director; nurses; Social stations; Social workers; Spiritual or other consultants; trained volunteers; and as required voice, body and occupational therapists. Doctors are often reluctant in the decision for hospice care, as may a treatable situation is established, which is beyond the scope of the hospice area. However, this reluctance is justified because many treatable diseases in the context of hospice care can be treated, the US health care for the elderly covers all medical care related to the hospice diagnosis, and patients still have claim on health care, not is related to the hospice diagnosis related. In addition, patients can leave the hospice at any time and register later. Advance planning for the impending death of the planning for the relief of symptoms and family support can help people come to terms with the difficult part of dying. If it is expected that death occurs at home, offers a hospice team usually drugs (a comfort kit) with instructions on how to use them to suppress symptoms such as pain or shortness of breath quickly. Family members should be informed of the changes that are likely during the dying process, including confusion, drowsiness, irregular or noisy breathing, cold extremities and purple skin color. Planning can also help prevent unnecessary, burdensome hospital visits at the end of life. Family members should be told who to call (z. B. the doctor or hospice nurse or a priest) and they should know whom they should not call (z. B. rescue service). to witness the last moment in the life of the patient can have a long lasting impact on the family, friends and care staff. The patient should be in a peaceful, quiet and comfortable environment. Doctors should encourage family to maintain physical contact with the patient how to keep the hand. Hospice managers should create the conditions for spiritual, cultural, local or personal death ceremonies, which are desired by the patient or his family. Families often need help with burial or cremation companies and arranging payment for them; Social workers can provide information and advice. Regardless of the place (eg. As home, hospital, nursing home, stationary or domestic hospice service), religious practices can affect the care of the body after death and should be discussed in advance with the family of the patient, or both. Decisions about organ donation and autopsy are usually like best before death, because this is usually a less stressful time than immediately after death. Financial aspects and impairment A US study has shown that in the US a third of the families have to spend a large part of their savings in the care of a dying relative. Families should be advised to consider the cost of care for the serious illness of a family member. Information on coverage and requirements can take significant and meticulous work to complete in order to receive them. In addition to the exploration of the clinical care team, it is a good start to see a “eldercare locator”. An increasing disability often accompanies fatal illnesses. Patients can not take care of their house or apartment alone, preparing meals, take care of their financial affairs, to walk or take care of themselves gradually. Most dying patients need help during their last weeks. The clinical care team should anticipate disability and meet the necessary preparations (eg. As accommodation in facilities for the disabled and next to family members). Services such as occupational therapy or physical therapy and hospice care can support a die at home if the disability progresses. Physicians should know the financing options and their consequences and discuss these issues with patients and relatives. Some lawyers specialize in geriatric care and can help in these questions patients and their family members. The legal and ethical aspects of the care involved the laws and the attitude of the institution against living wills, durable power of attorney, euthanasia and rules of conduct in terms of a waiver should know on revival and hospitalization. This knowledge helps to ensure them that the patient’s wishes are respected, even if the patient can not decide (advance directives). Many caregivers worry that the medical treatment which has in itself a pain relief or a reduction of serious symptoms (eg opioids for pain, dyspnea, or both.) Suffering the goal may hasten death; this is true only rarely in such treatment methods, however. With skillful medical care and Medikamententitration avoid physicians most troubling, adverse drug reactions caused by opioids such as respiratory depression. Death is not accelerated by conventional treatments of common symptoms of advanced disease. Even if intractable pain or dyspnea requiring high doses of opioids that speed up the death, the resulting death is not considered to be illegal, because the drugs were given to relieve symptoms and were titrated and metered. which address the symptoms generous and disregard provide life-sustaining treatments doctors, this decision gears must be carefully documented, continue to ensure adequate treatment and be willing to discuss these decisions honestly and sensitively with patients, other stakeholders and the public. Doctors should avoid any treatment in the rule that is generally regarded as a means of killing, z. Even if the intention is as a lethal injection, the release from suffering. (N. D. Talk .: In Germany, active euthanasia is prohibited and punishable, even if it is performed at the request of the patient. If a doctor is involved, he is liable to prosecution and acts against medical ethics.) Support for suicide (for . B, direct transfer of a fatally-acting medication to the patient as well as instructions for their use) is permitted under certain conditions in Oregon, Washington, Vermont and Montana, but may be cause for prosecution in most countries. In states where physician-assisted suicide is legal, doctors and patients must comply with country-specific requirements, including patients of residence, age, decision-making ability, incurable disease, prognosis and when asked for assistance the time. In all other states and the District of Columbia, government or general laws expressly prohibit physician-assisted suicide or are unclear. In these places, a charge of murder is more likely than an accusation of euthanasia when the patient’s interests are not properly protected if he is not capable of making decisions or immediately severely restricted functional before his death unless proper documentation is present or when to expect that the courts likely to favor such an accusation. Care after the death of a doctor, nurse or other authorized person should carry out as soon as possible the official determination of death to take the family anxiety and uncertainty. The doctor should issue the death certificate as soon as possible because funeral homes need a completed death certificate to make final arrangements. Even with the expected death, the physician must report the death of the patient may a judge or the police. to tell the family members that death has occurred, especially if it was unexpected, requires planning and a broader stance. The physician should use clear language when he informed the family about the fact that the death occurred (eg. As the use of the word “died”). Euphemisms (z. B. “asleep”) should not be used because they are easily misinterpreted. If the family was not there when you die, physicians should describe what has happened, including resuscitation, and that the patient suffered no pain or distress, if it is true. (If CPR is performed, nurses may prefer to let this witness, there is no evidence that this deteriorates revitalizing results.) The prudence requires it to try that close relationship does not hear the news alone. Especially when an unexpected death, family members can process the information immediately and may be in shock. Doctors, nurses and other caregivers should address the psychological needs of the members and provide appropriate advice, a pleasant environment in which the members can grieve together, and for sufficient time that they can spend together with the corpse. Before family members see the body, stains and hoses should be removed and smells, whenever possible, be masked. If possible, it may help if the doctor is there when the family members see the corpse for the first time, because this situation is unfamiliar to many. Sometimes it is best to leave the family alone for a while, and then return to talk with the members and answer their questions. Friends, neighbors and a priest can play a supportive role. Doctors should react cautiously to cultural differences in behavior at the time of death. When appropriate, the patient can decide about organ or tissue donation before death or the relatives and the clinical care team should address the issue of organ and tissue donation, it is best to discuss before the death or immediately afterwards; Such discussions are normally required by law. The attending physician must be familiar with organ donation, even in patients who die at home or in a care facility. An autopsy should be easily accessible, regardless of where the death occurred, and decisions about autopsies can be done before death or after death. A few families want an autopsy to clarify uncertainties, and doctors should appreciate the role of the autopsy in quality improvement.

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