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

2. World Mortality
*data extrapolated from current trends

3. 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:
Murray et al, BMJ 2008

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

5. MET DECISION TREE

6. 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

7. 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

8. 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

9. 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)

10. 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)

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

12. 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)

13. 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

14. Taken from here: http://www. npcrc

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

16. 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’

17. 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?

18. Stopping Artificial Nutrition & HydrationX
- 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

19. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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’

28. 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

29. 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

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

34. @psirides
wellingtonicu.com