Makindo Medical Notes

Death is a universal biological event and a profound human experience. For clinicians, understanding the physiology, recognition, certification, communication, and ethical frameworks around dying is essential to provide safe, compassionate, and lawful care.

📖 Introduction

• Death may be defined medically as the irreversible cessation of cardiorespiratory function or the irreversible loss of all brainstem function (brainstem death criteria in the UK).
• Dying is often a gradual process, with predictable physiological changes in the last days and hours of life.
• Doctors have responsibilities not just to the patient but also to the family, carers, and society.

🔬 Physiology of Dying

• Circulation: BP falls, peripheral shutdown, weak/absent pulses, mottled skin.
• Respiration: Cheyne–Stokes breathing, apnoeic episodes, reduced oxygenation.
• Neurology: Reduced consciousness, delirium, agitation, or peaceful withdrawal; pupils sluggish or fixed late.
• Metabolism: Reduced oral intake, dehydration, accumulation of metabolites → terminal restlessness.
• Other: Reduced urine output, loss of sphincter control, cool peripheries.

⚠️ Recognising the Dying Patient

• Bedbound, increasing sleepiness, reduced intake of food and fluids.
• Frequent hospital admissions, progressive irreversible decline.
• Failure of multiple systems (renal, cardiac, respiratory, neurological).
• Use of “Surprise Question”: Would you be surprised if this patient were to die in the next 6–12 months?

🩺 Causes & Patterns of Death

• Sudden death: MI, arrhythmia, PE, trauma, intracranial bleed.
• Terminal illness: Cancer, end-stage organ failure, dementia, frailty.
• Brainstem death: Severe head injury, intracranial haemorrhage, hypoxic brain injury.

📑 Certification & Legal Aspects (UK)

• Doctor must have seen patient in last 28 days to issue Medical Certificate of Cause of Death (MCCD).
• Report to coroner if: cause unknown, suspicious, surgery in last 24 h, industrial disease, or neglect suspected.
• Brainstem death: requires confirmation by two senior doctors using strict criteria.

🧪 Investigations Around Death

• Usually limited once dying is recognised → focus on comfort.
• In sudden/uncertain deaths: ECG, imaging, bloods as appropriate.
• Autopsy may be required by coroner for unexplained/suspicious deaths.

💊 Symptom Control at End of Life (Palliative Care)

• Pain: opioids (morphine, diamorphine SC infusion).
• Breathlessness: opioids, oxygen if hypoxic, fan/open window, benzodiazepines if anxious.
• Agitation/delirium: midazolam, haloperidol.
• Respiratory secretions (“death rattle”): glycopyrronium, hyoscine butylbromide.
• Nausea/vomiting: levomepromazine, cyclizine, metoclopramide depending on cause.

🧠 Psychological, Social & Spiritual Aspects

• Patients may experience fear, loss of identity, or existential distress.
• Families often need support with anticipatory grief and decision-making.
• Spiritual care: respect cultural/religious practices, chaplaincy referral if desired.

⚖️ Ethical Principles

• Autonomy: respect patient’s wishes, advance decisions, DNACPR orders.
• Beneficence & Non-maleficence: act in patient’s best interests, avoid unnecessary burdensome interventions.
• Justice: fair allocation of resources, equitable access to palliative care.

📢 Communication with Patients & Families

• Honest but sensitive → avoid euphemisms, use clear words (“dying”, “death”).
• Check understanding: allow silence, explore emotions.
• Discuss ceilings of care (DNACPR, ICU admission, IV fluids, antibiotics).
• Provide written information and signpost to bereavement services.

📊 Common Frameworks

• Gold Standards Framework (GSF): systematic identification and planning for end-of-life care in the community.
• Liverpool Care Pathway (LCP): now replaced, but triggered national awareness of structured dying care.
• ReSPECT process: personalised recommendations for emergency care and treatment.

Cases — End-of-Life Care (Managed Well)

• Case 1 (Advanced cancer with symptom control): 🎗️ A 68-year-old woman with metastatic pancreatic cancer is admitted with uncontrolled abdominal pain and nausea. Palliative team review her promptly. Opioids are titrated (oral morphine switched to syringe driver diamorphine), antiemetics rationalised, and laxatives added. A “Just in Case” medication box is prescribed for home use. Outcome: Pain and nausea are well controlled. She is discharged home with community palliative nursing support. She dies peacefully at home with her family, as per her wishes.
• Case 2 (End-stage heart failure with breathlessness): ❤️‍🩹 A 79-year-old man with severe heart failure has repeated hospital admissions for pulmonary oedema. He expresses a wish not to return to hospital. An advance care plan (ACP) is discussed and documented. Home-based diuretics are optimised, and low-dose oral morphine started for refractory breathlessness. Oxygen and fan therapy used as adjuncts. Outcome: No further hospital admissions. He dies at home in comfort, with ACP guiding care. His family are supported throughout by the palliative team.
• Case 3 (Neurodegenerative disease and anticipatory planning): 🧠 A 60-year-old woman with advanced motor neurone disease (MND) has progressive dysphagia and breathlessness. Multidisciplinary input ensures non-invasive ventilation, PEG feeding when appropriate, and communication aids. A DNACPR order and ReSPECT form are completed in discussion with her and her family. Anticipatory medications are prescribed early. Outcome: She avoids crisis hospital admissions. Care is delivered at home with dignity, with her family present. Death occurs peacefully with pre-agreed measures in place.

🧑‍⚕️ Teaching Commentary

Good end-of-life care involves: • Symptom control (pain, breathlessness, nausea, agitation). • Advance care planning (DNACPR, preferred place of care, ReSPECT forms). • Holistic support for patients and families (physical, psychological, spiritual). • Anticipatory prescribing with “Just in Case” medications. 🌟 These cases highlight that when managed proactively, patients can achieve a peaceful and dignified death in their preferred setting, avoiding unnecessary hospitalisations.

📚 References

• GMC. End of life care: Treatment and care towards the end of life. 2010.
• NICE NG31. Care of dying adults in the last days of life. 2015.
• Oxford Textbook of Palliative Medicine.
• RCPath & Academy of Medical Royal Colleges. Brainstem death testing guidance.

💡 Summary: Death and dying are inevitable yet challenging parts of clinical practice. Doctors must balance accurate recognition, sensitive communication, and effective palliative care, within ethical and legal frameworks. Good end-of-life care enables dignity, comfort, and support for both patient and family.