Hospice & Palliative Care

Cardinal Signs/ Indicators of Imminent Death (Learning about Hospice)

Physical symptoms of people that are actively dying may vary but often include:

  • Reduced level of consciousness – Cognitive changes with periods of lucidity 清晰alternating with those of confusion, disorientation, restlessness, and agitation are often evident.
  • Impaired visual acuity but increased sensitivity to light are common.
  • General dulling of senses except for hearing occurs.
  • Heart rate usually increases in the earlier stages but eventually becomes thread and weak and may slow or become irregular.
    • If blood pressure is being monitored, it will gradually descend. Even if the patient is given vasopressin, they will eventually fail.
  • Irregular labored breathing; Periods of no breath – Respiratory rate also usually increases in the earlier stages but then begins to slow and may be interspersed with periods of increasing apnea or Cheyenne-stokes respiration’s (cycles with period of deeper faster labored RR to lengthening period of apnea).
  • Weakening of cough and inability to clear secretions may result in rales (“death rattle,”)
    • Death rattle – as patients near death, they are unable to cough to clear secretions that begin to pool in the oropharynx and bronchi, resulting in rales (“death rattles”). Because the sound is often distressing to family members, an anticholinergic (glycopyrrolate or atropine) may be given subcutaneously to relieve respiratory distress. A hyoscine hydrobromide transdermal patch is also available, but action is slower, 12 hours compared to 1 minute for injections. Risks associated with anticholinergics include xerostomia 口干, increased sedation, and increased delirium. Elevating the head of the bed or turning the patient to the side may also relieve rattling. Patients normally stop taking fluids as they near death, resulting in dehydration and drying of the mucous membranes of the mouth. The death rattle also begins to lessen.
  • Decreased urine output – Urinary retention and or urinary incontinence are common. As patient’s fluid intake decreases (taking no fluids or only sips of fluids), urinary output falls and urine may become more concentrated.
  • Muscle tone and the ability to move decreases (usually dismally to proximal) until the patient is unable to move.
  • Progressing coldness and mottling in legs and arms – Patient’s skin may become cool, and distal cyanosis may be evident; legs may appear mottled.

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