Signs of impending death.

[Jo Dirt]

I work in the home health sector but we frequently care for patients even after they qualify for hospice and until their death.

I am caring for a 60 yr. old woman with chordoma (a rare bone cancer). She is one of the sweetest patients I've ever had. You can actually feel the tumors all over her body and yesterday she showed me two new ones on her leg, mainly this is on the left side of her body. She has struggled with is for 11 yrs. and it is finally coming to an end. She has been bedridden for over a month now and the past week or so she seems a little "out of it." She sleeps more than she is awake, she acts very weak and sleepy a lot of the time. But she has a good appetite still. She is not drinking as much and her urine is dark and has a lot of sediment (she has a foley).

I am wanting to say she is starting to go through the stages of dying. Does anyone have any experience with how long we can expect this process to last?

[EmptytheBoat]

I went back and reread your original post and realized i may not have addressed your question: how long can you expect the process to last?

From the brief history provided, it does appear that the acute dying process may have begun, but to predict a time-frame would be difficult.

Knowing her vital signs now and baseline would help but dying is much more than physical (mental, spititual, social) which makes it so difficult to predict a time frame. It is so very important to involve the family and caregivers in the process and to assure your patient's comfort to allow to work thru the process, and this is where the hospice experience should benefit your patient. Family/caregivers always want a time-frame and believe it is a cop-out when the hospice nurse defers, but it would be presumptuous if a hospice nurse predicts a time; after i have been taking care of a patient for some time and can experience the changes first-hand, i'm in a better position to attempt to predict a time-frame and i may be presumptuous enough to take what i believe is an educated guess; weeks as opposed to months/days as opposed to weeks/hours as opposed to days (this one is real tricky and usually only when i'm unable to auscultate a significant b/p). I try to to instill to the family and caregivers that the present is the only time to be concerned about and it is in the present that they need to stay.

[nckdl]

Has anyone ever heard of there ears curling back as a sign of impending death. I have never seen it but heard of it.

[Jo Dirt]

Never heard of ears curling back...that thought strikes me as kind of creepy, though.

I have heard of people who see others at their deathbed who have passed on. This really facinates me, but it's scary, too.

I have been thinking about my dying patient an awful lot lately. I hope the agency I work for can get past the greed of keeping a patient when it would be better for them to have hospice. This lady has a 20 something yr old son, he tries to act like he's got it together, doesn't show a lot of emotions and tries to act matter of fact, but the last time I was there he came downstairs and he just looked like he was lost and scared and I wanted to give him a hug.

I feel like such a creep telling the private duty LPN who was there I can't come by everyday. By golly, no matter how busy I am I am going to make time to drop by and see if they need anything and if I have to buy it myself I will get it for them.

[midcom]

I apologize if I'm hijacking this but wanted to thank you for the information. I'm not a nurse yet, heck, haven't even started school yet. I've been reading some of the various speciality forums to see just what is involved with each speciality. Hospice has been an interest to me since my Mother needed the services of our local one 3 years ago.

I was reading the signs of impending death you listed & you've answered some questions I've had since Mom's death, especially one about fear. Mom was a very very strong Christian. When she was diagnosed with stage 4 rectal cancer, she really didn't act too upset. She often would tell people, "I have cancer, I'm dying, and I'm going to heaven to be with Al." (my Dad) She was always so upbeat & even her hospice nurses were surprised by her attitude. Three weeks before her death, we could no longer take care of her ourselves & our hopsice didn't have room in their hopsice house so she went to a nursing home. A few days before her death, my sister & I realized she was slipping & stayed with her around the clock. It was during those days that something happened that really shook my faith. Suddenly she was terrified to die. What she had been begging God for almost 6 years, now had her almost mentally mad. She kept saying, "I'm bad. "I'm bad" and nothing we could say helped.

Req Read said- "During dying process a person's facade (mask) slowly dissolves... the real person is gradually revealed" and "There will usually come a time of panic... when the fear hits." Now I understand why Mom reacted like she did. She really was scared and I suspect she had been all along. We eneded up asking the nurses to give her more & more of her pain meds because she was physically uncomfortable and eventually they kept her calm.

Although it was her day off, her hospice nurse stopped in at the nursing home to check on Mom & realized she had only a short time. She told me to feel her arms & legs as she would start to run a fever shortly before the end & sure enough it happened.

I can't say enough good things about the wonderful nurse that was assigned to Mom & how she helped our family to accept Mom's leaving us. I'm planning to be a LPN & I don't believe the Hospice in our area hires LPNs so I can't work there but I will always be appreciative of them and anyone who works in that field.

Dixie

[req_read]

The goal of living and the goal of dying are the same; i.e. to do it consciously… but few accomplish either.

Living consciously means to be aware of who you are… the real you, not the façade. It means to be aware of your faults, your hidden agendas, your negative ego… to see and accept that in yourself and those around you. And that is no small task!

Dying process does dissolve the façade. Religious faith is often used as a façade; i.e. a mask used to hide from one’s fear. When the façade dissolves, the fear is revealed.

There is nothing wrong with that… everyone has fear. But it is easier to deal with if you are aware of that (conscious of it) and do not delude yourself into thinking you are above it (super human or super faithful.)

The goal of awareness… the passion of consciousness… is to be aware. In other words, it is not necessary to defeat or control or conquer your fear… just to be aware that you have it.

It is so common for people to live and then die with a low level of consciousness that a decreased level of consciousness is often assumed to be a natural part of dying process. That is not necessarily so. A relatively small proportion of dying people do so wide awake… fully conscious and aware of what they are doing. These people are no different than you or I… except that they practice being aware of themselves and are open minded (not “know-it-alls.) They are not perfect… no one is. But they do practice being aware of who they are… not just the parts they like or prefer about themselves, but ALL of themselves. Then, when dying process comes along and strips them down they are not terribly shocked, surprised or unprepared. They handle it… and stay conscious.

The passion of awareness is to be aware… and how better to be aware of one’s immortality than to cross over consciously? If you can manage to cross over wide awake you will KNOW, absolutely, once and for all, that you are immortal… and your personal awareness of that will be added to the collective consciousness.

A truly skilled hospice nurse understands the beauty of dying process and tries to help the dying cross over consciously… to live and die consciously… to be aware of who they are. It doesn’t happen often, but when it does… WOW!

But they don’t teach that in nursing school or CHPN.

[Jo Dirt]

Well, I guess I don't have to worry about my facade...I wear my heart on my sleeve! As much as I want to believe in heaven and an afterlife I'm terrified to die. I think that is why I am so fascinated by it.

But I know many people who I believe delude themselves with religion, and I think the more scared they are the more of a facade they will eventually have to break through. I guess it is a coping mechanism.

[leslie :-D]

And we all having them, coping mechanisms that is.

The ideal however, is to recognize our defense and coping mechanisms, and to chew through their etiologies.

The more insight we have at the end of our lives, the smoother the transition.

It's one thing to say " this is my coping mechanism for a, b & c"

it's quite another to say that i recognize and accept the realities of a, b & c.

The more work we do throughout our lives, the less work we have when we die.

We have many different ways of coping.

Some are drugs, alcohol, work, spending, the mechanisms of sheer denial, keeping busy, etc.

What if we stopped our coping mechanisms in its' tracks?

We would be forced to deal with and confront the stressors at hand.

Truth-seeking. That's all it really boils down to.

Granted, the journey isn't easy but the results can be invigorating.

If we choose not to run from ourselves throughout our lives, then the fear and anxiety of 'dying', will be proportionately diminished.

This has been my experiences in hospice.

[lesrn2005]

Alright req'd reading-please print more-always like to read your posts!

[steelydanfan]

I know nothing of dying, and have been at many deaths, but only 2 truly touched my soul. Two patients each with different diagnoses, but both well aware of thier impending death. One chose awareness as long as possible, then asked for and recieved "assisted suicide" with his doctor and loved ones at his bedside. A simple combination of morphine and decreased o2 granted his wish to die with the dignity that he had lived.

The other asked for terminal Morpheus, once her prognosis was asssured. She lived for 2 weeks in a morphine cloud, happy and smiling, surrounded by staff and family who took great comfort in the easy passage of this wonderful women.

May my family have such courage.

[Jo Dirt]

cateccrn said:

The other asked for terminal Morpheus, once her prognosis was asssured. She lived for 2 weeks in a morphine cloud, happy and smiling, surrounded by staff and family who took great comfort in the easy passage of this wonderful women.

May my family have such courage.

That's the way I want to go if I should realize when it is going to happen!

[chadash]

req_read said:

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.

Your whole post was great, but I really appreciated this insightful statement.

Even as an aide, this has been my experience.

[Demonsthenes]

Generally, it is almost impossible to ascertain how long a hospice patient will live. It is as varaible as the multitude of diseases processes with their concommitant relationship to the deterioration in the fundamental organ systems of the body.

One objective criteria is pulse oximetry readings. As they begin to deteriorate so do all of the body organ systems.

Concommitant with the same are changes in levels of consciousness, abnormal breathing patterns such as Kussmals and Biot respirations.

Signs and symptoms of shock concommitant with the aforementioned are invariably associated with impending death.