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Spring 2021 Patho > Death and Dying > Flashcards

Death and Dying Flashcards

1
Q

Death and Dying

In 2010, according to the CDC, __,468,435 individuals died in the US

Approximately 73% of deaths occur in those >___ years of age

It is estimated that in developed countries ~70% of all deaths are preceded by a ______ or condition, making it reasonable to _____ for dying in the foreseeable future

Despite this, plans for dying or even conversations about dying are far from _____place in the US healthcare system

A

2 million

>65 yo

disease, plan

conversations not commonplace

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2
Q

Top 2 causes of death in US and Britain

(2)

A

1) Heart Disease
2) Cancer

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3
Q

4 Basic patterns of Death

  1. Trajectory 1 =
  2. Trajectory 2 =
  3. Trajectory 3 =
  4. Trajectory 4 =
A
  1. Sudden death (acute MI, trauma)
  2. Short period of evident decline (cancer)
  3. Long term limitations with intermittent serious episodes (organ failure)
  4. Prolonged dwindling (frailty, dementia)
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4
Q

4 Basic Patterns of Death (Notes)

  1. Sudden Death: _____ level of functioning then traumatic injury/acc_____
  2. Long life at high funtioning then some significant ______ causes pre______ decline and death (cancer) “_____ case scenario”
  3. _____ decline in overall health with intermittent serious _______ of illness (organ failure, chronic disease with acute declines that require _______ intervention to recover), baseline ______ down to death
  4. ______ model - slow dwindling of function leading to d______ and eventual death (most common in this country)
    • What people think when?

Which 2 stages are becoming more of the norm?

A
  1. high level of functioning then traumtic injury/accident
  2. significant illness causes precipitious decline “best case scenario”
  3. Slow decline w ittermittent serious episodes of illness - requires medical intervention to recover), baseline dwindles
  4. Frailty model - slow dwindling leading to dementia
    • What ppl have in their heads when they talk about not wanting to get hold

3-4 becoming more common - with these 2, there is time to put plans in place (advanced directives)

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5
Q

Death is a _______ not an Event

  • When do you transition care?
  • End of life/Terminally Ill means when you have how long to live?
  • Actively Dying means when you have how long to live?
A

Process

  • When trajectory changes from years to months, or months to weeks, or weeks to days
  • Weeks to months
  • Days
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6
Q

Vital Signs

Good predictor of impending death?

  • Multistudy of ICU’s looking at SBP, DBP, HR, RR, O2, and Temp in last 2 weeks of death
    • SBP and DBP =
    • HR =
    • RR =
    • O2 sat =
    • Temp =
A

NO - can stay table until just before moment of death

  • slowly declines
  • increases and erratic
  • brainstem maintains RR until time of death
  • doesn’t deline until very close to death
  • stays fairly stable and then goes down
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7
Q

Clinical Signs in the last 1-3 days of life

(2) Changes in Breathing

(8)

A

Apneic, Cheyne Stokes Breathing

Death rattle

Dysphagia of liquids

Decreased LOC

Decreased performance status

Peripheral cyanosis

Pulselessness of radial artery

Respiration w mandibular movemen t

Urine output

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8
Q

Breathing Pattern Changes

  1. Apneic breathing =
    • ​​Negative sign =
    • Positive sign =
  2. Cheyne Stokes breathing =
    • ​Negative sign =
    • Positive sign =
A
  1. periods of no breathing and then a gasp
    • ​none
    • <30 sec, 30-60 sec, >60 sec
  2. alternating periods of apnea and hyperapnea (crescendo and descendo pattern)
    • ​​absent
    • present
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9
Q

Cheyne Stokes Breathing

  • Periods of apnea with periods of deep breathing where depth of breath?
    • For the family can be scary
    • Pattern of (1) breathing triggered by change in ___ (during apneic phase rise in acidity, ______ relieves it)
    • O2 sats _____ with hyperapneic phases
A
  • hyperapnea parts where depth of breath ascends toa peak then descends to periods of apnea
    • brain stem breathing, change in pH, hyperapnea relieves it
    • O2 sats improve with hyperapnea
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10
Q

Death Rattle

=

  1. Negative sign =
  2. Positive sign =
A

Gurgling sound produced on inspiration and/or expiration related to airway secretions (caused by impaired swallowing, secretions buildup and not clearing airway, gasping type breathing)

  1. None
  2. Audible if very close, at end of bed, or > 6m from door of room
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11
Q

Decreased LOC

=

  1. Negative sign =
  2. Positive sign =
A

Progressively declines or person becomes less and less present - Using the Richmond Agitation Sedation Scale

  1. -1 to 4
  2. -2 to -5 (sedation)
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12
Q

Decreased Performance Status

Using Palliative performance scale, validated for assessing function (0-100%)

  1. Negative sign =
  2. Positive =
A
  1. 30-100%
  2. < 20% (bed bound, completely dependent)
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13
Q

Peripheral Cyanosis

Blue discoloration of extremities bc =

  1. Negative Sign =
  2. Positive Sign =
A

blood shunts to organs/core - late sign of death, mottling of skin, loss of radial pulse

  1. None
  2. Toes; feet; up to knees
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14
Q

Pulselessness of Radial Artery

  1. Negative sign =
  2. Positive sign =
A
  1. Normal
  2. Left, Right, Both
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15
Q

Respiration with mandibular movement

=

  1. Negative sign =
  2. Positive sign =
A

Depression of jaw down or to one side with inspiration - sign of impending death

  1. Absent
  2. Present
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16
Q

Urine Output

Measured volume of urine over a ___ hour period

  1. negative sign =
  2. positive sign =
A
  1. Anything >100
  2. < 100 ml
17
Q

Death Rattle

  • Loss of _____ from weakness (Dysphagia) and increasing c_____
  • Impaired ____ reflex
  • Buildup of ______, bronchial and oropharyngeal ______
  • Gur_____, crackling, or rattling sounds with each breath
  • Family perception of ______
  • Rx with po_____, _______ agents (1)
A
  • swallow, coma
  • gag
  • saliva, secretions
  • gurgling
  • chocking
  • positioning, anticholinergic (scopolamine patches)
18
Q

Cardiovascular

  • _____ in cardiac output (despite _______)
  • ______ in blood pressure
  • ______ of blood to core
  • Decreased peripheral _______
  • Peripheral and Central C______
  • Skin m_______
  • Loss of peripheral p_______
A
  • Decrease in cardiac output (despite tachycardia)
  • Decrease in BP
  • Shunting
  • perfusion
  • cyanosis
  • mottling
  • pulses
19
Q

Timing of Diff S/S

Seen earlier (2)

Seen later (3)

A

Dysphagia of liquid, Decrease LOC

Pulselessness of Radial artery, Death Rattle, Respiration with mandibular movement

20
Q

7 Neurological Signs of Impending Death

Signs are fairly minimal until last ~___ days

  • Decreased response to V____ or V_____ stimuli
  • Drooping of the n______ fold
  • H_______ of neck
  • Inability to close _____
  • G_____ of vocal cords
A

~4

  • visual, verbal
  • nasolabial
  • hyperextension
  • eye lids
  • Grunting
21
Q

Onset of 7 Neurological signs of impending Death

Seen earlier around 3 days to go (2)

Seen last around 1 day till death (2)

A

Decreased response to visual stimuli, Hyperextension of neck

Grunting of vocal cords, inability to close eye lids

22
Q

Palliative Performance Scale

Describes activity or evidence of disease

  • Activity: self ____, in____, c_____ lvl, amb_____
  • NEGATIVE SIGN > ____ %
A
  • self care, intake, consciousness level, ambulation
  • > 30%
23
Q

Food and Dying

What should you educate the family about?

A

Research shows food does not prolong life but actually food restriction decreases discomfort, anxiety, dysphagia in secretions is improved

Get family to understand that withdrawing liquids and food is not abandoning your loved, its reducing their discomfort

24
Q

Clinical Course for Terminally Ill Patients

(1) stage right before comatose, very difficult to arouse

Less common (“more difficult path”) =

  • Likely pt is not aware of what’s happening, are caused by (1)
  • Interventions (2)
A

Obtunded

Excitation phase (restless, confused, delirium) -> seizures

  • reaction of CNS
  • Antiaxiety Meds
  • Dopamine (common pall care drug to enhance comfort at TOD) + CNS depression will also tend to decrease likelihood of diff path

Family often doesn’t recognize that this person is a person about to die, and dc curative treatments and switch to pall care

Spring 2021 Patho (14 decks)

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