Dying-What Really Happens

emotional fears of death

- Being unprepared for death and what happens after death

Terminal delirium overview

"The difficult road to death" Medical management benzodiazepines: lorazepam, midazolam neuroleptics: haloperidol, chlorpromazine Seizures Family needs support, education

physical signs of death minutes before

"fish out of water" or "death rattle" breathing "death stool"

overview of stages of dying

(not everyone goes through all stages) stages vary in length predictions are guidelines mind/body/spirit can affect process nothing to "do"

t/f: small percentage of individuals prefer to die in the hospital

true

masked grief

unaware that behaviors are a result of the loss

Non-pharmaceutical Options to manage pain

Alpha and theta-wave entrainment:Christian monastic death prep music Bio-energy interventions: Reiki, Healing Touch, Quantum Touch Guided visualization, prayer, meditation: Aromatherapy anxiety, confusion, pain relief, breathlesness Gentle massage: hands, feet, brow and head, ears Environment of quiet and serenity: low light, no TV, slow approach, co-breathing Soothing tone of voice Hand holding: under the hand

Tasks of the grieving (4)

1. Accept the reality of the loss 2. Experience the pain caused by the loss 3. Adjust to the new environment after the loss 4. Rebuild a new life

Skin Color Changes

A variety of changes may occur in the final hours-to-days before death: Vasoconstriction with cyanosis Mottling Ashen color Digital necrosis There is no specific treatment approach

Postmortem Care

ALLOW family/friends to spend time with the deceased and initiate the grieving process Postmortal care as per facility procedures Provide privacy, support and comfort Honor last wishes/requests from family members (within reason)

Signs of Death

Absence of heartbeat and respirations Pupils fixed Skin color appears yellow/waxen Muscles relaxed-Jaw falls open Eyes remain open

patients decreasing oral intake before death

All dying patients lose interest in oral intake in the days preceding death. Ketosis will blunt symptom of hunger Bedbound patient will not experience symptoms of postural hypotension No association between fluid intake and thirst in final days Oral cavity needs frequent assessment to ensure good hygiene

The patient with significant pain, entering the final days:

Assume that pain will continue to be present until death Do not discontinue opioids as mental status declines Dose reduction may be needed due to diminished renal/hepatic function: myoclonus is a sign of opioid toxicity Use physical signs of potential pain to judge analgesic need: Grimacing and groaning; Tachycardia

Bereavement care

Attendance at funeral Follow up to assess grief reactions, provide support Assistance with practical matters redeem insurance will, financial obligations, estate closure

The Dying Patient's Bill of Rights

Be treated as a human being Hope Freedom to express feelings and emotions Medical and nursing care (as indicated) Sensitive care Not to die alone Freedom from pain Honesty Help for self and family in accepting death Die in peace and dignity Retain individuality and beliefs Expect respect of body after death

Early Stage of Dying

Bed bound Loss of interest and ability to drink/eat Cognitive changes Increasing sedation; Lethargy Delirium: Hyperactive or Hypoactive

after expected death occurs,...

Care shifts from patient to family / caregivers Different loss for everyone Invite those not present to bedside Take time to witness what has happened Create a peaceful, accessible environment When rigor mortis sets in Assess acute grief reactions

physical signs of death 1-2 weeks prior

Disorientation: hallucinations; picking at clothes Body slows down: Decreased HR, BP, PO

Communication with the unconscious patient . . .

Distressing to family Awareness > ability to respond Assume patient hears everything

things that could be interfering with patient comfort

Does the patient have pain that is not being well-managed? (Outward facial expressions and body posture can be good indicators.) If the patient has a urinary catheter is urine flowing freely through it? Is the patient having regular bowel movements? Is there some other sudden change in function that may be causing distress to the patient? Could there an infection causing the agitation? Is the infection an expected effect of the disease, such as brain cancer? Is the patient going through obvious psychological and emotional distress? Has a new medication been added? Has a medication dosage been recently increased or decreased? Has the patient entered the pre-active phase of dying?

SPECIFIC SENSORY DECLINE

Dying person turns toward light - sees only what is near Can only hear what is distinctly spoken Touch is diminished - response to pressure last to leave Dying person might turn toward or speak to someone not visible to anyone else Eyes may remain open even if unconscious Person might rally just before dying

Fever

Fever is common in the 1-3 days prior to death. Pneumonia due to aspiration is the most likely cause. Scheduled rectal acetaminophen will control many patients cooling blankets, parenteral NSAIDs or steroids can be used for refractory cases.

loss, grief, coping

Grief = emotional response to loss Coping strategies conscious, unconscious avoidance destructive suicidal ideation

physical fears of death

Helplessness, dependence, loss of physical faculties, mutilation, pain

Site options for dying environment if opportunity to intervene

Home with hospice support Residential hospice (very few) Hospital: Inpatient hospice/palliative care unit Long-term care facility with hospice support

Dying in institutions

Home-like environment: permit privacy, intimacy, personal things, photos Continuity of care plans Avoid abrupt changes of settings Consider a specialized unit

Altered Respiratory Pattern

In the final days, the respiratory pattern usually changes to one or more of the following: Increased or decreased rate or depth Cheyne-Stokes breathing Periods of apnea

Gradual decline in cognitive ability

Increasing sedation and/or Delirium: hypoactive or hyperactive, followed by Obtundation and Coma

Medications

Limit to essential medications Choose less invasive route of administration buccal mucosal or oral first, then consider rectal subcutaneous, intravenous rarely intramuscular almost never

Summary of Sx/Signs of Approaching Death

Loss of mobility-bed bound Decreasing oral intake Decreasing cognition Loss of swallowing reflex Pain Altered respiratory pattern Fever Skin color changes

Loss of ability to close eyes

Loss of retro-orbital fat pad Insufficient eyelid length Conjunctival exposure: increased risk of dryness, pain, maintain moisture

late stage of dying

Loss of swallowing reflex "Death rattle" Pooled oral sections that are not cleared due to loss of swallowing reflex Coma Fever Altered respiratory pattern Skin color changes Death

Delirium management

Major tranquilizers prn (e.g. Haloperidol) Calm environment Frequent reminders of place/people

Loss of Mobility in process of dying

Mobility gradually declines in the days to weeks preceding death. Check for bedsores Frequent turning (q1-2h) Protect sites of bony prominence Special mattress/bed to reduce bedsore risk

The patient without significant pain entering the final days

New severe pain due to the dying process is unlikely, although discomfort from lack of mobility can occur; Use a trial of analgesics for suspected pain.

Caregiver education for pain management

Normalize signs/symptoms Affirm the importance of family observations for potential pain Confirm the role of analgesics near end-of-life Clarify confusion about opioid double-effect Encourage non-pharmacological treatments

caregiver education about oral intake before death

Normalize signs/symptoms Do not force feed Provide ice chips and small sips of liquid as tolerated Mouth swabbing q1hour with baking soda mixture Frequent moistening of lips with petroleum jelly to avoid cracking.

Caregiver Education for loss of consciousness

Normalize signs/symptoms Encourage a calm environment, favorite music Assume the patient can still hear and feel Encourage family members to say their goodbyes and offer statements of love.

caregiver training for loss of mobility

Normalize signs/symptoms Review bedsore prevention strategies

caregiver education for respiratory issues

Normalize symptoms/signs Review role of oxygen Review significance of apneic periods: death is likely within 24-48 hours

Normal grief (physical, emotional, cognitive)

Physical hollowness in stomach, tightness in chest, heart palpitations Emotional numbness, relief, sadness, fear, anger, guilt Cognitive disbelief, confusion, inability to concentrate

Moving the body

Prepare the body Choice of funeral service providers Wrapping, moving the body: family presence, intolerance of closed body bags

FURTHER NEUROLOGIC DECLINE AT DEATH

Pupils might react sluggishly or not at all to light Pain might be significant Assess for pain if person unable to talk: restlessness, tight muscles, facial expressions, frowns Provide pain medication as needed

Assessment of grief

Repeated assessments anticipated, actual losses emotional responses coping strategies role of religion Interdisciplinary team assessment, monitoring

Death Pronouncement

Requirements vary by hospital/state Physician role Confirm death has occurred by absence of respirations and heartbeat Comfort family Complete necessary paperwork Communicate with medical examiner for selected cases Check with local ME office for details

Impending Signs of Death

Separation from family and friends Withdrawal from the world and people Less communication Separation from body Going inside of self Decreased PO intake Excessive sleeping > 20 hours/day

social fears of death

Separation from family, leaving behind unfinished business

physiology of dying

Somatic death or death of the body Series of irreversible events leading to cell death Causes of death varies, but there are basic body changes leading to all deaths

Optimal Dying Environment

Space for patient/family privacy Ready availability of medications and equipment to manage distressing symptoms (try to anticipate) Nursing support when needed Round-the-clock patient access for family/friends/caregivers

physical signs of death days to hours before

Surge of energy!

INTERVENTIONS FOR FEARS

Talk as needed Avoid superficial answers, i.e. "It's God's will Provide religious support as appropriate Stay with the patient as needed Work with families to strengthen and support

Preparing for the last hours of life . . .

Time course unpredictable Any setting that permits privacy, intimacy Anticipate need for medications, equipment, supplies Regularly review the plan of care

tx of altered respiratory pattern

Treatment is only indicated for rapid breathing, which is often quite distressing for families/caregivers Careful titration of opioids can help control respiratory rate to a range of 10-20 bpm. Use oxygen only if it appears to reduce distressing symptoms.

Progression of Symptom/Signs in the last two weeks of life

Two semi-distinct stages over 1-14 days Difficult to prognosticate with precision within the last few days Time of high stress for family and caregivers Second guessing past decisions is common Most families are unfamiliar with the dying process—not sure what is "normal"

tx of pain

Use a trial of increased analgesics for suspected pain Use non-pharmacologic analgesics Music Massage

what does terminal agitation look like?

demand to move/transfer complaints of discomfort accusations/yelling out hallucinations/stories may not recognize others speak quickly/disconnected repetitive actions shuddering limbs

reasons for dyspnea

increasing tumor size/lung mets comorbidities pleural effusion pain or fatigue anxiety

The "Death Rattle" ensues when?

loss of swallowing. Retained oropharyngeal secretions leads to ... Loud noisy breathing—often very distressing to families. Treatment Discontinue artificial hydration/feedings Anticholinergic drugs to dry secretions Atropine, scopolamine, glycopyrrolate, others Use oropharyngeal suction only if necessary

why few residential hospitals

medicare become involved with reimbursement of hospice care. criteria: can't be controlled at home (need 24 hour nursing care)

delayed grief

normal grief reactions are suppressed or postponed

chronic grief

normal grief reactions over very long periods of time

2 roads to death

normal: sleepiness, lethargy, obtunded, semicomatose, comatose, dead difficult: restless, confused, tremulous, hallucinations, mumbling, myoclonic jerks, seizures, semicomatose, comatose, death

care and comfort measures

pain management, provide comfort turning/positioning hygiene/oral communication attend to psycho-social needs support (physical/emotional/spiritual)

Terminal Agitation symptoms

panic sweating muttering concern with details questions reassurance repeating

exaggerated grief

self-destructive behaviors eg, suicide

As expected death approaches , discuss:

status of patient, realistic care goals role of physician, interdisciplinary team What patient experiences , vs what onlookers see Reinforce signs, events of dying process Personal, cultural, religious, rituals, funeral planning Family support throughout the process

Physical Signs of death 1-3 months prior

withdrawal