Hospice Basics, Hospice at Home

Clinical Signs of Death

March 3, 2020

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Dying is a natural process accompanied by decrements in neurocognitive, cardiovascular, respiratory, and muscular function.

The dying process is highly variable and can last up to several weeks in some instances. Actively dying or imminent death represents the last week of life and has characteristic clinical signs detailed in the table below.

The expression of clinical signs varies substantially between patients, but the more clinical signs present within an individual increases the likelihood of death.

Signs of Active Dying

The identification of a patient transitioning to imminent death is important, so that clinicians can help educate patients and families about the natural dying process to inform decision-making as well as prepare the patient and family for death as much as feasible.

In addition, the care plan should be updated to reflect the change in the patient’s status, including any necessary clinical visits. A higher level of care may be needed on occasion for a period of crisis or uncontrolled symptoms not responding to initial treatments.

The below are median times.

7+ Days Before Death

Clinical Signs Description Management Techniques
Peripheral edema Accumulation of fluid resulting in swelling, location is generally most dependent parts of the body such as the arms and legs Repositioning; Diuretics
Delirium Poor attention with acute onset and fluctuating course; severe confusion sometimes associated with hallucinations, abnormal drowsiness and/or restlessness, pacing, and agitation Evaluate for contributing causes; Reassurance, orientation, eye glasses/hearing aides; Discontinue anticholinergic medications; Antipsychotics
Dysphagia of solids Difficulty swallowing solids Education; Change food consistency
Decreased Speech Less able to communicate through words Education
Cool/Cold Extremities Skin of legs and then arms feels cold to the touch Education; Blankets

4-6 Days Before Death

Clinical Signs Description Management Techniques
Abnormal vitals High heart rate (>100) or respiratory rate (>20); Low systolic (<100) or diastolic(<60) blood pressure Educate; Discontinue blood pressure medications
Decreased level of consciousness Somnolence (sleepiness, drowsy, ready to fall asleep) and/or lethargy (drowsiness where the patient can’t be easily awakened) Educate
Dysphagia of liquids Difficulty swallowing liquids Educate; Keep mouth moist (wet sponge or oral swab, crushed ice, coating the lips with a lip balm)

2-3 Days Before Death

Clinical Signs Description Management Techniques
PPS 20% or less Bedbound, unable to do any work, total care, minimal intake/sips Educate
Peripheral cyanosis Bluish discoloration of extremities Educate
Decreased response to visual stimuli Decreased response to visual cues Educate
Drooping of the nasolabial fold Decrease in prominence/visibility of nasolabial fold Educate
Hyperextension of the neck Neck becomes hyperextended Educate; Opioids if pain present
Cheyne-Stokes breathing Alternating periods of apnea and hyperpnea with a crescendo-decrescendo pattern Educate; Opioids if dyspnea present
Nonreactive pupils Flash light into pupils to see if they react Educate
Decreased response to verbal stimuli Decreased response to verbal cues Educate

Less Than 2 Days Before Death

Clinical Signs Description Management Techniques
Death rattle Gurgling sound produced on inspiration and/or expiration related to airway secretions Educate; Repositioning; Anticholinergics if patient suffering
Apnea Prolonged pauses between each breath Educate; Opioids if dyspnea present
Respiration with mandibular movement Depression of jaw with inspiration Educate
Decreased urine output Measured volume of urine over a 12-hour period, <100 mL Educate
Pulselessness of radial artery Inability to palpate radial pulse Educate
Inability to close eyelids Eyelids do not close Educate; Wet washcloth if eyes dry/irritated
Grunting of vocal cords Sound produced predominantly on expiration, related to vibrations of vocal cords Educate; Opioids if pain present
Fever Temperature > 100 Cool wash cloth on their forehead and removing blankets; Fan; Acetaminophen

Clinical signs are based upon study in cancer patients but are generalizable to other causes of death (e.g. heart disease, advanced lung disease, sepsis, and dementia). The list is not exhaustive but includes some of the more common symptoms.

Link Between Clinical Signs of Dying and Impending Death

A direct relationship exists between the number of clinical signs of dying and death:

  • Persons with two clinical signs of dying had a 40% chance of dying
  • Persons with eight  clinical signs of dying had a more than 80% chance of dying

Therefore, the more clinical signs of death that are present necessitates a care plan update including necessary discipline visits.

The natural dying process results in clinical signs of dying where the greater the number present increases the likelihood of death will occur.

Hospice Team Involvement During Clinical Signs of Dying

When clinical signs of dying emerge, the hospice interdisciplinary care team initiates a care plan update that includes:

  • Updating necessary interdisciplinary visits
  • Education on the dying process
  • Adjustments / additions of necessary medications
  • Assure appropriate HME in place to assist your patient and family

The hospice team provides support in a variety of ways, specific to the team member's discipline.

Nurse, nurse practitioner, and/or physician:

  • May discuss the discontinuation of non-beneficial or burdensome treatments
  • Ensure symptom medications and necessary equipment are available
  • Educate family on use, and describe physiologic changes associated with the dying process

Social worker and chaplain:

  • Help patients and families explore their feelings and relationships
  • Participate in life review, including the search for meaning and contributions
  • Conduct life closure, including forgiving and facing regrets, be able to say goodbye, and try to come to terms with the acceptance of ongoing losses and death

Hospice aides recognize the clinical signs of dying and communicate them to the other team members, as well as support the patient and family through the dying process.

References:
  • Hui D, dos Santos R, Chisholm G. et al. Bedside Clinical Signs Associated With Impending Death in Patients With Advanced Cancer: Preliminary Findings of a Prospective, Longitudinal Cohort Study. Cancer 2015;121:960-967.
  • Hui D, dos Santos R, Chisolm G, et al. Clinical Signs in Cancer Patients. The Oncologist 2014;19:681–687