The Death of Actively Dying

Dear Editor:

“I want to let you know that your patient is actively dying. Is it okay to increase the morphine drip?” I received this call from an outpatient hospice nurse early Saturday morning regarding my brain tumor patient.

The term “actively dying” is used ubiquitously in medicine to describe the process of death near the end of life. It is meant to convey the severity or rapidity of the dying process. It emphasizes urgency and immediacy. In ICU patients, it often conveys that we need to do something to reverse the dying process. Or worse, that it's too late to intervene and that active treatment must end. In patients with terminal cancer, it conveys that we need to make the process smoother, rounding out the edges of a long journey with cancer. Sometimes, the phrase indicates that patients are driving this process. As some practitioners suggest, some patients are “trying to die.”

Such a characterization is problematic, however. This description can imply that our patients may want their lives to end, and it can cause practitioners to act erratically in response to a term that causes anxiety. If our patients are actively dying, should we slow or hasten this process? Does the term indicate that our patients are suffering or merely that their bodies are shutting down? How fast do we need to act when we hear this term, and what should we do about it?

Most importantly, we must be careful about what message we convey to our patients' family and friends. This phrase may be at odds with their awareness of the patient's will or perhaps worse, at odds with the patient's spiritual or religious leanings. This can create a therapeutic chasm between the health care team and the patient's loved ones in what is almost uniformly an emotionally charged time, forging long-lasting negative emotions regarding the dying process.

Instead of using the term “actively dying,” we can acknowledge to ourselves and to the patient's loved ones that the rate of dying may be accelerating and that death is imminent. And we can acknowledge that our patients are terminally ill without retreating from their care. When our colleagues suggest that their patients are actively dying, we might inquire more specifically about their patient's dying process. We might ask whether any aspect of their care appears insufficient or what we can do to quiet the perhaps painful-appearing dying process. We might revisit their goals of care or wishes for their last days of life. Critically, we should emphasize our resolve to our patients and their families that we will maintain the same commitment to their care throughout the living and dying phase of their lives.

In response to the hospice nurse, I said that it was fine to increase the patient's morphine drip to allow more comfort during the dying process. I did not delve further into the active dying process at the time, quietly hoping for the term itself to die.