Mitsumoto and Rabkin identified clinical findings that justify starting to talk to a patient with amyotrophic lateral sclerosis (ALS) about end-of-life issues. The trick is to time the discussion before the person descends into a terminal state. The authors are from Columbia University in New York City.


End-of-life issues include:

(1) advanced directives related to care

(2) will and other legal documents

(3) terminal care (hospice, other)

(4) funeral arrangements


Clinical findings:

(1) Advanced dysphagia that necessitates the placement of a feeding tube.

(2) The loss of function in 2 or more body regions (arms, legs, etc).

(3) Severe respiratory impairment, indicated by one or more of the following:

(3a) FVC <= 50% of predicted

(3b) severe dyspnea

(3c) symptomatic hypoventilation

(4) Severe pain, necessitating high doses of potent analgesics.

(5) Severe levels of physical suffering

(6) Severe levels of psychological or emotional distress


Other triggers:

(1) The patient or family have asked about end-of-life issues, directly or indirectly.


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