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Signs of Impending Death

Physiologic Changes

Signs/Symptoms

Intervention

Cardiac and Circulation Changes
Decreased blood perfusion Skin may become mottled and discolored. Mottling and cyanosis of the upper extremities appear to indicate impending death versus such changes in the lower extremities. Provide good skin care. Turn patient every 2-3 hours if this does not cause discomfort. Lotion to back and extremities. Support extremities with soft pillows.
Decreased cerebral perfusion Decreased level of consciousness or terminal delirium.
Drowsiness/disorientation		 Orient patient gently if tolerated and this is not upsetting. Allow pt. to rest.
Decrease in cardiac output and intravascular volume Tachycardia
Hypotension
Central and peripheral cyanosis and peripheral cooling.		 Comfort measures. Space out activities.

Urinary function

    
Decreased urinary output Possible urinary incontinence.
Concentrated urine.		 Keep patient clean and dry. Place a Foley if skin starts to break down or if patient is large and difficult to change diapers or if caregiver unable to provide diaper and linen changes.

Food and Fluids
Decreased interest in food and fluid. Weight loss/dehydration Do not force fluid or foods.
Provide excellent mouth care.
Swallowing difficulties Food pocketed in cheeks or mouth/choking with eating/coughing after eating Soft foods and thickened fluids (e.g. nectar) as tolerated. Stop feeding patient if choking or pocketing food.

Skin
Skin may become mottled or discolored. Patches of purplish or dark pinkish color can be noted on back and posterior arms/legs. Keep sheets clean and dry-avoid paper chux directly to skin. Apply lotion as tolerated.
Decubitus ulcers may develop from pressure of being bedbound, decreased nutritional status. Red spots to bony prominences are first signs of Stage I decubiti and open sores may develop. Relieve pressure to bony prominences or other areas of breakdown with turning and positioning Q2 hrs if tolerated. If patient has increased pain or discomfort with position changes, decrease the frequency.
Special mattress as needed.
Duoderm or specialized skin patch to Stage I-II ulcers. Change Q5-7 days or as needed. Goals of wound care for Stage III and IV decubiti should be to promote comfort and prevent worsening rather than healing since healing most likely will not occur.

Consider application of specialized products such as charcoal or metronidazole paste (compounded) if odors are present.

Respiratory
Retention of secretions in the pharynx and the upper respiratory tract. Noisy respirations – usually no cough or weak cough. Head of bed up at 45 degrees. Can fold small soft pillow or towel behind neck for extra support.
Dyspnea

 

 Shortness of breath Oxygen at 2-3 liters may help for some patients and often helps families to feel better. Link to Dyspnea module
Cheyne-Stokes respirations

Definition

 

 Notable changes in breathing. A gentle fan blowing toward the patient may provide relief.
Educate families that this is normal as the patient is dying.

General changes
Profound weakness and fatigue. Drowsy for extended periods. Sleeping more. This is normal. Educate family.
Disoriented with respect to time and a severely limited attention span. More withdrawn and detached from surroundings. May appear to be in a comatose-like state. This is normal. Educate family.
Patient may speak to persons who have already died or see places others cannot see. Family may think these are hallucinations or a drug reaction. If patient appears frightened may need to treat with medication. Otherwise, educate family that this is normal and common.

 
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