Question about breathing at end of life

[Spotty44]

I'm a newer nurse (only been working for 5 months) and work in a skilled nursing facility. One of my patients is on hospice and nearing the end of life and this is my first experience with a hospice patient that is probably close to death.

I know that apnea is common towards the end, but everything I've read and learned seems to imply that the apnea is consistent. Over the course of about 24 hours, the pt developed apnea only while sleeping, but when she is woken up her breathing is about 20/min (she is arousable, although drowsy and will respond verbally, but not appropriately, which is probably a combination of severe dementia, morphine, and probably hypoxia as well) .

Is apnea only during sleep common at the end of life? I only work night shift, and I've known this patient since before she was put on hospice and she hasn't had a problem with sleep apnea in the past....

[nhelkhound]

I have never seen apnea only during sleep at the end of life, but I'm always surprised by the things I haven't seen (yet)! I would try repositioning this Pt when she exhibits apnea during sleep; if this stimulates breathing she may have had a blockage (like her tongue).

[jeannepaul, BSN]

when they start to decline, the apnea will come and go. Sometimes it just depends on the way they are positioned. They can also switch between breathing fast, then slow with apnea. This can go back and forth up until the usual final breathing change. Everyone is different, but I have seen it many times, nothing to worry about. It doesn't mean a much until you see A +B+C, meaning more than a few symtoms lasting longer than a few days.

[ErinS, BSN, RN]

Often in my patients I have seen cheyne-stokes breathing with periods of apnea begin only at night. During the day people will sometimes be a little more arousable, and like all of us, sleep deeper at night.

I just wanted to address something you mentioned: "(she is arousable, although drowsy and will respond verbally, but not appropriately, which is probably a combination of severe dementia, morphine, and probably hypoxia as well)". It is important to realize that cognitive changes, in my experience, are rarely related to pain medicine. Someone who is well and having pain and is given morphine, does not usually have a change in cognition. Often the change in cognition at the end of life is seen with terminal restlessness. I would encourage you, anytime you are seeing signs of impending end of life (such as breathing changes, circulation changes, or intermittent unresponsiveness), that you consider whether your pt is actually in discomfort. Discomfort at the end of life triggers the sympathetic nervous system, and someone who would normally be comatose all the time, suddenly has a surge of adrenaline that keeps them falsely alert. I am not saying we should arbitrarily make everyone comatose at the end of life, but we need to be aware that usually pt's are comatose or pretty close to it at the end of life, and if we are seeing someone with signs of active dying who is still relatively alert, we need to assess for other possible signs of discomfort.