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Flashcards in Non-Pain 2 Deck (27):

Preparing for the last hours of life- for caregivers

- Be aware of patient choices
- Knowledgeable, skilled, confident
- Rapid Response
- Likely events, signs, symptoms of the dying process


How many people die of prolonged illness



Common signs and symptoms of imminent Death- 1-3 months

- Withdrawal from the world
- Turning inward
- Less communication with the world
- Increased reflection
- Decreased nutritional intake


Common Signs and Symptoms of Imminent Death 1-2 weeks

- Altered states of consciousness
- Dreams/visions/conversing w /seen/unseen
- Maybe restless/agitated/wanting up/down
- May want to remove clothing
- Maybe quiet/resting deeply
- Eyes appear unfocused/dreamy
- Sleeping/waking hours prolonged
- Not eating/maybe drinking
- Then may request an occasional meal


Common Signs and Symptom of imminent death- Days to hours

- Maybe surge in energy
- Breathing grows shallower in chest
- Maybe apnea- up to 60 sec
- Gurgling (throat)
- Eyes maybe teary or dry/shiny
- Eyes may remain open/not blink
- Skin grows dusty/blotchy
- Little observable response to outside environment


Physiological Changes during the Dying Process

- Increasing weakness, fatigue
- Decreasing appetite/fluid intake
- Decreasing blood perfusion
- Neurological dysfunction
- Pain
- Loss of ability to close eyes


The things that require the most amount of treatment or prevention a day or two before death

- Respiratory tract secretions
- Pain
- Dyspnea
- Restlessness
- Agitation


ICHABOD Syndrome

I- immobility (less than 20% can stand within 2 days of death)
C- Confusion and Coma (40% are comatose, 30% confused in the 2 days before death)
H- Homeostatic failure (temp, BP, circulation)
A- Anorexia
B- Breathing changes
O- Oral intake decreased/Oservation
D- Dyspnea/Detachment


Weakness/Fatigue general symptoms

- Decreased ability to move
- Joint position fatigue
- Increased risk of pressure ulcers
- Increased need for care- activities for daily living, turning, movement, massage


Decreasing Appetite/Food intake

- Fears: "giving in", starvation
- Reminders-
-- food may be nauseating
-- anorexia may be protective
-- risk of aspiration
-- Clenched teeth express desires, control
- Help family find alternative ways to care


The differences between the body shutting down and starvation

Body Shutting Down
- Loss of Body fluids/electrolyte changes
- Decreased blood flow/oxygen to GI tract
- Absence of hunger sensation

- Lack of nutrition
- Physiological homeostasis
- Hunger


Artificial Hydration.... should it be used?

- is the patient's well-being enhanced?
- What symptoms are relieved by hydration
- Are other EOL symptoms aggravated?
- Does hydration improve LOC? (values and goals)
- What is the impact on well-being, mobility, ability to interact and be with family?
- What is the burden on the family- caregiver stress, finances


Decreasing fluid intake...

- Oral rehydrating fluids
- Fears: dehydration, thirst
- Remind family and caregivers that dehydration does not cause distress and dehydration may actually be protective


Decreasing Blood perfusion

- Tachycardia, hypotension
- Peripheral cooling, cyanosis
- Mottling of skin
- Diminished urine output
- Parenteral fluids will not reverse


Neurological Dysfunction

- Decreasing level of consciousness
- Communication with the unconscious patient
- Terminal delirium
- Changes in respiration
- Loss of ability to swallow, sphincter control


Communicating with the unconscious patinet

- Distressing to family
- Awareness is more important than an ability to respond
- Assume the patient hears everything
- Create a familiar environment
- Include in conversations- by assuring they are present/safe
- Give permission to die
- Touch - some want it/some don't

- Much depends on the type of relationship to the person
- Many people "wait" for cues from the people in the room for "permission to die"


Two roads to death

- The Usual road- decreasing level of consciousness
- The Difficult road- Restless, confusion, hallucinations- difficult symptoms in general


Terminal Delirium

- "The difficult Road to death"
- Seizures
- Family will need support, education
- Medical management
---- Benzodiazepines
---- Neuroleptics


Changes in Repiration

- Altered breathing patterns
- diminished tidal volume
- Apnea
- Cheyne-Stokes Respirations
- Accessory muscle use
- Last reflex breaths (gasping)


How to treat/help with changes in respiration

- Fears- suffocation
- Management- Family support !
---- help them understand taht breathlessness will happen, and that oxygen may prolong the dying process


Loss of Ability to Swallow

- Loss of gag reflex
- Build-up of saliva, secretions
--- scopolamine to dry secretions
--- postural drainage
--- Positioning
--- Suctioning is rarely indicated


Loss of Sphincter Control

- Incontinence of urine, stool
- Family needs knowledge, support
- Cleaning, skin care
- Urinary catheters
- Absorbent pads, surfaces


Pain in the last hours of life

- There is a huge fear of increased pain
- Need to assess the patient to know....
- persistent vs. fleeting expression
- Grimace or physiologic signs
- Incident vs. rest pain
- Distinction from terminal delirium


Loss of ability to close eyes

- Loss of retro-orbital fat
- Insufficient eyelid length
- Conjuctival exposure- increased risk of dryness, pain , and maintain moisture


Dying in Institutions

- "home-like environment"
- permit privacy, intimacy
- Continuity of care plans
- Avoid abrupt changes of settings
- Consider a specialized unit


As expected death approaches

- Discuss status of patient to family and realistic care goals
- What the patient experiences don't necessarily equal what onlookers see
- Reinforce signs, events of dying process
- Personal cultural, religious, rituals, funeral planning
- Family support throughout the process


Laying out the body

- Can be very helpful for all involved
- lay flat with arms crossed and eyes, mouth closed/chin tucked