How do you know when a pt. is actively dying?

[mjm1979]

I'm a new grad LPN working in a LTC facility. I've only been there a couple of months. I had fifteen days of preceptorship and am now on my own. I only work every other weekend for now. I have so many questions constantly d/t the fact that I'm a new grad and also have never worked as an aide. Sometimes when I ask a question I get the 'deer in the headlights' look from the nurse. The nurses have been wonderful but sometimes I think the veteran nurses forget what it's like being fresh out of school. Here's a question I'm so hesitant to ask, I guess b/c I think they'll think I'm a complete idiot... but here goes.

How do you know when your pt. is dying?

I went in last weekend and one of my residents had all her PO meds D/C'd. (a lot can happen in two weeks) I was reading her chart and I guess she had started declining.... all the chart said, so I'm not sure what all was going on. So basically she refused her meds for two days and they D/C'd them and now she stays in bed and is on SL Roxanol q4h. She looked good and vitals were good when I was in last weekend. She did eat some mashed potatoes at lunch and some liquid, but for the most part has stopped eating and drinking. So of course family had been notified prior that she was dying and she's had lots of relatives in visiting. How would I know she was dying?

About a month ago my preceptor was called into the dining room and one of our res. was sitting in her W/C unresponsive (staring straight ahead) with a brown foam coming from the corner of her mouth. We got her to her room got her on O2 and the pulse Ox machine and Dynamap. Got an order for Roxanol. Her pupils were sluggish. Called all the family to say they'd better come in coz she was dying. At least she didn't suffer long, she died later that evening. I feel so stupid, but how did they know she was dying?? People have strokes all the time, even severe ones and they survive. Anyway, thank you all so much in advance for sharing your knowledge with this newbie.

[logans_mommy]

hi mjm. i am still in nursing school but i have had a lot of experience with elderly patients. its usually a matter of the patient themselves knowing that they are going to pass. usually when this happens they tell their family members and make it clear how and what they want to happen. so i am guessing she knew and and everything fell into place. dont be scared to ask questions! everyone has been in your place and even know some nurses respond better to questions than others its always better to ask! after all, its not their licence on the line if soemthing happens. protect yourself and your job! you sound like a sweetie and i wish you the best of luck at your new job!!!!

[leslie :-D]

everyone dies differently, and will be according to their own disease process w/its unique presentations.

but for those whose death is expected, there are 2 stages to dying.

the preactive phase, which lasts on avg around 2 wks.

during this time, you will note:

- withdrawal from social activities

- increased sleep

- decreased po intake

- seeing others who have already passed

- pt awareness of dying process, i.e., "i'm dying"...

- delayed healing of wounds, infections.

- rallying, where there will be short period of good appetite and energy level.

active phase:

- inability to rouse

- sometimes, severe agitation/hallucinations (variant from baseline)

- cheyne-stokes w/periods of apnea

- resp congestion

- inability to swallow

- breathing open-mouthed, not speaking when awake

- eyes open, semi-opened but unaware of environment

- decreased uo, w/darkening of urine

- decrease in bp

- extremities cold and mottled

not everyone will present with all, but you will see some or even most.

it is believed that hearing is the last to go, so encourage verbal communication of family, friends.

best of everything in your new environment!

leslie

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[lpnflorida]

I use this as the only way I truly know someone is on their way to dying without the use of tele etc. Once you start seeing a patient in Cheyne Stokes breathing that was always a clear sign to me that someone was dying.

I have seen many instances of patient's who have had respiratory or cardiac arrest with proper treatment go on to live. Just as you have seen with strokes and such. So that darn breathing is what always sticks in my mind.

I am sure others probably have many more signs they use.

[rn2bnwi, BSN, RN]

the breathing is always the give away to me. ive heard it referred to as the 'death rattle' but every persons process is different even within the same disease. but motteling on the legs, if the pt is diaphoretic, and even the temp. of hands and feet are good indicators of impending death

[Virgo_RN, BSN, RN]

Leslie's description is very good.

[CoffeeRTC, BSN, RN]

Excellent post Leslie!

Start off by looking at the chart too. LTC pts have a ton of dx listed, look at the primary or what they are being treated for at the present.

I only word prn, so often times the residents take a turn for the worse and it is quite sudden. Week to week, day to day...things do change.

Keep asking questions....that is what good nurses do!

[WalkieTalkie, RN]

Hospice has a really good book they give patients and families that explains the death process.

http://www.hospicefoundation.org/endoflifeinfo/signs.asp

[VivaLasViejas, ASN, RN]

When their toes and feet are beginning to mottle, their skin is turning waxy-yellow, they're Cheyne-Stoking........and five minutes after you give them "permission" to let go, they do.

Had one pass on exactly this way tonight. She'd been CTD (circling the drain) for a couple of days, but no one really thought she'd go for another day or two as she was still minimally responsive and holding her own---BPs in the 100/60 ranges, sats in the mid-90s etc. When I went in at 1550 to assess her, I found her awake, but staring at the ceiling expectantly as though she saw someone highly interesting up there. (Who's to say she didn't?) Her toes were turning that funky purple-white color and her skin was cool to the touch; since her family was in Texas and there was no one to say "Go ahead, it's OK, you can relax and go now", I said it. Two minutes later she was gone.

Each patient has an individual moment in time when they switch from the pre-terminal phase to the active dying process. If they're lucky, it comes much like this one did, right at the very end.