THE PHYSIOLOGY of Death & DYING Alex Psirides December 9th 2016

World Mortality *data extrapolated from current trends

How People Die Murray et al, BMJ 2008 How many of these trajectories should even be admitted to hospital, never mind reach ICU or receive CPR? Murray, S. A et al. BMJ 2008;336:958-959 Murray et al, BMJ 2008

The problem with sick people and dying people is they often look the same

MET DECISION TREE

Most people have never seen someone die Many doctors & nurses outside acute care may never have seen someone die. Hospital mortality is 1.2% (25 patients per month in our hospital) 1900 admissions per year with 9% mortality = 171 deaths per year, 14 per month, 3.3 per week or 1 every 2 days Death in ICU is common

YEARS The Language of Life Expectancy MONTHS WEEKS DAYS ‘End of Life’,’Terminally Ill’ Actively Dying Death is a process, not an event. It used to be priests who declared death; now it is doctors. This is not what death looks like in ICU Adapted from Hui et al: concepts & definitions for actively dying (2014) J Pain Symptom Manage Transition of Care* Transition of Care* Transition of Care* YEARS MONTHS WEEKS DAYS *Transition of Care: change in place, level, or goals of care

COMING UP NEXT Vital signs Weakness Fluids Neurology & delirium Dr. Cheyne & Dr. Stoke The death rattle Cardiovascular changes The family The only palliative care joke I know

2 acute palliative care units, 357 patients, 55% died in hospital Vital signs recorded twice daily SBP, DBP, SpO2 all decrease in last 3 days of life Temperature & HR increase Significant no. patients had normal vital signs even on day of death i.e. not poor positive predictive value Bruera et al. Variations in Vital Signs in the Last Days of Life in Patients With Advanced Cancer (2014)

Presence/absence 10 physical signs documented every 12 hrs from admission to death or discharge for 357 patients with advanced cancer admitted to 2 palliative care units Hui et al. Clinical Signs of Impending Death in Cancer Patients (2014)

Hui et al. Clinical Signs of Impending Death in Cancer Patients (2014)

7 neurological signs of impending death amongst 203 patients with advanced cancer who died in an acute palliative care unit Hui et al. Bedside Clinical Signs Associated with Impending Death in Patients with Advanced Cancer (2015)

Hui et al. Bedside Clinical Signs Associated with Impending Death in Patients with Advanced Cancer (2015) 7 neurological signs of impending death amongst 203 patients with advanced cancer who died in an acute palliative care unit All these data are for patients dying of cancer in palliative care units ?external validity

Taken from here: http://www. npcrc

Weakness - Loss of ability to transfer or turn - Toileting - Pressure areas

Decreased Oral Intake - Impaired swallowing common Impaired swallow may be as part of weakness - Impaired swallowing common (weakness, meds, hypercalcaemia) - Eating & drinking has social function - Family perception of ‘starvation’

Fluid & the Family Be aware that some families may perceive provision of food or water as signs of respect or caring, even if provided by artificial means (includes i/v fluids, TPN, PEG/NG feed etc) Also treating yourself.. Would you insert an NG to treat the family? Or an i/v to treat the family? Or a CVL to treat the family?

Stopping Artificial Nutrition & Hydration X - 88 palliative cancer pts: thirst frequent but associated with stomatitis, oral breathing, administration of opioids - 52 inpatients: no association between thirst & objective measures (fluid intake, plasma osmolality, [Na], [Urea] - 68 cancer patients: state of consciousness inversely correlated with [Na] & urine Cosmo during last 48 hrs of life - Studies of thirst in dying patients show no relationship between artificial hydration & thirst

Nutrition Studies in Dementia Provision of artificial nutrition (tube fed) did NOT: - Prolong life - Improve overall function - Prevent aspiration - Reduce pressure sores Consistent demonstration of lack of benefit of artificial nutrition in this group. Although pressure sores would be expected to be reduced in well nourished patients, likely offset by immobility & incontinence related to tube feeding

X Why fluid restrict? - Relief from choking or drowning - Less coughing & pulmonary oedema - Decreased UO with less need for catheter - Decreased GI fluid so less N,V, diarrhoea - Less peripheral oedema - Less pain Impaired swallow may be as part of weakness

Fluids in Summary - Thirst seems unrelated to dehydration & [Na] & is unrelieved by fluid therapy - Family members needs should be acknowledged & addressed - Thirst, dry mouth & fatigue are not specific for hydration status; hydration will not help - There is a lack of benefit of hydration at end of life - It is ethical to withhold & withdraw artificial hydration Impaired swallow may be as part of weakness

Neurology Two paths to death: - Decreasing LOC leading to coma then death - Terminal delirium with confusion, agitation, day/night reversal, then death Groaning may be misinterpreted as physical pain Delirium may be interpreted as ‘a horrible death with uncontrolled pain’ unless recognised & treated

The Neurological Path to Death Tremulous Confused Hallucinations Restless THE DIFFICULT PATH Mumbling Delirium BASELINE Myoclonic Jerks Sleepy THE USUAL PATH Lethargic Seizures Obtunded Semicomatose Comatose DEAD

X Delirium Numerous medications may cause delirium Causing include opioids, BZI, glucocorticoids, neuroleptics Withdrawal include opioids, BZI, SSRIs, alcohol Need to consider benefit vs burden of each med Withdrawal from medications may cause delirium X

Breathing Tidal Volumes Time Cheyne-Stoke breathing first described in 19th century (John Cheyne, William Stokes) Pattern repeats over 30 seconds to 2 minutes Oscillation between apnoea & hyperpnoea with crescendo-diminuendo pattern. Caused by altered responses to hyper/hypocapnia due to likely brain stem hypoperfusion Hospices often report CSB in patients nearing death. Not associated with distress but may disturb the family. Tidal Volumes Time

Death Rattle - Loss of swallow from weakness & increasing coma - Impaired gag reflex - Build up of saliva, bronchial & oropharyngeal secretions - Gurgling, crackling or rattling sounds with each breath - Family perception of choking - Rx with positioning, anticholinergic agents Hyoscine or glycopyrrolate may minimise secretions ?role of suctioning The ‘death roll’

Cardiovascular - Decrease in cardiac output (despite tachycardia) - Decrease in blood pressure - Shunting of blood to core - Decreased peripheral perfusion - Peripheral & central cyanosis - Skin mottling - Loss of peripheral pulses These are helpful because this is what families think dying people look like

Reflection & The Family Think about the physiology of what you are witnessing. Explain to yourself and to the family what to expect. This may be their first death. It may be your first death. But it may also be your hundredth. Don’t treat the family Don’t treat yourself Treat the dying person

“I want to die peacefully in my sleep like my father, not screaming & yelling like the passengers on his bus.” Steven Wright

@psirides wellingtonicu.com