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Section II: Frequent Symptoms Associated
with Imminent Death
Core
Two Roads to Death
Confused
Restless
Tremulous
THE DIFFICULT
ROAD
Hallucinations
Mumbling Delirium
NORMAL
Myoclonic Jerks
Sleepy
Lethargic
Seizures
Obtunded
THE USUAL
ROAD
Semicomatose
Comatose
DEAD
NCI, 2014; Seow et al, 2011
Core
Most Common Symptoms in Final Days of Life
Kehl & Kowalski, 2013
Core
Physical Symptoms Vary
Confusion,
disorientation, delirium
vs. unconsciousness
Drowsiness, sleeping
vs.
restlessness/agitation
Weakness and fatigue
vs. surge of energy
Physical
considerations:




Fever
Bowel changes
Incontinence
Decreased intake
Core
Pain During the Final Hours of Life
Changes in level of consciousness may make
assessment and management of pain challenging.
 If self-report is not possible, behavioral cues, proxy report,
analgesic trials
What is causing the pain?
Core
Opioids
Dosing of opioids given during last hours based on
appropriate assessment and reassessment.
Dose may be decreased or increased
Consider other routes:



Oral
Rectal
Subcutaneous
Core
What About the Principle of Double-Effect?
Is it morally permissible?
Intent
There will always be a last dose.
Core
National Comprehensive Cancer Network
(NCCN): Guidelines for Treating Pain Weeks to
Days Before Death
Titrate to comfort
Recognize and treat
toxicities
Analgesia vs. reduced
LOC
Use equianalgesic
dose conversions
Consult
Consider sedation for
refractory pain
Core
Myoclonus
Assess potential etiologies
Benzodiazepines can be helpful (i.e., diazepam)
Switch opioids
Can lead to seizures
Core
Terminal Secretions
Respiratory congestion/terminal secretions
Distressing and frightening to family, friends,
healthcare providers
Assessment
Management
Core
Palliative Sedation at End of Life
Consider:
All possible etiologies and treatments
Education of patient/family regarding goals and
outcomes
Interdisciplinary team approach
Medications
Core
Symptoms of Imminent Death
Decreased urine output
Cold and mottled extremities
Vital sign and breathing changes
Delirium / confusion
Restlessness
Core
Case Study: Gail (cont)
Gail is now unconscious
Pain assessment
Reassurance to family
Death rattle
Concerns about dehydration
Core
The Death Vigil
Family presence
Common fears
 Being alone with patient
 Painful death
 Time of death
 Giving “last dose”
Bedside Vigil
Core
Nursing Interventions: Support
Collaboration with physician/team
Reassurance and education
Role model comforting
Physical comforting
Spiritual care; honor culture
Core