Watch the video/tutorial at Medscape nurses on
The Last Hours of Living
Have Kleenex handy
There is a quiz in the comments
Also in the comments are signs and symptoms you would expect to see in the dying person.
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1. Mr. Larson is a 62-year-old building maintenance worker who is dying of advanced lymphoma. He has not had much pain during his illness. He has been unconscious most of the past 24 hours. The family calls to report that he has begun to moan, and they are very distressed. This moaning most likely represents:
Terminal delirium
Crescendo pain
Spiritual distress
Depression
2. Ms. Montaldo is dying of uterine cancer. She has been essentially comatose for the past 12 hours. Her family is at her bedside stroking her hair. However, over the past hour, they have noticed a "choking or gurgling" sound in her throat. The most likely medication to be helpful is:
Morphine
Scopolamine
Diphenhydramine
Lorazepam
3. Mr. Cianci is a 45-year-old former football player who is dying of advanced testicular cancer. He is in the hospital, mostly somnolent, but has periods of lucidity which his wife and children cherish. His urine output has declined over the past 48 hours. He has 4+ pitting edema to his thighs bilaterally. You should:
Increase IV fluids
Administer IV dopamine
Discontinue IV fluids
Administer morphine
4. Mr. Barnard has had good pain control with regular doses of morphine. He is now unconscious and near death and has begun to moan and be restless. You should administer:
Oxygen
Morphine
Scopolamine
Lorazepam
5. Mr. Takayashi is a 66-year-old engineer with far advanced gastric cancer. He has deteriorated steadily over the past several months and finally dies peacefully at his home with his family and his hospice nurse at his bedside. Approximately what percent of patient deaths in developed countries are expected deaths?
< 55%
55% to 60%
75% to 80%
> 90%
6. Ms. Kim is a 61-year-old Vietnamese immigrant with widely metastatic cervical cancer who is being cared for at home by her family. You have made a home visit to her to ease the family's anxiety as she enters the active phase of dying. While you are in the home, Ms. Kim dies. After offering condolences and support to the family, the most appropriate next step is to:
a. Call the funeral home
b. Call the coroner
c. Notify the tumor registry
d. Notify the police
7. Mr. Forrester, an 82-year-old widower who resides in an extended care facility under your care, has just died after a long struggle with metastatic prostate cancer. His closest family lives more than 300 miles away. You must notify his daughter, who is the Power of Attorney, by telephone that her father has just died. You decide to use the 6 steps of good communication that you learned as part of a continuing education program. Step one is "Getting the setting right." Step two is:
a. Finding out the circumstances of the death
b. Providing a warning shot
c. Asking what the person understands
d. Clarifying the relationship of the person to the patient
8. Mr. Jarrod, a 56-year-old gentleman with metastatic pancreatic cancer, is nearing death. He is not hungry and is no longer interested in eating. He is rapidly losing weight. His family is concerned that he is "starving to death." On your evaluation, you note that he is cachectic, his breath is ketotic, and he is developing wounds on his sacrum. Part of your treatment plan should be:
a. Offer parenteral nutrition to alleviate ketosis and promote wound healing
b. Educate the family that the patient is not "starving to death," but is dying as a result of his cancer
c. Educate the patient about the importance of eating small frequent meals to improve his sense of well-being
d. Offer nasogastric feedings, as the enteral route of nutrition is preferable over the parenteral route
9. Mr. Khan is a 71-year-old gentleman who is terminally ill with metastatic lung cancer. Although his pain and shortness of breath are adequately controlled with medications and continuous supplemental oxygen, he complains of severe dry mouth. The most appropriate intervention is:
a. Administer intravenous hydration to reverse the effects of dry mouth and dehydration
b. Moisten the oral mucosa every 1 to 2 hours with lemon glycerin swabs
c. Moisten the oral mucosa every 15 to 30 minutes with baking soda mouthwash
d. Coat the lips and anterior nasal mucosa hourly with petroleum jelly to reduce evaporation
10. Ms. Lightfoot, a 69-year-old woman with widely metastatic colon cancer, is bedfast and near death. Although she seems comfortable when lying still, she cries out with the slightest attempt at moving her, even though she is on high doses of opiate analgesia. She is developing numerous stage I and II areas of skin breakdown on her buttocks, sacrum, and shoulders. An appropriate intervention is:
a. Increase the frequency of turning from every 2 hours to every hour to prevent further skin breakdown
b. Order a pressure reduction mattress and reduce the frequency of turning
c. Remove the draw sheet from the bed to reduce shearing forces on the skin
d. Massage areas of nonblanching erythema to increase circulation and decrease pain
Table 1. Changes During the Dying Process
Change Manifest by/Signs
Fatigue, weakness Decreasing function, hygiene
Inability to move around bed
Inability to lift head off pillow
Cutaneous ischemia Erythema over bony prominences
Skin breakdown, wounds
Decreasing appetite/food intake, wasting Anorexia
Poor intake
Aspiration, asphyxiation
Weight loss, loss of muscle and fat, notable in temples
Decreasing fluid intake, dehydration Poor intake
Aspiration
Peripheral edema due to hypoalbuminemia
Dehydration, dry mucous membranes/conjunctiva
Cardiac dysfunction, renal failure Tachycardia
Hypertension followed by hypotension
Peripheral cooling
Peripheral and central cyanosis (bluing of extremities)
Mottling of the skin (livedo reticularis)
Venous pooling along dependent skin surfaces
Dark urine
Oliguria, anuria
Neurologic dysfunction, including:
Decreasing level of consciousness Increasing drowsiness
Difficulty awakening
Unresponsive to verbal or tactile stimuli
Decreasing ability to communicate Difficulty finding words
Monosyllabic words, short sentences
Delayed or inappropriate responses
Verbally unresponsive
Terminal delirium Early signs of cognitive failure (eg, day-night reversal)
Agitation, restlessness
Purposeless, repetitious movements
Moaning, groaning
Respiratory dysfunction Change in ventilatory rate -- increasing first, then slowing
Decreasing tidal volume
Abnormal breathing patterns -- apnea, Cheyne-Stokes respirations, agonal breaths
Loss of ability to swallow Dysphagia
Coughing, choking
Loss of gag reflex
Buildup of oral and tracheal secretions
Gurgling
Loss of sphincter control Incontinence of urine or bowels
Maceration of skin
Perineal candidiasis
Pain Facial grimacing
Tension in forehead, between eyebrows
Loss of ability to close eyes Eyelids not closed
Whites of eyes showing (with or without pupils visible)
Rare, unexpected events:
Bursts of energy just before death occurs, the "golden glow"
Aspiration, asphyxiation
Changes During the Dying Process
Change Manifest by/Signs
Fatigue, weakness Decreasing function, hygiene
Inability to move around bed
Inability to lift head off pillow
Cutaneous ischemia Erythema over bony prominences
Skin breakdown, wounds
Decreasing appetite/food intake, wasting Anorexia
Poor intake
Aspiration, asphyxiation
Weight loss, loss of muscle and fat, notable in temples
Decreasing fluid intake, dehydration Poor intake
Aspiration
Peripheral edema due to hypoalbuminemia
Dehydration, dry mucous membranes/conjunctiva
Cardiac dysfunction, renal failure Tachycardia
Hypertension followed by hypotension
Peripheral cooling
Peripheral and central cyanosis (bluing of extremities)
Mottling of the skin (livedo reticularis)
Venous pooling along dependent skin surfaces
Dark urine
Oliguria, anuria
Neurologic dysfunction, including:
Decreasing level of consciousness Increasing drowsiness
Difficulty awakening
Unresponsive to verbal or tactile stimuli
Decreasing ability to communicate Difficulty finding words
Monosyllabic words, short sentences
Delayed or inappropriate responses
Verbally unresponsive
Terminal delirium Early signs of cognitive failure (eg, day-night reversal)
Agitation, restlessness
Purposeless, repetitious movements
Moaning, groaning
Respiratory dysfunction Change in ventilatory rate -- increasing first, then slowing
Decreasing tidal volume
Abnormal breathing patterns -- apnea, Cheyne-Stokes respirations, agonal breaths
Loss of ability to swallow Dysphagia
Coughing, choking
Loss of gag reflex
Buildup of oral and tracheal secretions
Gurgling
Loss of sphincter control Incontinence of urine or bowels
Maceration of skin
Perineal candidiasis
Pain Facial grimacing
Tension in forehead, between eyebrows
Loss of ability to close eyes Eyelids not closed
Whites of eyes showing (with or without pupils visible)
Rare, unexpected events:
Bursts of energy just before death occurs, the "golden glow"
Aspiration, asphyxiation
Table 2. Signs That Death Has Occurred
The heart stops beating
Breathing stops
Pupils become fixed and dilated
Body color becomes pale and waxen as blood settles
Body temperature drops
Muscles and sphincters relax (muscles stiffen 4-6 hours after death as rigor mortis sets in)
Urine and stool may be released
Eyes may remain open
The jaw can fall open
Observers may hear the trickling of fluids internally, even after death
Table 3. Guidelines for Communicating Bad News
1. Get the setting right
2. Ask what the person understands
3. Provide a "warning shot"
4. Tell the news
5. Respond to emotions with empathy
6. Conclude with a plan
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