Catholic Medical Quarterly Volume 63(4) November 2013
Practical Medical Ethics:
CONSIDER: a mnemonic for care
of the dying
C is for Consider
- the situation calmly, with care and compassion.
- Is the patient imminently dying?
- Where does your patient want to be- home or hospital?
- How secure is the diagnosis?
- Have all reversible aspects been considered?
- Have legal issues been considered? What is your intention for this patient?
- Is it time to change gear and to stop striving to keep the patient alive?
- No one should be asked to consent to be sedated, except for medical reasons such as severe distress or lack of sleep, nor be subjected to dehydration.
- Is the patient able to give informed consent to any action that is proposed
O is for Other.
- Consider other approaches- e.g. active treatment of chest infection, heart failure, UTI etc.
- Consider other diagnoses
N is for Nutrition and hydration.
- Is it possible to feed the patient? Have you considered the need for a PEG?
- Can hydration be maintained by the use of subcutaneous fluids? If not why not?
- Always relieve thirst by mouth or in any other way.
S is for Spiritual care
- Simple services cheer souls.
- Dying patients may want to see a priest.
- See Spiritual Guidelines in the Dying: published by Catholic Bishops.
I is for Information
- Give the patient information if they seek it, but do so gently. Be honest but gentle. It is so important for patients generally to realise the reality of the situation and attend to their spiritual needs, but it may take a considerable time for some to reach this moment. The "Five Stages of Grief" (see below) have to be worked through.
- Minimise potential problems and assure your patient that help will be available if needed.
- Do not overstep the bounds of your competence in such discussions.
- Consult colleagues and get professional help when necessary.
- Few patients wish to know their proximity to death.
- Some cope by denying death until it can no longer be ignored.
- Be realistic- but leave room for hope, and always try to breathe hope into impossible situations in one way or another.
D is for Distress and Dying.
- Discuss any issues that arise, but do not force discussions about death on your patients.
- Assure adequate and appropriate relief of pain and distress
- Remember Cicely Saunders model of “Total pain” including Physical, Mental and existential pain
- Help your patient to live with dignity until they die.
- Try to ensure that family and friends whom they wish to see are contacted in time.
- It is always helpful to remember the "Five stages of Grief" hypothesis introduced by Elizabeth Kublar-Ross (from her book "On Death and Dying") that patients have to pass through before accepting death.
E is for Euthanasia which should remain unlawful.
- Resist pressure to assist a suicide - or risk a 14 year jail sentence.
- If you have serious concerns about a death alert the police and report death to the Coroner.
R is for Relatives.
- Are the patients relatives and carers coping? Have they said their good byes?
- Beware of those who wish the patient dead.
- The bad death of a loved one can destroy lives and cause post-traumatic stress.
- Some relatives will need bereavement counselling.
We are grateful to dr Gillian Craig for the original version of this mnemonic.