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Physiological Changes in Dying
- 1. Palliative Care Physiological Changes in Dying BY SN Sung Za Ting & SN Ei EI Khin
- 2. Objectives To know the definition of Palliative Care. To understand the physiological changes in the following systems and to provide care. Circulatory System Integumentary System Neurological System Respiratory System Urinary System Gastro-intestinal System
- 3. Palliative Care Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. http://www.who.int/cancer/palliative/definition/en/
- 4. Changes in Circulatory System Decreased Blood Perfusion • Mottled or discolored skin Decreased Cerebral Perfusion • Decreased Level of Consciousness • Delirium • Disorientation • Hallucination • Drowsiness Promote good Skin care. Orientate gently. Be patient.
- 5. Mottled or discoloured skin
- 6. Changes in Circulatory System – Cont’d Decreased in Cardiac Output & Intravascular volume. • Tachycardia • Hypotension • Peripheral cyanosis • Peripheral cooling • Pulse become weak and irregular (death is imminent) Slow down and pace out activities.
- 7. Changes in Integumentary system Increase risk of pressure related injuries. • Decreased blood perfusion • Decreased mobility • Decreased nutritional status • Increased risk of friction & shearing Pressure relieving devices Regular turning Gentle handling Good Hygiene Moisturize
- 8. Changes in Respiratory System Cheyne-Stokes Breathing Dyspnoea Agonal Gasp Death Rattle Semi-Fowler’s position Oxygen Therapy Gentle Fan blowing Oral toilet Assure Family – normal process of dying
- 9. Changes in Neurological System - Confused, Disorientation, Hallucination, Delirium, Drowsiness, Decreased or Loss of consciousness • Decreased circulation to the brain • Decreased oxygen to the brain • Medication induced • Decreased attention span Orientate if needed Low stimuli environment Therapeutic touch Gentle massage
- 10. Changes in Neurological System – Cont’d Difficulty understanding or finding the right words Sensation and power loss in legs first, followed by hands Pupils might become sluggish to light Pain might be significant Assurance Analgesics / Pain relieving measures
- 11. Pain General pain assessment Assessment of pain in non-verbal resident Pharmacological management Non-drug interventions for pain Nursing assistant role in observing and relieving pain
- 12. Pain intensity tools Pain scales ( facial expression ) Visual analog scale Verbal scale Numerical scale
- 13. Non- drug symptom relief specifics Massage Application of cold and heat. Cold – numbing nerve ending ,reducing m/s spasms ,decreasing inflammation . Hot – relieves pain by reducing inflammation & soreness decrease sensitivity to pain and increases blood flow to the skin Positioning Distraction Relaxation Music Comfort foods
- 14. Medications for pain Opioids: referred to as narcotics eg. Morphine ,Duragesic,Codeine Non-opioids: 1) Acetaminophen 2) Nonsteroidal anti-inflammatory drugs (NSAIDs) a)Ibuprofen b)Synflex c)Celebrex Adjuvants /co – analgesics a)Antidepressants b)Anticonvulsants c)Topical
- 15. WHO 3 Step Analgesic Ladder Pain Management
- 16. Changes in Urinary System Decreased Urine output • Decreased intake • Blood pressure too low for kidney filtration Possible Incontinence Keep resident clean and dry. Ensure Comfort.
- 17. Changes in Gastro-intestinal system Decreased appetite Decreased urge to drink Difficulty swallowing Constipation Bowel incontinence Comfort feeding Thickened Fluid Excellent oral care Hygiene needs Perineal Care
- 18. Other physiological changes Edema • Hypoalbuminemia • Underlying medical conditions • E.g. Cardiac failure, Liver failure, Renal failure Hair loss • If on chemotherapy
- 19. Conclusion Through the physiological changes of dying, remember the following… Symptomatic relief Comfort Assurance Pace
- 22. References https://palliative.stanford.edu/transition-to-death/signs-of-impending-death/ https://www.webmd.com/palliative-care/emotional-changes-as-death- approaches https://www.youtube.com/watch?v=6_kxzDyV6J8 https://www.youtube.com/watch?v=CBMxH4xtE8w https://www.youtube.com/watch?v=3j0Ittpv1So http://www.palliativecarensw.org.au/pdfs/PCNSW-Signs-Symptoms-of- Approaching-Death-ARTICLE.pdf. https://emedicine.medscape.com/article/166724-overview http://www.msdmanuals.com/en-sg/home/fundamentals/death-and-dying/when- death-is-near https://www.healthline.com/health/death-rattle https://www.ncbi.nlm.nih.gov/pubmed/16377843 https://www.healthline.com/health/agonal-breathing
Editor's Notes
- Stress importance of QOL of Patients and their Families. Some of the actions done are not so much for patients, but for families to understand and feel better.
- Ask staffs what can a nurse do in such a situation. Ask for examples when appropriate.
- Death rattle : They may not be physically strong enough to cough or swallow to clear the secretions from the back of their throat. Secretions in the throat or the relaxing of the throat muscles can lead to noisy breathing, sometimes called the death rattle. Repositioning the person, limiting fluid intake, or using drugs to dry secretions can minimize the noise. Such treatment is aimed at the comfort of the family or caregivers because noisy breathing occurs at a time when the dying person is unaware of it. The death rattle does not cause discomfort for the dying person. This breathing can continue for hours and often means that death will occur in hours or days. Cheyne-Stokes respiration (CSR) is one of several types of unusual breathing with recurrent apneas (dysrhythmias). Reported initially in patients with heart failure or stroke, it was then recognized both in other diseases and as a component of the sleep apnea syndrome. CSR is potentiated and perpetuated by changing states of arousal that occur during sleep. The recurrent hypoxia and surges of sympathetic activity that often occur during the apneas may have serious health consequences. Heart failure and stroke are risk factors for sleep apnea. The recurrent apneas and intermittent hypoxia occurring with sleep apnea further damage the heart and brain. Although all breathing dysrhythmias do not have the same cause, instability in the feedback control involved in the chemical regulation of breathing is the leading cause of CSR. Mathematical models have helped greatly in the understanding of the causes of recurrent apneas. PMID: 16377843 DOI: 10.1385/NCC:3:3:271 Common cause of agonal gasp is Cerebral Ischemia.
- Decreased circulation to brain = Decreased brain function.
- Pain is usually brought about by underlying diseases.
- Urine may be constipated
- Constipation – Decreased peristalsis. Bowel incontinence – Weakening of anal sphincter.
- Hypoalbuminemia can be caused by various conditions, including nephrotic syndrome, hepatic cirrhosis, heart failure, and malnutrition; however, most cases ofhypoalbuminemia are caused by acute and chronic inflammatory responses. Serum albumin level is an important prognostic indicator