Nurses often enter their profession to save lives. This is what nursing is most often advertised as to the average consumer. You show up and do whatever it takes to help your patients improve their health and discharge out of the hospital either to home or to rehabilitation. Unless you are working in hospice, it’s infrequent that the acute care nurse will experience a patient reaching the end of life without a fight. This does, however, occasionally happen. Perhaps a patient in the ICU has been terminally extubated. Perhaps treatment did not go well for an acute illness and the patient and family have decided they want to let things run their natural course. You, as the nurse, will be expected to know what to expect and how to explain it to the family.
Here are five signs that death will occur soon.
1. The patient stops eating and drinking.
This is often a gradual process, with appetite and thirst diminishing in the final weeks of life. Once a person stops eating and drinking completely, they will likely only survive between seven and ten days. This greatly depends on the previous hydration status of the patient. A person who suddenly stops eating and drinking may have a better amount of fluid reserved in their tissues to draw from, and therefore may survive longer. Alternatively, a patient who has been taking only sips of fluid and a bite or two of food for weeks prior may last less than a week once all intake stops. It is a very individual process for each patient, and the family often needs reassurance that it is normal and expected.
2. The patient is exhibiting increased amounts of sleep and periods of unresponsiveness.
As a person approaches end of life they have little energy to expend, and their sleep needs increase drastically. It is not uncommon that a person is only awake for a few hours per day in their last weeks of life, and they may choose to spend these awake times in the company of only certain family members and friends. It should not be taken personally by family and friends. The patient simply has little energy left and conserves it for the things they feel are most important to them at the time. A patient will most likely become completely unresponsive in the last few days of life, but reassure family that although they are witnessing these changes, the patient can often hear them until the very end of life.
3. The patient is having changes in mental status, perhaps seeing things that are not there, or having visions of people who have passed on before them.
This is all very common at the end of life and can be alarming for family and friends. There are medications, often benzodiazepines, that can be used if these visions or hallucinations become upsetting to the patient; however, patients often find peace and happiness in these visions. They may speak freely with visitors about family members who have come to visit them from “the other side.” Encourage family members and other visitors to try not to challenge the patient’s experience and to be accepting that what the patient is experiencing is real to them.
4. The patient is presenting with tachycardia and hypotension, or changes in breathing patterns.
The patient may also have some changes in body temperature regulation. Toward the last few days of life, there are often changes in vital signs and respiratory patterns. The blood pressure will often drop below the normal range and the pulse will speed up. This is a product of the regulatory functions of the autonomic nervous system shutting down, as well as one of the common sequelae of dehydration (related to not eating and drinking, as mentioned in number one). It is normal and expected, but can be very alarming to family members. The main goal of the nurse should be to assure that the patient feels comfortable and stays safe while these changes are occurring.
5. The patient is mottling.
Mottling is often a late sign of impending death, and happens when peripheral circulation, especially in capillaries, is poor. Blood flow tends to slow down and causes purplish or reddish patches on the lower extremities. The extremities may be cool to touch as well, but not always. Mottling sometimes can come and go, but more often progresses in nature as a patient approaches end of life. Reassure the family that this is a normal process and is not at all painful for the patient.
With the right knowledge of what to expect, the nurse can be a key player in helping a patient and their family approach the end of life with comfort and confidence.