1. Section II: Frequent Symptoms Associated with Imminent Death

2. Two Roads to Death Tremulous Confused Hallucinations Restless
THE DIFFICULT ROAD
Tremulous
Confused
Hallucinations
Restless
Mumbling Delirium
NORMAL
Myoclonic Jerks
Sleepy
Lethargic
Seizures
Obtunded
THE USUAL ROAD
Semicomatose
Comatose
DEAD
NCI, 2014; Seow et al, 2011

3. Most Common Symptoms in Final Days of Life
Kehl & Kowalski, 2013

4. Physical Symptoms Vary
Confusion, disorientation, delirium vs. unconsciousness
Weakness and fatigue vs. surge of energy
Drowsiness, sleeping vs. restlessness/agitation
Physical considerations:
Fever
Bowel changes
Incontinence
Decreased intake

5. Pain During the Final Hours of Life
Changes in level of consciousness may make
assessment and management of pain challenging.
If self-report is not possible, behavioral cues, proxy report, analgesic trials
What is causing the pain?

6. Opioids
Dosing of opioids given during last hours based on appropriate assessment and reassessment.
Dose may be decreased or increased
Consider other routes:
Oral
Rectal
Subcutaneous

7. What About the Principle of Double-Effect?
Is it morally permissible?
Intent
There will always be a last dose.

8. National Comprehensive Cancer Network (NCCN): Guidelines for Treating Pain Weeks to Days Before Death
Titrate to comfort
Recognize and treat toxicities
Analgesia vs. reduced LOC
Use equianalgesic dose conversions
Consult
Consider sedation for refractory pain

9. Myoclonus Assess potential etiologies
Benzodiazepines can be helpful (i.e., diazepam)
Switch opioids
Can lead to seizures

10. Terminal Secretions Respiratory congestion/terminal secretions
Distressing and frightening to family, friends, healthcare providers
Assessment
Management

11. Palliative Sedation at End of Life
Consider:
All possible etiologies and treatments
Education of patient/family regarding goals and outcomes
Interdisciplinary team approach
Medications

12. Symptoms of Imminent Death
Decreased urine output
Cold and mottled extremities
Vital sign and breathing changes
Delirium / confusion
Restlessness

13. Case Study: Gail (cont)
Gail is now unconscious
Pain assessment
Reassurance to family
Death rattle
Concerns about dehydration
Three days after going home, Gail became unconscious. The hospice nurse came to make an assessment and to speak with Tim. Both agree that Gail appears to be comfortable, though her breathing is quite labored. The hospice nurse recommends some morphine for this. Tim is afraid to give this to her, as he states, “I don’t want to give her too many drugs or I will kill her.”
Tim and his 2 sons are frightened by the death rattle and ask the hospice nurse if it can be stopped. One son asks if she should not be getting IV fluids so she will not get dehydrated.
She is also showing signs of myoclonus.
Questions:
1. How would you respond to Tim’s statement, “I don’t want to give her too many drugs or I will kill her.”
What about the death rattle? Treatments?
How would you respond to the son’s request for IV fluids to prevent dehydration?
How would you treat the myoclonus?
As the nurse observing the care that Tim has provided to his wife over these past few days, what would you say to encourage him and to thank him for his compassionate care for Gail?
Faculty: Stress the importance of providing encouragement and support to the caregiver. The caregiver plays a critical role in these final hours. Fatigue, sorrow, a sense of “being overwhelmed” are all common feelings of the caregiver at this time. They need much support. Do not forget to check on their well-being.
Asking some of these simple questions will assess the needs of the caregiver: Have you eaten in the past 4 hours? Is there food in the house? Is there someone who can stay at the bedside for a few hours while you sleep? Do you need to go to the pharmacy? If so, is there a neighbor or family member that I can call to assist you?

14. The Death Vigil Family presence Common fears Being alone with patient
Painful death
Time of death
Giving “last dose”

15. Nursing Interventions: Support
Collaboration with physician/team
Reassurance and education
Role model comforting
Physical comforting
Spiritual care; honor culture