Presented

1. Prolonged Dying Phase
is licensed under aCreative Commons Attribution-ShareAlike 3.0 Unported License
Christian Sinclair, MD, FAAHPM – ctsinclair@gmail.com @ctsinclair
March 2012 - AAHPM Annual Assembly
Slides available on Slideshare before during and after the conference http://www.slideshare.net/ctsinclair
Disclosures: none
Objectives:
Describe the challenge of prolonged dying from the perspective of patient and family
Understand the difference between objective and subjective measurements of time and prognosis
Describe how the perspective of time and prognosis influences suffering at the end of life
Working definition:
Prolonged dying phase is identified when the dying process ofa terminal patient with minimal functionexceeds
the expected or true prognosisto the degree whichthe patient, family or health care teambegins to question
the expected time frame.Physical symptoms and physical sufferingdo not need to be present for PDP,yet
suffering related to time and expectationsmay be experienced by all involved.
Aspects of PDP
• Patient is terminally ill
• Care setting and tenor reflects terminal status
• PPS ≤ 30%
• May be identified by patient, family or staff
• Usually acceptance; even welcoming of death
• Suffering dependent on perception of time/ meaning as opposed to physical symptoms
What PDP is not…
• “We’re all dying…”
– Denial/minimizing coping mechanisms
• Lack of consensus of impending death
• Not from first declaration of terminality/diagnosis
• Not a side effect of medically hastened deaths
• Depression
Subjective vs. Objective PDP
SUBJECTIVE OBJECTIVE
• Prognosis dependent • Stochastic (random)
– Errant prediction • Medical interventions
• Communicated • Failed external outcome
• Formulated • Organ transplant
• Perceived • Special event
– Multiple predictor (wide range) • Statistical deviation
– Altered time passage
• Prognosis independent
– Stochastic (random)
– Labeling
– Acceptance
– “Time bind” hypothesis
– Altered time passage

2. Time bind hypothesis (Hothschild 1997) – The fast pace of our lives makes us less patient with indefinite
or extended periods of time
University of Wisconsin Donation after Cardiac Death Evaluation Tool (2003)