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Terminal Velocity

I just read Mona Simpsons beautiful and loving eulogy about her brother Steve Jobs. Her description of her brother’s final hours reminds me of the final hours of many dying patients.

In fluid dynamics, an object is moving at its terminal velocity if its speed is constant due to the restraining force exerted by the fluid through which it is moving. There is another type of terminal velocity I have encountered numerous times in my practice. This happens to patients who are actively dying. There comes a point in the trajectory of the illness when the underlying disease is firmly designated to the back seat and the dying process takes over .

Having cared for numerous dying patients, I have come to the conclusion that dying  involves intense work that a patient has to do before they successfully pass away. Patients who are actively dying are suspended somewhere between the sleep and wake state. They gradually start losing ostensible  responsiveness to sensory stimuli with touch being the last to go. The patient’s breathing takes on a different rhythm and tenor. The skin can feel cool to touch with initial lower limb mottling followed by upper limb mottling.  Some patients will demonstrate a “final glow” as it is sometimes called in the field i.e. a seemingly unconscious patient can transiently regain consciousness and connect briefly with their loved ones, only to revert go back to their inexorable journey.

At this stage, the anticipated prognosis is in the order of minutes to hours. Anxious family members at the bedside often ask about what is happening to their loved one and when their loved one will pass.  In coaching families about this, an useful metaphor is the concept of riding the waves.

Imagine that you are standing on the shore and a wave comes in and gently pulls you into the ocean, only to deposit you back on the shore sometime later. Each passing wave draws you further and further into the water and the time spent on the shore is proportionately lesser. It is hard to say which wave is the final one,  but  it will come and transition the person “to the next living space” as one of my patients stated.

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 respirationsDefinition 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.

 References:

Stanford eCampus: http://endoflife.stanford.edu/M06_last48hr/commun_fam.html

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    This is such a
    valuable outline!  Not only is there physiological order but it also has
    a  spiritual order where awareness is enhanced and fear is mitigated.

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  • Gatito

    I find your language to be remarkably resonant with my own.  I speak to families about the mysterious work of individual as they turn inward deeply.   That there is effort and time required for humans to disentangle the self from the failing physical form.  I counsel that the time required is exactly that which is required, and that the opportunity to witness and courageously observe this process has profound value in teaching us viscerally about the nature of our human existence.  Such a rare opportunity to suspend our typical conscious experience of life and expose ourselves to the impenetrable mystery that provides context for meaning.  I appreciate your description of waves and will look for them at the bedside…..Thanks

    • VJ Periyakoil

      Gatito:
      I agree that those of us who have been caring for imminently dying patients see these patterns of introspection and disentanglement. I appreciate you for sharing your verbiage as I suspect that many of us have specific metaphors, analogies, language we have used effectively to convey to the family the intrinsic mystery of the dying process. The more examples we have, the better we will be able to tailor our message in a way to reassure and support loving family members.Thanks,VJ

  • Nancy English

    Nancy English, Palliative Care Nurse and Educator   As someone said there is an order to the dying process, this is such a valuable outline!  Not only is there physiological order but it also has a  spiritual order where awareness is enhanced and fear is mitigated.   Mona’s sharing her brothers death may help others to reduce the myths and fears surrounding death.    Thanks for this important ‘blog’.   

    • VJ Periyakoil

      Thanks Nancy for your kind words and for joining our conversation. I totally agree that there is a heightened awareness at the end of life where each individual seems to have a unique manual they seem to working off. Those of us in the business like you and I do see the commonalities, but I also marvel at the uniqueness of each person’s trajectory. To quote from the Tibetan Book of the Dead  “Learn to die and thou shall learn how to live. There shall none learn how to live that has not learnt to die.” 

  • Shahina Lakhani

    A beautiful article, and wonderful analogy. ” I have come to the conclusion that dying  involves intense work that a patient has to do before they successfully pass away.” I agree with this statement a 100%  And your patient’s comment about the next living space is beautiful! If its ok, I’d love to borrow both these comments to explain the process of dying to people I coach. Thanks and keep up the great work.

    • VJ Periyakoil

      Shahina, I am all for recycling helpful phrases ( I call this Green Communication i.e. in the recycle green Earth lingo :-) . I borrow from my patients all the time and I have not first had experience with dying ( came close twice but escaped).

  • Kennan Moore, LCSW

    Lovely (and informative!) piece all around.  I particularly will remember your patient’s comment as to “the next living space.”  Thank you…….

    • VJ Periyakoil

      Thanks Kennan. Patients sometimes use such beautiful phrases – which I collect and recycle to help other patients and families. Call it Green Communication if you will :)

  • Jared Porter

    Dying seems such hard work, yet there’s something I find very comforting: knowing that the body follows a “program” of sorts during those final days and hours. At some point, nothing more is required of us. The body takes over. It follows nature’s process. It knows what to do. 

    I’ve heard it said of lunar space voyages that, somewhere along the way, the moon’s gravity would take hold of a spacecraft and pull it toward its destination. The laws of nature took over, requiring nothing more of the spacecraft or astronauts as the journey proceeded. As I think of the dying time, it is comforting to know that the laws of nature apply then, too. At some point nothing more is required of us … only rest as we’re carried onward.

  • Jared Porter

    Dying seems such hard work, yet there’s something I find very comforting: knowing that the body follows a “program” of sorts during those final days and hours. At some point, nothing more is required of us. The body takes over. It follows nature’s process. It knows what to do. 

    I’ve heard it said of lunar space voyages that, somewhere along the way, the moon’s gravity would take hold of a spacecraft and pull it toward its destination. The laws of nature took over, requiring nothing more of the spacecraft or astronauts as the journey proceeded. As I think of the dying time, it is comforting to know that the laws of nature apply then, too. At some point nothing more is required of us … only rest as we’re carried onward.

  • Jared Porter

    Dying seems such hard work, yet there’s something I find very comforting: knowing that the body follows a “program” of sorts during those final days and hours. At some point, nothing more is required of us. The body takes over. It follows nature’s process. It knows what to do. 

    I’ve heard it said of lunar space voyages that, somewhere along the way, the moon’s gravity would take hold of a spacecraft and pull it toward its destination. The laws of nature took over, requiring nothing more of the spacecraft or astronauts as the journey proceeded. As I think of the dying time, it is comforting to know that the laws of nature apply then, too. At some point nothing more is required of us … only rest as we’re carried onward.

    • VJ Periyakoil

      I love that you describe the “gravity assist”. I use this exact phrase often in describing active dying to our trainees  i.e. at some point, the gravity of dying process takes over results in the terminal velocity. 

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