End of Life
"He's dying."
I heard this hushed statement from a nurse assistant as she hurried out of room C-17. She had spent the last 20 minutes cleaning the patient and preparing him for bed.
"How can you tell?" I asked her.
"Because he's talking to his mother," she told me.
To me, that made no sense. This patient was 90 years old; how could he have a conversation with his mother?
I caught up to the nurse assistant before she disappeared into another room. "What do you mean by you can tell he's dying just because he's talking to his mother?" I asked.
"I see it all the time," she said. "They start to talk to family that are long gone. They see them and start talking with them when it's close to their time."
As a nurse, death and the process of dying is familiar to me. Before I became a registered nurse, I specialized in forensic facial reconstruction. In special cases in which scientific evidence could not help identify a person, I reconstructed that person's face onto a natural or a replica skull. I also volunteered time to assist with special museum exhibits involving insect identification in decomposing bodies.
But since working as an RN in a long-term care facility, death and dying are resonating much more with me.
Right now, my position as a new grad RN gives me the opportunity to care for military veterans. Nursing school emphasized how to maintain health in the living patient. But in the dying patient, some lessons on theory were not detailed.
Subtle Changes
In the 4 months since I began employment, four patients on my unit have died. All were elderly. All exhibited signs of impending death. Until I cared for a patient exhibiting these signs, I was not cognizant of the subtle changes that often mark the beginning of the dying process.
Working alongside my preceptor, I learned the signs of end-of-life. One occasion, I assisted my preceptor in the care of a man who was dying. I didn't know it at the time, but he had many common symptoms of impending death.
When I entered his room to do morning rounds, I saw he was very frail. I was clearly able to see all his bones on his body, with the rib cage and articulation of his joints as most prominent. I was even able to see the pulsing of his abdominal aorta. He was breathing with his mouth open using short, shallow rapid breaths; a moist cough followed each breath. I saw cracks on the edges of his mouth and deep furrows in his tongue. His face was gaunt and both his eyes and cheeks were sunken.
I found myself talking loudly to him; I was trying to wake him up. I offered him a cup of water. He focused his eyes on me briefly then his eyes returned to stare at the ceiling. He didn't blink or respond verbally. I touched his hands and wrist as I started to take vitals signs. His hands were cold.
When my preceptor came to check on me, she removed the blankets and turned the patient. His skin was blotchy with dark red demarcations over his hips. It wasn't present at the time, but my preceptor told me not to be alarmed to see seepage of stool. When the Dinamap beeped, I told my preceptor that his systolic blood pressure was over 180, his pulse was rapid and he had a temperature over 100 degrees F.
I asked if I should call the doctor. She obviously knew I was unaware of what I was witnessing, because she whispered, "He's dying, Bridgette."
I was speechless. This is what death looks like? My preceptor then walked with me outside the room to describe the physical changes and the rationales. By the time the shift was over, I realized I cared for a man in his final hours of life and didn't even know it.
End-of-Life Signs
Signs of end-of-life are multiple and occur simultaneously. A common sign is profound loss of appetite. Signs of dehydration include dry, chapped lips and deep fissures in the tongue. The loss of desire to eat or drink can result in anorexia. When a patient is diagnosed with anorexia, he or she reports feeling full with very little eating.
If anorexia is prolonged, the result is often the wasting syndrome cachexia, a loss of fat tissue, muscle mass and weight. This results in severe weakness. The patient is fatigued because the body is far below ideal weight. Cachexia is usually associated with late-stage cancer.
Another sign is changes in skin color. Particularly over bony areas, the skin appears reddened on pressure points. This is caused by immobility, shearing forces and breakdown in skin integrity. Bony prominences such as elbows, hips and knees are vulnerable to discoloration. Loss of skin integrity can result in wounds.
Two other signs, restlessness and vacillating levels of consciousness, presents as if the patient cannot stop moving or constantly tries to get out of the bed. Speech may be nonsensical, and the patient can have unusual or inappropriate responses to commands. Disoriented to person, place and time, hallucinations and purposeless gestures such as reaching out to grasp at the air are common.
Other signs are changes in respiration patterns and pulse. Labored breathing can manifest as short, rapid breaths with periods of apnea. Sometimes the shallow breaths hve a moist quality; this is often referred to as "death rattle." I learned to avoid this term because it causes stress for family members.
Rapid pulse can be indicative of pain and/or anxiety. Opioid medications such as morphine often are given to alleviate this symptom. Commonly used to alleviate pain and anxiety in the end of life, the effects of morphine are twofold: it desensitizes the pain receptors in nerves and promotes relaxation. Be aware morphine also can cause changes in bowel elimination.
Changes in patterns of elimination, such as constipation are common in end of life. Side effects from medications such as morphine can cause this. Also, weakness, immobility, and poor nutrition can lead to increase frequency of constipation. If constipation persists, impaction can result. Oozing of liquid stool is a typical sign of impaction.
How Nurses Can Help
I've learned that as a new graduate nurse, I'm at an advantage to assist in comforting someone who approaches end of life. As nurses, there are many simple things we can do to manage the signs of impending death in the patient.
- Offer favorite foods in small, frequent servings. Avoid strong, odorous foods.
- Decrease environmental stimuli, turn down the lights and increase ventilation.
- To ease breathing, raise the head of the bed at least 45 degrees; place pillows under the head and under the back. Avoid deep-suctioning the lungs; this can cause pain.
- Provide frequent oral care.
- Place disposable pads underneath the patient.
- Turn the patient every 2 hours or as much as the patient can tolerate.
- Cover the patient with blankets to provide warmth.
- Listen and speak softly to the patient. Ask for a chaplain to assist with religious support.