The Ultimate Challenge: Managing Falls During Progressive Physical Decline

Falls are a seemingly preventable occurrence in most settings. However, in end of life care, the progressive deterioration of both cognitive and physical/motor skills with disease process, treatment effects, and aging means falls are increasingly common. Along with such, patient and family autonomy become more important as they seek quality of life as death nears.

How do we approach this clinical conundrum?

A Natural Occurrence

Falling risk increases with disease and decline at end of life.¹ It is unreasonable to believe that a person can go from normal activity to their last breaths without experiencing some increased fall risks. Even The Joint Commission recognizes that a certain number of falls are endemic to all care environments and supports agency program development to specifically address falls in the context of palliative or hospice client needs.

Triangle of Safety

Communication with both the patient and family caregivers is essential. Initial contact should focus on listening to their concerns and stories of recent events. These may shed light on the nature of the fall risks in the context of each person’s desire for living as they go forward.

After performing an appropriate assessment, a group discussion should ensue. Together we can identify pertinent risk factors, and suggest a variety of abatement measures including equipment options, environmental changes, and possible levels of assistance.

Establishing goals should come from a mutual agreement of all three parties; patient, family/caregiver, and therapist. Using this concept of the Triangle of Safety, all parties can collaborate on an acceptable plan with full knowledge and informed consent after risks and solutions are identified.

Explaining Terminal Falls

Falls can potentially occur at the last moments of life and will need to be put into context. In anticipation of such circumstances and timing, a hospice therapist is well equipped to act as a guide in this transition to a terminal event.

Spirit Leaving the Body

Some people experience terminal agitation and try to get up, even when their body is no longer able to support weight or manage safe ambulation. This can be seen as an attempt of the body to follow the spirit, which it has done in unity throughout a lifetime, as now the natural separation at end of life occurs. The collapse is inevitable and not a caregiver’s responsibility, despite the sadness and possible remorse for not preventing the event.

Going Toward the Light

Another conceptualization of this type of fall is the oft-reported and observed occurrence of the dying person going toward the light, or being called by a dead loved one from the other side.² The dying person must go along, and in their leaving, falls.

Either of these ideas, when sensitively explained as a possibility, can both assure the family/caregiver of their adequate attention to care and the ultimate safe passage in the dying person’s last acts.