Editing Terminal illness (section)

== Dying ==
When dying, patients often worry about their quality of life towards the end, including emotional and physical suffering.<ref name="Hendry-2013"/>

In order for families and doctors to understand clearly what the patient wants for themselves, it is recommended that patients, doctors, and families all convene and discuss the patient's decisions before the patient becomes unable to decide.<ref name="AHRQ-2017"/><ref name="Qaseem-2008"/><ref name="Brinkman-Stoppelenburg-2014">{{Cite journal|last1=Brinkman-Stoppelenburg|first1=Arianne|last2=Rietjens|first2=Judith AC|last3=van der Heide|first3=Agnes|date=2014-09-01|title=The effects of advance care planning on end-of-life care: A systematic review|journal=Palliative Medicine|volume=28|issue=8|pages=1000–1025|doi=10.1177/0269216314526272|pmid=24651708|s2cid=2447618|issn=0269-2163}}</ref>

=== Advance directives ===
At the end of life, especially when patients are unable to make decisions on their own regarding treatment, it is often up to family members and doctors to decide what they believe the patients would have wanted regarding their deaths, which is often a heavy burden and hard for family members to predict. An estimated 25% of American adults have an advance directive, meaning the majority of Americans leave these decisions to be made by family, which can lead to conflict and guilt. Although it may be a difficult subject to broach, it is important to discuss the patient's plans for how far to continue treatment should they become unable to decide. This must be done while the patient is still able to make the decisions, and takes the form of an [[Advance healthcare directive|advance directive]]. The advance directive should be updated regularly as the patient's condition changes so as to reflect the patient's wishes.<ref name="Cancer.org-2017">{{Cite web|url=https://www.cancer.org/treatment/finding-and-paying-for-treatment/understanding-financial-and-legal-matters/advance-directives/faqs.html|title=Frequently asked questions|website=www.cancer.org|access-date=2017-10-30}}</ref><ref name="Mitnick-2010b"/>

Some of the decisions that advance directives may address include receiving fluids and nutrition support, getting blood transfusions, receiving antibiotics, resuscitation (if the heart stops beating), and intubation (if the patient stops breathing).<ref name="NCI-2007">{{Cite web |date=2007-12-18 |title=Last Days of Life |url=https://www.cancer.gov/about-cancer/advanced-cancer/caregivers/planning/last-days-pdq#section/all |access-date=2017-11-26 |website=National Cancer Institute}}</ref>

Having an advance directive can improve end-of-life care.<ref name="Brinkman-Stoppelenburg-2014"/>

It is highly recommended by many research studies and meta-analyses for patients to discuss and create an advance directive with their doctors and families.<ref name="AHRQ-2017"/><ref name="Brinkman-Stoppelenburg-2014" /><ref name="Qaseem-2008"/>

=== Do-not-resuscitate ===
{{Main articles|Do not resuscitate}}
One of the options of care that patients may discuss with their families and medical providers is the [[Do not resuscitate|do-not-resuscitate]] (DNR) order. This means that if the patient's heart stops, CPR and other methods to bring back heartbeat would not be performed. This is the patient's choice to make and can depend on a variety of reasons, whether based on personal beliefs or medical concerns. DNR orders can be medically and [[legally binding]] depending on the applicable [[jurisdiction]].<ref name="Osinski-2017">{{Cite journal|last1=Osinski|first1=Aart|last2=Vreugdenhil|first2=Gerard|last3=Koning|first3=Jan de|last4=Hoeven|first4=Johannes G. van der|date=2017-02-01|title=Do-not-resuscitate orders in cancer patients: a review of literature|journal=Supportive Care in Cancer|volume=25|issue=2|pages=677–685|doi=10.1007/s00520-016-3459-9|pmid=27771786|s2cid=3879244|issn=0941-4355}}</ref>

Decisions like these should be indicated in the advance directive so that the patient's wishes can be carried out to improve end-of-life care.<ref name="Cancer.org-2017"/>

=== Symptoms near death ===
A variety of symptoms become more apparent when a patient is nearing death. Recognizing these symptoms and knowing what will come may help family members prepare.<ref name="NCI-2007"/>

During the final few weeks, symptoms will vary largely depending on the patient's disease. During the final hours, patients usually will reject food and water and will also sleep more, choosing not to interact with those around them. Their bodies may behave more irregularly, with changes in breathing, sometimes with longer pauses between breaths, irregular heart rate, low blood pressure, and coldness in the extremities. It is important to note, however, that symptoms will vary per patient.<ref>{{Cite web|url=http://www.hospicepatients.org/hospic60.html|archive-url=https://web.archive.org/web/19990826174709/http://www.hospicepatients.org/hospic60.html|url-status=usurped|archive-date=26 August 1999|title=Hospice Patients Alliance: Signs of Approaching Death|website=www.hospicepatients.org|access-date=2017-11-26}}</ref>

=== Good death ===
Patients, healthcare workers, and recently bereaved family members often describe a "good death" in terms of effective choices made in a few areas:<ref name="pmid10819707">{{cite journal |vauthors=Steinhauser K, Clipp E, McNeilly M, Christakis N, McIntyre L, Tulsky J |title=In search of a good death: observations of patients, families, and providers |journal=Annals of Internal Medicine |volume=132 |issue=10 |pages=825–32 |date=16 May 2000|pmid=10819707 |doi=10.7326/0003-4819-132-10-200005160-00011|s2cid=14989020 }}</ref>

* Assurance of effective pain and symptom management.
* Education about death and its aftermath, especially as it relates to decision-making.
* Completion of any significant goals, such as resolving past conflicts.<ref name="Steinhauser-2000"/>

In the last hours of life, [[palliative sedation]] may be recommended by a doctor or requested by the patient to ease the symptoms of death until they die. Palliative sedation is not intended to prolong life or hasten death; it is merely meant to relieve symptoms.<ref>{{Cite journal|last1=Claessens|first1=Patricia|last2=Menten|first2=Johan|last3=Schotsmans|first3=Paul|last4=Broeckaert|first4=Bert|date=2008-09-01|title=Palliative Sedation: A Review of the Research Literature|journal=Journal of Pain and Symptom Management|volume=36|issue=3|pages=310–333|doi=10.1016/j.jpainsymman.2007.10.004|pmid=18657380|doi-access=free}}</ref>