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
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.
Orient patient gently if tolerated and this is not upsetting. Allow pt. to rest.
Decrease in cardiac output and intravascular volume
Central and peripheral cyanosis and peripheral cooling.
Comfort measures. Space out activities.
Decreased urinary output
Possible urinary incontinence.
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.
Do not force fluid or foods.
Provide excellent mouth care.
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 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.
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.
Shortness of breath
Oxygen at 2-3 liters may help for some patients and often helps families to feel better. Link to Dyspnea module
Watch and share this five minute video about the need for prophylactic end-of-life conversations. Laura Heldebrand, an ICU nurse tells her mother's story.
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