Fast Fact and Concept #3: Syndrome of Imminent Death

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Title: Fast Fact and Concept #3: Syndrome of Imminent Death

Author(s): Weissman, D.

Main Teaching Points:

1. Recognition
Early Stage: bed bound; loss of interest and ability to drink/eat; cognitive changes: either hypoactive or hyperactive delirium or increasing sleepiness.

Mid Stage: further decline in mental status--obtunded; "death rattle" -- pooled oral secretions that are not cleared due to loss of swallowing reflex; fever is common.

Late Stage: coma, cool extremities, altered respiratory pattern--either fast or slow, fever is common; death.

2. Time Course: The time to traverse the various stages can be less than 24 hours or up to 10-14 days. Once entered, it is difficult to accurately predict the time course, which may cause considerable family distress, as death seems to "linger".

3. Treatment:

a) Once recognized, discuss with family, confirm treatment goals; Write in progress note: "patient is dying", not "prognosis is poor".

b) Discuss with family goal of stopping all treatments that are not contributing to comfort - pulse ox, IV hydration, antibiotics, finger sticks, etc. Hydration and feeding issues will need to be discussed sensitively, often eliciting more concern among the medical team than the family (future Fast Fact topic).

c) Use Scopolamine Patch (1or 2) or Atropine to decrease oral secretions - "Death rattle".

d) Use morphine to control dyspnea (see Fast Fact #27: Dyspnea at End-of-Life) or tachypnea (it's very disturbing to families to see their loved one in a coma breathing 40/min (a goal should be to keep respiratory rate in range of 10-15).

Note: this is not euthanasia! e) Opioids used to treat pain should not be stopped as death approaches -- assume that the pain stimulus is still present; families always want reassurance that their loved one is not suffering.

f) Provide excellent mouth and skin care.

Oxford Textbook of Palliative Medicine, 2nd ed. 1999, pages 982-989.

Fast Facts and Concepts are developed and distributed as part of the National Internal Medicine Residency Education project, funded by the Robert Wood Johnson Foundation.

Disclaimer Concerning Medical Information: Health care providers should exercise their own independent clinical judgment. Accordingly, the official prescribing information should be consulted before any product is used.

Contact: Dr. David Weissman at [email protected]

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman, D. Fast Fact and Concepts #03: Syndrome of Imminent Death. June, 2000. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 1/2000

Format: Handouts

Purpose: Instructional Aid

Training: 3rd/4th Year Medical Students, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Nurses

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Adult, Caring for families, Hydration, Negotiating treatment goals, Neurologic, Non-oral feeding, Oral/communication, Pain treatment, Prognosis, Skin/lymphatic

The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).