Signs of impending death.

req_read · Jul 7, 2006

Predicting how much time is left is very difficult, but there are general indicators that could give you some idea. You mention 2 indicators but they point in different directions.

As dying process becomes more active the sleeping pattern tends to become off & on, day & night. Overall, sleep time increases. It is similar to the sleeping pattern of newborns. If you have ever had a baby you know that you will be up with them off & on, day & night. That is normal.

The increase in sleep time facilitates dreaming. Much of the work of processing one’s life takes place while dreaming. Sometimes the dying complain that they are “wasting time” sleeping. Actually their sleep/dream time is very important. Talk to them about their dreams. If they can remember their dreams (and trust you enough to share them with you) you might find it interesting.

During dying process a person’s facade (mask) slowly dissolves… the real person is gradually revealed. For them to trust you, you must be willing to do the same… to set your mask aside voluntarily and be as “real” as you know how. You must become vulnerable. In that sense, skilled hospice nurses must be willing to “die” with their patients. If you are not willing to do that your patient will sense it and not share.

Appetite decreases. You say your patient still has a good appetite. That should change as dying process progresses.

What are your patient’s views & expectations regarding life after death? Avoid asking about this in a religious context because then you will be likely to get a religious answer. Ask in a personal context; e.g. “What is your idea of where you are going next?” Or, “Where are you going after you leave here?”

There will usually come a time of panic… when the fear hits. Given proper support they might work through that in a short period of time… perhaps an hour or two. Then again it might go on much longer. If they get through that period it is like one more road marker passed. You don’t necessarily know how much time is left, just that you have passed one more marker.

Dying process is just that… a process. To get an idea of where a person is in that process you must first understand the process itself, then take the time to engage your patient in intimate, detailed discussion about their life, expectations, fears, hopes, experiences, dreams, etc. Hospice care involves assisting a dying person through a complex transition… it is a process… it takes time, care and understanding.

“End of life” care, on the other hand, involves symptom control; i.e. adjusting meds, making sure there are sufficient supplies on hand and that the CNA has been scheduled. It’s focus is simply attending to the death of a body.

If you want to know when the body will end, like one physician once said to me, “Don’t worry, sooner or later the bleeding stops.” If you want to know when the person will move on… cross over… however you want to put it… then you have to get involved with them on a deep, personal level.

ONSnrs · Jul 7, 2006

Thank you so much for sharing that knowledge, I deal w/ dying patients a lot and without any formal hospice training. I became very sentimental while reading your post, and there are many golden nuggets that I will take away with me, use and cherish from your post.

Thank you again for taking the time to share that valuable information.

leslie :-D · Jul 7, 2006

Nice post, ladyjane.

Motorcycle mama,

everything that req_read said: eventual atc sleep, decreased appetite...possible to see disorientation, fear upon waking. Please do not tell them it's the medications. They need validation. This 'work' they do while sleeping is tenuous. They may be reluctant to share what they remember, for fear of being viewed as crazy.

Many will try to tell you that they've been 'somewhere' but unable to expound.

Many appear anxious, as if there's a sense of urgency.

Go with their leads.

Try to understand what they need to do, who they need to see, where they're headed.

Where they go (hold my hand, req) almost seems non-dimensional, in that no matter how hard they try and explain, mere words cannot express the journey they have taken or are going to take.

But the majority of my pts have taken a trip.

Sometimes all they talk about is a boat, train, mule, horse, car, walking, tickets...look for any sort of words that relate to a journey.

These people are not crazy or confused.

They have been places, and will be going places that someday, we will understand and fully appreciate.

Enough cannot be said about the work that takes place as their sleep increases.

As for hands-on care, keep resp secretions at a minimum (scope patch, atropine, levsin gtts)

avoid suctioning; it only produces more secretions and is highly invasive.

The greater amt of narcs, the more aggressive of a bowel regimen.

When you notice mottled extremities and irreg breathing (apnea, cheyne-stokes, biots), then death is near.

If you validate, support your pt and keep her pain-free (physical, emotional and spiritual pain), her transition should be blessed and peaceful.

doodlemom · Jul 7, 2006

Motorcycle Mama,

Is she on hospice services? If not, it sounds like she would be an appropriate referral to hospice services. I know that you are giving her excellent care but she and her family could possibly benefit from having a whole team of people helping her through this time. With most insurances her comfort meds, most equipment, and supplies will be paid for. If she has medicare or medicaid, the service is 100% covered. After she dies, her family will have the benefit of bereavement counseling. Just a thought.

Jo Dirt · Jul 8, 2006

doodlemom said:
Motorcycle Mama,
Is she on hospice services? If not, it sounds like she would be an appropriate referral to hospice services. I know that you are giving her excellent care but she and her family could possibly benefit from having a whole team of people helping her through this time. With most insurances her comfort meds, most equipment, and supplies will be paid for. If she has medicare or medicaid, the service is 100% covered. After she dies, her family will have the benefit of bereavement counseling. Just a thought.

That sounds like such a good idea. I really know very little about hospice but I am going to talk to the DON Monday, I hope it will not be too late. She has a private duty nurse with her at all times, but I agree it would be to her benefit to have hospice take over, I wish I had realzied this sooner. Such a sweet woman this patient is, I woke up very early and though about her and it was hard to get back to sleep. In the leg where her cancer is she is starting to get a lot of skin breakdowns.

I have heard that dying people many times mention going on a "trip." In the nursing home where i worked when we saw paralyzed, mottled legs we always knew the end was very near.

I feel guilty because before she started going downhill it seemed she always "needed" something, like lancets and alcohol wipes and such, and since the agency doesn't supply those but another agency does (though I never let the patient know it because she was so nice and seemed appreciative) I would get kind of annoyed by it when she would ask. Now I feel an inch tall. Now I'm looking for things I can get to help her be more comfortable. I would like to just go sit and visit with her, but she seems too tired the times I drop in for a visit.

I hope we can get her switched to hospice care.

leslie :-D · Jul 8, 2006

If one of my pts were looking for lancets, i would try and find out why.

I would never supply her with etoh wipes or lancets.

Often their language is metaphorical so it takes some exploration to find their real needs.

But if she was frantically looking for some stuffed, baked lobster and chilled champagne.....heck, i'd join her in the hunt! Talk is cheap anyway, right???

doodlemom · Jul 8, 2006

earle58 said:
if one of my pts were looking for lancets, i would try and find out why.
i would never supply her with etoh wipes or lancets.
often their language is metaphorical so it takes some exploration to find their real needs.
but if she was frantically looking for some stuffed, baked lobster and chilled champagne.....heck, i'd join her in the hunt! talk is cheap anyway, right??? :balloons:
leslie

While they are not generally covered by hospice services, why wouldn't you want your pt to have diabetic supplies?

leslie :-D · Jul 8, 2006

doodlemom said:
While they are not generally covered by hospice services, why wouldn't you want your pt to have diabetic supplies?

I suppose it's a kneejerk reaction.

Yrs ago, i had a young hospice pt who was determined to shave her legs.

An electriz razor would not suffice.

Because she was so heavily medicated, i had safety/injury concerns.

Later that noc, i received a phone call from one very frantic husband.

This pt had deliberately gashed herself all over her body.

Granted, they weren't deep, since the razor had a cartridge and not a blade.

But there was blood everywhere and a dozen notable lacerations.

So comparable to a mom when her radar goes off, i automatically try and protect my pts from harm, esp if they're medicated.

I'm not trying to take away anyones' autonomy.

It's something that is unique to each pt. Situation.

Jo Dirt · Jul 8, 2006

doodlemom said:
While they are not generally covered by hospice services, why wouldn't you want your pt to have diabetic supplies?

It wasn't that she needed diabetic supplies why I would get a little annoyed. First of all, I'm usually very rushed, and second, it was just and example. Actually, I would get phone calls very frequently wanting to know if I could run something by, like sween cream, or alcohol wipes, or 4x4's, extra duoderms, or extra insulin needles, or chux pads, or gloves. She wanted my bottle of betadine but I told her I couldn't afford to leave it because the agency didn't supply it to us and it was over $12 a bottle (of course, since she started going downhill I not only gave her my bottle of betadine but I gave her a whole box of 4x4's for soaks to her feet. Anyway, things are really hectic with this HH agency, and I can't realistically come for visits every day, I wish I could though. But I wouldn't say anything about it. I would try to oblige. One visit I made 4 trips (way across the parking lot of her apartment) back and forth to my car because she kept thinking of things she needed and I would go try to find them in my trunk. Maybe exasperated is a better word.

But now, I think she is past the point of caring about any of that stuff. I just want what is best for her.

req_read · Jul 8, 2006

Here’s a thought on a different tack… an interesting tidbit.

You said your patient has multiple tumors. I once had a patient with the same thing. He & his wife were very bright, down-to-earth people. As his disease progressed he would see the MD occasionally and have x-rays taken which would reveal new tumors. But his wife said she had figured out how to detect them herself… and she showed me how.

She would move her hand slowly over her husband’s body… not touching him, but maybe an inch or half inch off the skin. When her hand passed over a tumor she said she could feel a sort of heat. I tried it and sure enough, I could feel it too… but only with my left hand.

I fell into the habit of doing it to other patients and found that it worked fairly well. I also tried feeling over the chest of patients who did not have cancer but were near death and lingering… the kind of patient that you find yourself wondering, “Gee… how much longer can this go on?” What I found was, if the patient was not ready to go I would feel a warmth. For patients whose death was imminent I felt… not a coolness… but an emptiness… a nothingness.

Anyway, no big deal… just thought I’d mention it. Most of you are still seeing patients (I don’t… except via emails) and it may help give a clue in some cases when you are being vexed by that old question, “How much longer?”

I wouldn’t talk about this too much though… people are inclined to think hospice nurses are about half a bubble off level anyway. It can be done quietly and unobtrusively during a routine exam.

EmptytheBoat · Jul 8, 2006

Motorcycle mama, Bravo for looking out for your patient and seeking guidance. doodlemom is right on to refer your patient to Hospice. Your

patient needs expertise in pallative care now! To answer your inquiry as to

signs of impending death: decreased LOC, decreased/absent appetite,

decreased B/P, increased pulse, respirations, temperature to name a few.

urine color indicative of hydration level. As body shuts down, not wanting

food/hydration, important not to force as it may cause aspiration resulting

in pneumonia/respiratory distress. I wouldn't worry about Lancets and

alcohol wipes at this point in time, your patient may benefit from oxygen,

and definitely would benefit from comfort management, both sustained and

immediate. Hospice should also provide social services, spiritual guidance,

and a nursing assistant trained for end-of-life assistance with ADL's.

Hospice should pay 100% of equipment, services, and all medications

related to symptom management which is what your patients needs at

this time. Please keep us posted, with some training, you present as one

who would make a good Hospice nurse. Good Luck!