SIGNS AND SYMPTOMS OF APPROACHING DEATH

1. Policy # H:5-008.1 SIGNS AND SYMPTOMS OF APPROACHING DEATH

2. Purpose: • To provide guidelines for recognizing the signs and symptoms of approaching death and taking appropriate action • Policy: • A family/caregiver instruction sheet will be provided to hospice patients and family/caregivers describing signs and symptoms of approaching death and appropriate actions to take Signs and symptoms of approaching death – policy # h:5-008.1

3. Catheterization– insertion of tube into patient’s bladder to facilitate removal of urine Pulmonary Edema – Fluid accumulation in the tissues of the lungs Terminal Anguish – state PRIOR to death where patient is unable to suppress or repress painful, unresolved psychological issues Terminal Restlessness – Prior to entering semi comatose state patient becomes restless, confused and possible seizure activity Definition of Terms

4. Each of us will face death sooner or later • Less than 10% will die suddenly • More than 90% of us will die due to a prolonged illness • There is NO typical death experience. Each person dies in their own way, own time, and their own cultural, belief system, values, and unique relationships with others • The time of death generally cannot be predicted • The final days and hours before a patient dies is the last opportunity for growth and development to occur in the pt/family unit • The final hours allow for patient/family to say goodbye and complete end of life closure • Emphasis should be placed on facilitating a comfortable death that honors patient/family choices What is death all about?

5. Patient/family must continue to be seen as a collaborative unit • Emphasis must be placed on optimizing patient comfort, dignity, choice, acceptance, final tasks, and life closure • All aspects of care need to intensify in order to minimize suffering • The interdisciplinary team must remain focused in order to: • Help patient achieve a dignified death • Identify emerging problems • Help family deal with immediate care needs up to and including moment of death as well as after death event • Arrange for privacy and intimacy if possible Dying is a physical, psychological, social, spiritual event

6. The time cannot be predicted Some patients instinctively know WHEN death will occur S/sx only serve a s guideline, not all patients experience all symptoms and the s/sx do not necessarily occur in sequence The dying process is a natural slowing down of physical and mental processes Can occur over days or weeks or may be present only hours/minutes prior to death What do we know about “preparing for death?” – Active Dying: Last few weeks of Life

7. Fear of dying Fear of abandonment Fear of the unknown Dreams and visions Withdrawal Increased focus on spiritual issues Terminal anguish Psychological and spiritual Signs of Active Dying

8. Increased weakness/fatigue Loss of appetite, physical wasting Nausea and vomiting Dehydration and decreased fluid intake Changes in renal and bladder function Changes in bowel function Pain Managing Physiologic/Emotional Changes

9. GENERALLY progresses to point that patient is unable to move muscles and joints independently • Turning may be painful. Head may need to be supported and/or positioned for patient • Increased need for care • ADL’s • Turning and movement INCREASED WEAKNESS AND FATIGUE

10. May begin earlier in the dying process. However, tends to intensify during active phase of dying • Family members especially need support at this time. Want to continue to feed and it is difficult for them to “let go” • Help family find alternative ways to care for their loved one • Feeding is potentially dangerous at this time as it may lead to aspiration • Anorexia may be a protective mechanism of they body. It results in a chemical imbalance (ketosis) which, in turn, creates a greater sense of well-being in the patient as well as a diminished perception of pain Loss of appetite, physical wasting

11. Along with anorexia may come nausea and vomiting This needs to managed aggressively to promote and maintain patient’s comfort Nausea and vomiting

12. Like food, your patient usually stops drinking fluids before the phase of active dying Giving fluids can prevent renal failure with subsequent accumulation of opioid metabolites, electrolyte imbalance and some elements of confusion and restlessness. HOWEVER, as death approaches, aggressive hydration therapy can actually hasten death due to pulmonary edema, worsened breathlessness, and increased oral/bronchial secretions Give oral mucosa care every 15 to 30 minutes to minimize sense of thirst and avoid bad odors or tastes and painful cracking; use lip balms Dehydration/decreased fluid intake

13. Urine output usually diminishes gradually in response to decreased food and fluid intake Incontinence and/or retention may also occur. Retention may require catheterization to promote comfort Changes in kidney and bladder functions

14. Constipation may continue as a problem due to decreased food intake as well as decreased activity of the gut due to continued pain medication routines Impaction may need to be addressed if contributing to marked patient discomfort Changes in bowel function

15. Like other symptoms, pain must continue to be managed with the same vigor as at any point in the illness Although pain intensity may decrease and/or may not be self-reported due to altered states of consciousness and/or metabolic changes, pain therapy may need to e adjusted to accommodate for changes in LOC or RR Pain

16. Semi comatose state Impaired heart and renal function Respiratory dysfunction Neurologic dysfunction Last hours of life

17. Eyes become sunken and glazed; often are half open Senses are generally dulled except hearing may not be lost; sensitivity to light may remain Ability to move decreases, beginning in the legs and progressing to the arms Body becomes still and joints painful when moved Only essential medications for symptom management are given Semi comatose state

18. Cardiac output decreases with a corresponding decrease in peripheral and renal perfusion Pulse rate increases initially (compensatory mechanism – need more volume) and then weakens and becomes irregular. Radial pulse may be so faint – nonpalpable BP decreases Peripheral cooling (lack of perfusion) bluish coloring and mottling of skin noted Patient may perspire; peripheral edema may develop Body temperature may increase due to possible infection and/or increased tumor activity in cancer patients Impaired heart and renal function

19. Breathing may become shallow or labored Respiration may increase in rate and then decrease, (compensatory mechanism) increase in rate and then slow again Secretions may increase; resident may have difficulty coughing and clearing secretions and swallowing effectively Feelings of “lack of air” and breathlessness may increase as death approaches Death “rattle”: Terminal congestion occurs due to changes in respiratory rate and inability of patient to clear secretions Respiratory dysfunction

20. Result of multiple nonreversible factors: • Metabolic imbalances • Acidosis • Kidney failure • Infection • Reduce blood flow to brain • Leads to “2” roads to death: Neurologic symptoms

21. The majority of persons travel the “usual road.” • They experience increasing drowsiness and eventually become unarousable. Stages are as follows: • Decreasing LOC • Sleepiness • Lethargic • Semi comatose • Comatose (almost equivalent to full anesthesia) • DEATH The “usual road” to death

22. Due to nervous system agitation prior to entering semi comatose state • Restlessness • Confusion • Tremors • Hallucinations • Mumbling delirium • Muscle jerking • Seizures • Semi comatose • Comatose • DEATH The “difficult road’ to death

23. Absence of heartbeat, respirations • Fixed pupils • Release of stool and urine • No response to stimulation • Coloration of patient turns to a waxen pallor as blood settles/pools • Body temperature drops • Muscles, sphincter relax • Eyes may remain open • Jaw falls open • Body fluids may be heard trickling internally Signs that death has occurred

24. Care shifts from resident to family/caregivers KNOW who to call; goal is NOT to call 911 on a routine basis Follow traditions, rites, rituals; prepare body accordingly Know whether resident has requested organ donation – how to proceed Follow procedures as outlined in Ambercare’s Policy and Procedure Initiate bereavement support Remember every patient and family are unique! What to do when death occurs

25. Stay with me…. Walk with me…. Help me to “fear no evil”…. Comfort me…. Facilitate my closure….. Help me leave my legacy in peace…. Last thoughts…..

27. References:Various resources incorporated into this presentation: Adapted from: - HOM/IOG: Barker, C., & Foerg, M.,- Hospice of Michigan