Presentation on theme: "SIGNS AND SYMPTOMS OF APPROACHING DEATH"— Presentation transcript:
1SIGNS AND SYMPTOMS OF APPROACHING DEATH Policy # H:Comfort Measures for s/sx of approaching death (informational sheet) is provided in the Admission packet.SIGNS AND SYMPTOMS OF APPROACHING DEATH
2Signs and symptoms of approaching death – policy # h:5-008.1 Purpose:To provide guidelines for recognizing the signs and symptoms of approaching death and taking appropriate actionPolicy: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 takeThe Signs and Symptoms of Approaching Death handout can be found in the Family Guide to Hospice (in the final stages of approval) and in the admit pack; I have provided for each of you, a copy of “comfort measures for s/sx of approaching death” and the handout entitled “The Natural Dying Process” for your review and education. Please note that our education department also has extensive education (handouts) on common s/sx of end-stage disease that outlines each specific disease process (such as): Cardiac / Pulmonary, Cancers, Alzheimer’s, etc. Please contact our Education department at ext to obtain a copy. (In Jodi’s orientation manual).
3Definition of TermsCatheterization – insertion of tube into patient’s bladder to facilitate removal of urinePulmonary Edema – Fluid accumulation in the tissues of the lungsTerminal Anguish – state PRIOR to death where patient is unable to suppress or repress painful, unresolved psychological issuesTerminal Restlessness – Prior to entering semi comatose state patient becomes restless, confused and possible seizure activityHello, welcome to Ambercare. We are excited to have you on board with us. Let’s start out by reviewing a common list of terms associated with EOL care. The above processes may or may not be present during the last stages of the death/dying process.Let’s turn our attention to What the death and dying process is all about….
4What is death all about? Each of us will face death sooner or later Less than 10% will die suddenlyMore than 90% of us will die due to a prolonged illnessThere 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 othersThe time of death generally cannot be predictedThe final days and hours before a patient dies is the last opportunity for growth and development to occur in the pt/family unitThe final hours allow for patient/family to say goodbye and complete end of life closureEmphasis should be placed on facilitating a comfortable death that honors patient/family choicesIt is important to explore your “own” feelings regarding the death experience. An important question to answer is “what does it feel like to be with someone dying.” How do I, as a clinician feel about death. Does my own belief or value system get in the way of the patient’s/families wishes? Will I truly be “present and bear witness” to such a tremendous privileged event?Dying is a physical, psychological, social, spiritual event….let’s take a look at what this statement means….
5Dying is a physical, psychological, social, spiritual event Patient/family must continue to be seen as a collaborative unitEmphasis must be placed on optimizing patient comfort, dignity, choice, acceptance, final tasks, and life closureAll aspects of care need to intensify in order to minimize sufferingThe interdisciplinary team must remain focused in order to:Help patient achieve a dignified deathIdentify emerging problemsHelp family deal with immediate care needs up to and including moment of death as well as after death eventArrange for privacy and intimacy if possibleWhat do we know about “preparing for Death?” Let’s explore….
6What do we know about “preparing for death What do we know about “preparing for death?” – Active Dying: Last few weeks of LifeThe time cannot be predictedSome patients instinctively know WHEN death will occurS/sx only serve a s guideline, not all patients experience all symptoms and the s/sx do not necessarily occur in sequenceThe dying process is a natural slowing down of physical and mental processesCan occur over days or weeks or may be present only hours/minutes prior to death
7Psychological and spiritual Signs of Active Dying Fear of dyingFear of abandonmentFear of the unknownDreams and visionsWithdrawalIncreased focus on spiritual issuesTerminal anguishSome or all of these may be present. A great resource that you may want to jot down is Ira Byock, MD – he has published extensively on this subject matter….
8Managing Physiologic/Emotional Changes Increased weakness/fatigueLoss of appetite, physical wastingNausea and vomitingDehydration and decreased fluid intakeChanges in renal and bladder functionChanges in bowel functionPainManaging the physical/emotional/spiritual/psychological signs of death requires an interdisciplinary approach; Utilize the expertise of your team members to help formulate the best “plan of care” for your patient and family/caregivers. Medications and other forms of therapies may be required.
9INCREASED WEAKNESS AND FATIGUE GENERALLY progresses to point that patient is unable to move muscles and joints independentlyTurning may be painful. Head may need to be supported and/or positioned for patientIncreased need for careADL’sTurning and movement
10Loss of appetite, physical wasting May begin earlier in the dying process. However, tends to intensify during active phase of dyingFamily 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 oneFeeding is potentially dangerous at this time as it may lead to aspirationAnorexia 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
11Nausea and vomiting Along with anorexia may come nausea and vomiting This needs to managed aggressively to promote and maintain patient’s comfortAgain, medication management (such as antiemetic's) may serve to be a useful intervention.
12Dehydration/decreased fluid intake Like food, your patient usually stops drinking fluids before the phase of active dyingGiving 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 secretionsGive oral mucosa care every 15 to 30 minutes to minimize sense of thirst and avoid bad odors or tastes and painful cracking; use lip balmsEducating and partnering with your patient’s family members/caregivers is key to carrying out the best plan of care for your patient. Getting them involved (providing frequent oral care for example) can help them feel as though they haven’t lost ALL control of their loved one’s impending death.
13Changes in kidney and bladder functions Urine output usually diminishes gradually in response to decreased food and fluid intakeIncontinence and/or retention may also occur. Retention may require catheterization to promote comfort
14Changes in bowel function Constipation may continue as a problem due to decreased food intake as well as decreased activity of the gut due to continued pain medication routinesImpaction may need to be addressed if contributing to marked patient discomfort
15PainLike other symptoms, pain must continue to be managed with the same vigor as at any point in the illnessAlthough 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 RRIf oral route becomes unavailable, other routes (rectal/subcutaneous) should be considered.
16Last hours of life Semi comatose state Impaired heart and renal functionRespiratory dysfunctionNeurologic dysfunctionAs death approaches, the heart, lungs and nervous system begin to fail. Primary, irreversible organ failure is occurring. The patient becomes semi comatose, following s/sx become evident as death approaches.
17Semi comatose state Eyes become sunken and glazed; often are half open Senses are generally dulled except hearing may not be lost; sensitivity to light may remainAbility to move decreases, beginning in the legs and progressing to the armsBody becomes still and joints painful when movedOnly essential medications for symptom management are given
18Impaired heart and renal function Cardiac output decreases with a corresponding decrease in peripheral and renal perfusionPulse rate increases initially (compensatory mechanism – need more volume) and then weakens and becomes irregular. Radial pulse may be so faint – nonpalpableBP decreasesPeripheral cooling (lack of perfusion) bluish coloring and mottling of skin notedPatient may perspire; peripheral edema may developBody temperature may increase due to possible infection and/or increased tumor activity in cancer patientsCO = HR x SV (generally 5-6 liters come in out of the heart every minute). Pulse rate may increase (tachycardia) initially due to compensatory mechanism – dry intravascular bed, attempting to bring up BP because of low volume via tachy syndrome.
19Respiratory dysfunction Breathing may become shallow or laboredRespiration may increase in rate and then decrease, (compensatory mechanism) increase in rate and then slow againSecretions may increase; resident may have difficulty coughing and clearing secretions and swallowing effectivelyFeelings of “lack of air” and breathlessness may increase as death approachesDeath “rattle”: Terminal congestion occurs due to changes in respiratory rate and inability of patient to clear secretionsIt is important not to use the term “death rattle” around family/caregivers – the “noise” itself is traumatic enough and very distressing to family but not often not as troublesome to patient. Medication management such as anticholinergics would be useful to dry up secretions.
20Neurologic symptoms Result of multiple nonreversible factors: Metabolic imbalancesAcidosisKidney failureInfectionReduce blood flow to brainLeads to “2” roads to death:
21The “usual road” to death The majority of persons travel the “usual road.”They experience increasing drowsiness and eventually become unarousable. Stages are as follows:Decreasing LOCSleepinessLethargicSemi comatoseComatose (almost equivalent to full anesthesia)DEATH
22The “difficult road’ to death Due to nervous system agitation prior to entering semi comatose stateRestlessnessConfusionTremorsHallucinationsMumbling deliriumMuscle jerkingSeizuresSemi comatoseComatoseDEATHThe nervous system becomes highly agitated prior to entering the semi comatose state. The following occurs: confusion and tremors; Experiences of hallucinations and mumbling delirium may occur. May progress to muscle jerking and seizure activity before progressing to coma and death.
23Signs that death has occurred Absence of heartbeat, respirationsFixed pupilsRelease of stool and urineNo response to stimulationColoration of patient turns to a waxen pallor as blood settles/poolsBody temperature dropsMuscles, sphincter relaxEyes may remain openJaw falls openBody fluids may be heard trickling internally
24What to do when death occurs Care shifts from resident to family/caregiversKNOW who to call; goal is NOT to call 911 on a routine basisFollow traditions, rites, rituals; prepare body accordinglyKnow whether resident has requested organ donation – how to proceedFollow procedures as outlined in Ambercare’s Policy and ProcedureInitiate bereavement supportRemember every patient and family are unique!
25Last thoughts….. Stay with me…. Walk with me…. Help me to “fear no evil”….Comfort me….Facilitate my closure…..Help me leave my legacy in peace….