Signs approaching Death

Pulmonary function impairment.

Failure of the heart's pumping function causes fluid to collect in the pulmonary circulation. Breath sounds become moist. Oxygen does not diffuse very well, and the client cannot exhale carbon dioxide adequately, compounding the state of generalized hypoxia (low oxygenation).

Central nervous system alterations.

Central nervous system alterations. With hypoxia, the brain is less sensitive to accumulating levels of carbon dioxide; therefore, the client may experience periods of apnea (no breathing). Pain perception may be diminished, the client may stare blankly through partially open eyes, and the senses may become impaired, although hearing tends to remain intact. Eventually, the client becomes insensitive to all but extreme pressure.

Cardiac dysfunction

Failing cardiac function is one of the first signs that a client's condition is worsening. At first, heart rate increases in a futile attempt to deliver oxygen to cells. The apical pulse rate may reach 100 or more beats/minute. Cardiac output, the amount of blood the heart pumps per minute, may decrease, because a fast heart rate impairs the heart's ability to fill with blood. This may diminish the heart's own oxygen supply, which causes the heart rate to decrease and blood pressure to fall

Peripheral circulation changes.

Reduced cardiac output compromises peripheral circulation, and impaired cellular metabolism produces less heat. The skin becomes pale or mottled, nail beds and lips may appear blue, and the client may feel cold.

Musculoskeletal changes.

Reflexes become hypoactive. The client loses urinary and rectal sphincter muscle control, causing incontinence of urine and stool. The jaw and facial muscles also relax. As the tongue falls to the back of the throat, respirations become noisy. The accumulation of secretions in the respiratory tract coupled with noisy respirations is referred to as the death rattle. A brief period of restlessness may occur just before death.

Renal impairment.

Low cardiac output causes urine volume to diminish and toxic waste products to accumulate.

Gastrointestinal disturbances.

Peristalsis slows, causing gas and intestinal contents to accumulate. This buildup may stimulate the vomiting center, resulting in nausea and vomiting.