Dying at home: cultural and religious preferences

Excerpt

We were pleased to read the brief report by Beuks et al. in a recent issue of Intensive Care Medicine [1]. The authors reported two cases of patients discharged from ICU to die at home. The two patients have late-stage neoplasic diseases beyond any therapeutic options. We agree with the procedure used in these two patients. In our ICU, this procedure has been used for many years nearly for 10% of our patient deaths (10 of 102 deaths in 2005). This procedure involved critically ill non-cancer patients who were discharged in-extremis to die at home when their clinical state was considered as intractable despite well-conducted diagnostic and therapeutic procedures (i. e., late septic shock state, multi-organ failure, etc.). In such patients, information was given daily to family members. Prognosis and therapeutic possibilities were discussed and corrected daily. Family members became progressively aware of the instability of the clinical state of their loved one. When the clinical state became irreversible as merely judged by the medical staff, family members were asked about their preferences regarding end of life. When family members preferred their parent dying in the hospital, they could be called even at late hours at night when dying is judged imminent by the medical staff to allow proximity when the event happens. When they expressed preference for their parent dying at home, geographical conditions and clinical stability were checked to allow the patient to be transferred home. The procedure is triggered and the family is explained that dying will occur within several hours after withdrawal of respiratory and hemodynamic life support. In some cases the procedure is spontaneously suggested by family members to the medical staff. The procedure is performed with the awareness of the hospital administration. Medical transportation is arranged for this purpose. Patient conditioning is simplified to respiratory and hemodynamic life support. A resident and nurse usually accompanied the patient to withdraw life support at home. When, at home, the patient is carefully installed in his room, tracheal tube and vasopressive drugs are withdrawn and the family members are told that death will rapidly ensue. This procedure has several advantages. Firstly, it permits to meet family members needs and satisfaction because it allows an ultimate contact with their loved one at home when death occurs, a situation culturally strongly desired and approved. Secondly, it avoids all administration procedures when death occurs at hospital especially for family living far from the institution, and allows rapid funeral, within 24 h after death occurred, which is religiously strongly recommended. This procedure has been used since many without any problem. Bereaved family members frequently returned to thank us for having afforded them such an opportunity and to report a favorable dying experience. …