The Last Hours Flashcards
___ people die remains in the memory of those who live on
How
The Dying Process
- Death is a normal part of life
- Your patients will die
- This is not a failure of your care
___ % recognized dying
49%
How long does the active dying process usually take?
Hours to days
- Sudden death is uncommon
- Rarely occurs over weeks
Physiologic changes at EOL
- Bedbound from weakness and fatigue
- Loss of ability to close eyes and mouth
- Changes in skin color and temperature
- Loss of bowel sounds
- CV, neuro, respiratory
Changes that are most apparent to family
- Breathing
- Altered level of consciousness
- Decreased appetite/fluid intake
Function of decreased oral intake
- Food may be nauseating
- Increased risk of aspiration
- Not utilizing nutrients
- May be protective (ketosis increases endorphin release)
Patient is NOT starving to death (death is from underlying disease). Not eating/drinking is a normal part of this process
Does artificial hydration/nutrition improve QOL or prolong life?
- NO, it may be harmful (fluid overload, edema, dyspnea, secretions)
What can a family member do to help comfort with decreased oral intake?
- Use a water swab to keep lips/mouth moist
CV changes
- Hypotension, tachycardia –> bradycardia
- Decreased urine output
- Peripheral cooling, cyanosis
- Mottling of the skin
Will parenteral fluids help manage CV changes?
Nope.
Neurologic changes
- Loss of ability to swallow
- Loss of sphincter control
- Decreased level of consciousness
- Terminal delirium
Management of terminal delirium
- Support/family
- Calm, familiar environment
- Drugs: Neuroleptics - haloperidol, chlorpromazine
Pain
Under-treated at EOL
- recognize non-verbal ways of expressing pain
- warrants trial of opioids
- facial grimacing, moaning, restlessness
Changes in breathing
- Inc or dec respiratory rate
- Shallow, rapid
- Deep, slow
- Apnea
- Cheyene-stokes breathing
- Gurgling, rattling, snoring
If you get the death rattle, should you suction?
No, also don’t add O2. Just turn off the fluids
What do you do if someone has excess secretions?
Use atropine eye drops sublingually.
Communicating with the dying patient
- Say things you need to say
- Some patients may be waiting for “permission” to die from loved ones - tell them its okay to go
- Assume they can hear everything
Signs that death has occurred
- Not breathing
- No pulse
- Grey-ashen skin, cold
- Eyes and mouth may remain open
- Body fluids may trickle/seep
- Stiffening of body
Death pronouncement
- Nonresponsive
- Absence of respirations
- Absence of heartbeat
- Absence of cranial reflexes (pupils fixed, no corneal reflex)
After death care
- Focus on loved ones
- Chaplain support
- Okay to touch and talk to the body
- Let the family have the time they need with the body
- Family may have rituals post-death
What do YOU do after death?
- Words are not what is important
- Your role is not to make it better
- We grieve
- Most important to let the family know you are there for them
