What trajectories of death are shown below?
Black = cancer, Red = organ failure, Blue = physical/cognitive frailty. Green = sudden death
Early dying changes (1-3 months prior)
Attention span decreases, fatigue, muscle weakness, decreased appetite (a result of fatigue, dyspnea, surgeries, medications), social/emotional withdraw
How does artificial hydration affect the dying process?
Dehydration is not painful, artificial hydration prolongs the dying process
Mid stage (1-2 weeks prior) changes before death
Cognition declines (hallucinations, confusion), sleeping 20-24 hrs, minimal appetite (ice chips), social impairment (speaking stops)
Causes of near death experiences
Patient feels like they’re dying in their cortex -> Dreaming of who they may see when they die -> Reticular Activating System impaired by medications -> Wakeful dreams
Active stage (72 hours prior) of death
Cognition is minimal, sleep is constant, no muscle control, no nutrient intake (IV not effective) and obtunded
Neurologic homeostatic deficits in the last 72 hours of life
Obtunded or minimally responsive (higher brain function ceases), body temperature fluctuates (hypothalamic axis not functioning properly), Cheyne-stokes breathing, loss of muscle control (ileus, loss of swallow reflex causing tracheal congestion, “death rattle")
How do you treat the death rattle?
Stop fluids, elevate the head of the bed, put them on their side, give Lasix/Levsin drops/sublingual atropine…this is only to appease the family.
Circulatory changes in the last 72 hours of life
BP decreases, HR increases, extremities get cyanotic and blood shunts centrally. Note that the radial pulse is one of the last ones to go (24-48 hours prior).
Blue-purple blotchy hue on knees, lips and nail beds and blood shunts centrally.
Respiratory changes in the last 72 hours of life
Abdominal breathing, short/shallow breathing, accessory neck muscles and stacked breathing (Cheyne-Stokes). Note that the Cheyne-Stokes breathing looks like gasping, but its just breaths on top of each other and they’re not gasping (agonal breathing).
5 things families should say to their dying relatives
Please forgive me, I forgive you, thank you, I love you and goodbye.
Changes that occur with active dying (hours to weeks)
Patients can live for weeks w/o food/fluids
Final stages of death in dialysis patients? Stroke patients?
They get hyperkalemic and they die suddenly. Stroke patients first become obtunded, and then organs shut down 2 weeks later. Explain to the patient that there are 2 deaths, loss of person and actual death.
2 pathways to dying
M6G and M3G metabolites from morphine do not get excreted and have significant side effects to complicate dying
How does dying in kids differ from that in adults?
They spend longer amounts of time in each stage of death
What happens when physiologic death occurs?
No respirations/heart beat. Loss of sphincter control. No response to verbal commands or painful stimuli. Eyelids slightly open, pupils fixed. Jaw relaxed and mouth slightly open. Skin turns waxen pallor as blood settles.