The Last Hours

Question 1

___ people die remains in the memory of those who live on

Answer 1

How

Question 2

The Dying Process

Answer 2

• Death is a normal part of life
• Your patients will die
• This is not a failure of your care

Question 3

___ % recognized dying

Answer 3

49%

Question 4

How long does the active dying process usually take?

Answer 4

Hours to days

• Sudden death is uncommon
• Rarely occurs over weeks

Question 5

Physiologic changes at EOL

Answer 5

• 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

Question 6

Changes that are most apparent to family

Answer 6

• Breathing
• Altered level of consciousness
• Decreased appetite/fluid intake

Question 7

Function of decreased oral intake

Answer 7

• 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

Question 8

Does artificial hydration/nutrition improve QOL or prolong life?

Answer 8

• NO, it may be harmful (fluid overload, edema, dyspnea, secretions)

Question 9

What can a family member do to help comfort with decreased oral intake?

Answer 9

• Use a water swab to keep lips/mouth moist

Question 10

CV changes

Answer 10

• Hypotension, tachycardia –> bradycardia
• Decreased urine output
• Peripheral cooling, cyanosis
• Mottling of the skin

Question 11

Will parenteral fluids help manage CV changes?

Answer 11

Nope.

Question 12

Neurologic changes

Answer 12

• Loss of ability to swallow
• Loss of sphincter control
• Decreased level of consciousness
• Terminal delirium

Question 13

Management of terminal delirium

Answer 13

• Support/family
• Calm, familiar environment
• Drugs: Neuroleptics - haloperidol, chlorpromazine

Question 14

Pain

Answer 14

Under-treated at EOL

• recognize non-verbal ways of expressing pain
• warrants trial of opioids
• facial grimacing, moaning, restlessness

Question 15

Changes in breathing

Answer 15

• Inc or dec respiratory rate
• Shallow, rapid
• Deep, slow
• Apnea
• Cheyene-stokes breathing
• Gurgling, rattling, snoring

Question 16

If you get the death rattle, should you suction?

Answer 16

No, also don’t add O2. Just turn off the fluids

Question 17

What do you do if someone has excess secretions?

Answer 17

Use atropine eye drops sublingually.

Question 18

Communicating with the dying patient

Answer 18

• 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

Question 19

Signs that death has occurred

Answer 19

• Not breathing
• No pulse
• Grey-ashen skin, cold
• Eyes and mouth may remain open
• Body fluids may trickle/seep
• Stiffening of body

Question 20

Death pronouncement

Answer 20

• Nonresponsive
• Absence of respirations
• Absence of heartbeat
• Absence of cranial reflexes (pupils fixed, no corneal reflex)

Question 21

After death care

Answer 21

• 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

Question 22

What do YOU do after death?

Answer 22

• 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