You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.



The Last Hours of Living: Practical Advice for Clinicians

  • Authors: Linda Emanuel, MD, PhD; Frank D. Ferris, MD; Charles F. von Gunten, MD, PhD; Jamie H. von Roenn, MD
  • CME/CE Released: 2/12/2010
  • Valid for credit through: 2/12/2012, 11:59 PM EST
Start Activity

Target Audience and Goal Statement

This activity is intended for physicians, physician assistants, nurse practitioners, nurses, students, and other clinicians who care for patients during their last hours of life.

The goal of this activity is to provide a comprehensive overview of the last hours of life, focusing on the assessment and management of common physical symptoms and syndromes near the time of death.

Upon completion of this activity, participants will be able to:

  1. Assist families to prepare for the last hours of life
  2. Assess and manage the pathophysiologic changes of dying
  3. Pronounce a death and notify the family


As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


  • Linda Emanuel, MD, PhD

    Director, Buehler Center on Aging, Health & Society, Chicago, Illinois; Professor of Health Industry Management, Kellogg School of Management, Northwestern University, Evanston, Illinois; Professor of Medicine, Northwestern University Medical School, Evanston, Illinois


    Disclosure: Linda Emanuel, MD, PhD, has disclosed no relevant financial relationships.

  • Frank D. Ferris, MD

    Director, International Programs, Institute for Palliative Medicine at San Diego Hospice, San Diego, California


    Disclosure: Frank D. Ferris, MD, has disclosed the following relevant financial relationships:
    Served as a speaker or member of a speakers bureau for: Wyeth Pharmaceuticals Corporation
    Received grants for clinical research from: National Cancer Institute; Open Society Institute

  • Charles F. von Gunten, MD, PhD

    Provost, Institute for Palliative Medicine at San Diego Hospice, San Diego, California; Editor-In-Chief, Journal of Palliative Medicine, San Diego, California


    Disclosure: Charles. F. von Gunten, MD, PhD, has disclosed no relevant financial relationships.

  • Jaime H. Von Roenn, MD

    Medical Director, Palliative Care and Home Hospice Program, Northwestern Memorial Hospital, Chicago, Illinois; Professor of Medicine, Division of Hematology/Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Co-Principal, The EPEC Project; Editor, EPEC-O Curriculum; Member, Board of Directors, American Academy of Hospice and Palliative Medicine; Member, Board of Directors, American Society of Clinical Oncology; Editor-in-Chief, The Journal of Supportive Oncology


    Disclosure: Jamie H. von Roenn, MD, has disclosed no relevant financial relationships.


  • Susan Yox, RN, EdD

    Director, Editorial Content, Medscape, LLC


    Disclosure: Susan Yox, RN, EdD, has disclosed no relevant financial relationships.

  • Cheryl Arenella, MD, MPH

    Cancer Education Program Specialist, Contractor, National Cancer Institute, Office of Education and Special Initiatives, Rockville, Maryland


    Disclosure: Cheryl Arenella, MD, MPH, has disclosed no relevant financial relationships.

Nurse Planner

  • Susan Yox, RN, EdD

    Director, Editorial Content, Medscape, LLC


    Disclosure: Susan Yox, RN, EdD, has disclosed no relevant financial relationships.

CME Reviewer(s)

  • Laurie E. Scudder, MS, NP

    Accreditation Coordinator, Continuing Professional Education Department, Medscape, LLC; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC; Nurse Practitioner, School-Based Health Centers, Baltimore City Public Schools, Baltimore, Maryland


    Disclosure: Laurie E. Scudder, MS, NP, has disclosed no relevant financial relationships.

Accreditation Statements

    For Physicians

  • This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Medscape LLC, The EPEC Project (Education on Palliative and End-of-life-care), and the National Cancer Institute. Medscape LLC is accredited by the ACCME to provider continuing medical education for physicians.

    Medscape, LLC designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™ . Physicians should only claim credit commensurate with the extent of their participation in the activity.

    Medscape, LLC staff have disclosed that they have no relevant financial relationships.

    Contact This Provider

    For Nurses

  • Medscape, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

    Awarded 1.5 contact hour(s) of continuing nursing education for RNs and APNs; 0.5 contact hours are in the area of pharmacology.

    Accreditation of this program does not imply endorsement by either Medscape, LLC or ANCC.

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. MedscapeCME encourages you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates by accessing "Edit Your Profile" at the top of your Medscape homepage.

*The credit that you receive is based on your user profile.


The Last Hours of Living: Practical Advice for Clinicians

Authors: Linda Emanuel, MD, PhD; Frank D. Ferris, MD; Charles F. von Gunten, MD, PhD; Jamie H. von Roenn, MDFaculty and Disclosures

CME/CE Released: 2/12/2010

Valid for credit through: 2/12/2012, 11:59 PM EST


Introduction to the Last Hours of Living

Clinical competence, willingness to educate, and calm and empathic reassurance are critical to helping patients and families during a loved one's last hours of living. Clinical issues that commonly arise in the last hours of living include the management of feeding and hydration, changes in consciousness, delirium, pain, breathlessness, and secretions. Management principles are the same whether the patient is at home or in a healthcare institution. However, death in an institution requires accommodations that may not be customary to assure privacy, cultural observances, and communication. In anticipation of the event, inform the family and other professionals about what to do and what to expect. Care does not end until the family has been supported with their grief reactions and those with complicated grief have been helped to get care.

Case Study: A.F. Is Dying at Home

A.F. is a 79-year-old woman with metastatic breast cancer who is in her own home, cared for by her daughter with the help of the home hospice program. She developed aspiration pneumonia, and was treated with oral antibiotics. Advance care planning indicates she does not want to go to the hospital under any circumstances, and oral antibiotics were an intermediate level of care. The patient and daughter agree that if she gets better, she may have some quality of time left. But if she doesn't, A.F. says she is ready to go. Her physician makes a joint home visit with the home hospice nurse in order to assess changes in mental status and because it sounds like her daughter panicked and considered calling 911.

This feature requires the newest version of Flash. You can download it here.

Of all people who die, only a few (< 10%) die suddenly and unexpectedly. Most people (> 90%) die after a long period of illness, with gradual deterioration until an active dying phase at the end.[1] Care provided during those last hours and days can have profound effects, not just on the patient, but on all who participate. At the very end of life, there is no second chance to get it right.

Most clinicians have little or no formal training in managing the dying process or death. Many have neither watched someone die nor provided direct care during the last hours of life. Families usually have even less experience or knowledge about death and dying. Based on media dramatization and vivid imaginations, most people have developed an exaggerated sense of what dying and death are like. However, with appropriate management, it is possible to provide smooth passage and comfort for the patient and all those who watch.