It can be very frustrating to us doctors and nurses trying to “play God” and try to predict “how long more the patient can live”.
Yet, it can be very useful for us to try to prognosticate the patient’s impending death for the following reasons.
- It allows us to communicate with more confidence to the patient’s family members.
- It allows us to make a better choice of the location of care of the patient.
- For example, if we knew that the patient is impending demise in the next few hours or days, would we still subject them to a meaningless and possibly painful hospital stay?
- It helps us “choose our battles” and be more confident in recommending discontinuation of aggressive treatment and investigations.
So, if it is so useful, why aren’t we taught how to do it? It can be extremely difficult, but here are what some studies have agreed on.
Signs and symptoms
The following 5 signs occurred only in the last days of life and were highly predictive of impending death within 3 days
- Pulselessness of the radial artery
- Decreased urine output
- Cheyne-Stokes breathing (deep and fast breathing, which stops, then restarts again)
- Respiration with mandibular movement (the jaw drops when breathing: can someone contribute a video please?)
- “Death rattle” (this “sound”)
Another 7 neurological signs of impending death (<3 days)
- Decreased response to visual stimuli
- Hyperextension of the neck (bending backwards of the neck)
- Drooping of the nasolabial fold (the line between the mouth and the nose)
- Nonreactive pupil
- Decreased response to verbal stimuli
- Grunting of vocal cords (“snoring sound”)
- Inability to close eyelids
|Physiologic changes||Signs||Nursing Intervention|
|Decreased blood perfusion, decreased cardiac output and intravascular volume||BP drops, HR goes up, skin becomes mottled and blue and cold||Good skincare. Turn patient every 2-3 hours, keep patient warm, support with soft pillows|
|Food and fluids|
|No interest in food/fluids||Dehydration, lips dry, skin turgor low, no urine output, no bowel movements||Do not force fluids or food, the patient who is dying does not require a lot of food/fluids. Provide excellent oral care|
|Swallowing difficulties due to drop in conscious level||Food stuck in mouth, coughing or choking after food||As above, or add thickener or soft food|
|Retention of secretions||Noisy breathing with no or weak cough||Nurse patient propped up at 45 degrees or fold small towel/pillow behind the neck|
|Profound weakness and fatigue||Sleeps the whole day||Let the patient sleep. Reinforce the idea that they look very comfortable, peaceful and having a good rest.|
|May start speaking to persons who have already died or see places that others cannot see.||Could be due to decreased function of the brain.||Sometimes might need medication. Otherwise, the patient can generally be left alone.|
What to do?
Read the chapter here on basic palliative framework.
Some basic nursing interventions have been covered above.
Any other questions or feedback? Please drop them here.