When the Time is Near

cerah.lakeheadu.ca

Palliative Care EducationFor Front-line Workers

In First Nations Communities

The last hours of living

Over 90% of those who suffer a long illness will die

The last hours can be the most significant time of our lives

Think about…

• The importance of final hours which are independent of the site of dying/death

• Addressing physical, psychological, social, and spiritual needs

• Skilled around-the-clock care • Anticipating medication, equipment, and

supply needs

Caring in the last hours

• If possible, the setting should allow loved ones private, 24-hour access without disturbing others

• There is a need for regular reassessment of the patient’s condition and the family’s ability to cope with rapid and unexpected changes

• Caregivers must respond quickly and modify plans especially when a dying person is at home if readmission to hospital is to be avoided

Who can receive palliative care in Canada?• Any person with a life expectancy of less than six

months• Any person about whom you can say: “If she/ he

died within the next year, I would not be surprised”

• Any person with an incurable, progressive disease

• Any person who elects a palliative or comfort- care approach

What to expect weeks to months before death:• Social withdrawal, personal reflection, less

communication or sometimes a desire to address old conflicts

• Increased sleep and decreased intake of food and water

• Postponing death until meaningful events occur• Saying good-bye, looking for permission to die,

expressions of soul weariness (i.e. “I’m tired of living”)

Caring for the Terminally Ill: Honouring the Choices of the People, p. 66-67

(CHPCA, 2008)

Communication with the individual who is unconscious• Plan ahead to reduce family distress(Caring for the Terminally

Ill: Honouring the Choices of the People, p. 92)

• Assume the individual who is unconscious can hear everything

• Encourage families and friends to create an environment that is familiar and pleasant

• Recognize touch as heightening communication

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Choices about eating & drinking• 2/3 of individuals who are terminally ill

experience a loss of appetite• The reduced need for food is a normal part of

the dying process• Most individuals who are dying are not hungry or

thirsty• Weight loss is expected in an individual who is

dying• A dry mouth is also a common occurrence

Caring for the Terminally Ill: Honouring the Choices of the People, p. 38-42

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If a person stops eating but is still taking in fluids:

• S/he is able to live for weeks to months• Their feelings of hunger are blunted• Their mental function may remain normal until

just before death

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If a person stops drinking…• S/he may typically live 1-3 weeks but in rare

cases may live as long as 6 weeks• Dehydration results in a gradual loss of

consciousness• Death while dehydrated may be more peaceful

and comfortable than death with intravenous (IV) fluids

• Good mouth care is an important part of comfort care

Reasons to recommend the use of tube feeding or IV fluids• Artificial nutrition and hydration can be used

temporarily to support a person who may recover from a non-terminal illness

• May improve comfort for individuals who express hunger or thirst

• May be used to keep a person alert while awaiting a special visit or event prior to death

• Client or family members’ religious beliefs or strong feelings may require continued use of these treatments until death

Reasons not to recommend tube feeding or IV fluids (1 of 2)• Can lead to increased lung secretions, shortness

of breath, swelling, edema, and incontinence• Lack of IV fluids and tube feeding often results in

a gradual, peaceful loss of consciousness• Artificial nutrition may prolong the dying process• Most dying people do not experience hunger or

thirst

Reasons not to recommend tube feeding or IV fluids (2 of 2)

• Restraints may be necessary to hold IVs or feeding tubes in place which may distress the person and/or family members

• Tube feeding does not provide taste pleasure or social contact around meals

Some suggestions about making good decisions around eating and drinking• Evaluate the person for treatable causes of

reduced intake such as depression, painful teeth, or other correctable problems

• Consider a trial of an appetite stimulant• Acknowledge the emotional and social meanings

of food• Recognize the naturalness of stopping eating and

drinking at the end of life

Other physical changes

• Sore mouth• Difficulty breathing• Skin problems• Feeling weak• Constipation• Not sleeping well and feeling tired

Caring for the Terminally Ill: Honouring the Choices of the People, p. 43-52

Delirium (1 of 3)

• A disordered altered mental state that may present with hallucinations, agitation, paranoia, sleeplessness, confusion, moaning and groaning, incoherent speech and continual aimless physical activity

Caring for the Terminally Ill: Honouring the Choices of the People, p. 69-70

Delirium (2 of 3)

• May occur in the last 12-24 hours of life• Makes the assessment of pain and

symptoms extremely challenging• It can be devastating for families to watch

their loved one in a state of terminal delirium• Some possible causes may include brain

metastases, and renal and liver failure• Early onset of delirium should be investigated

as some causes of delirium are reversiblewww.cerah.lakeheadu.ca

Delirium (3 of 3)

• Some suggestions• Educate yourself, staff, and families about the

difference between pain and terminal delirium• Advocate on behalf of the client and their

family• Do not abandon the client or their family

Continued presence of staff may assist in maintaining a calm environment and supporting the family and client

Some changes when death is near• Coolness of the skin• Decreased alertness• Disorientation or delirium• Restlessness• Decreased intake food and water• Incontinence and/or decreased urine output• Changes in vital signs (i.e. pulse, blood pressure)• Changes in breathing patterns

Caring for the Terminally Ill: Honouring the Choices of the People, p. 93-95

Signs and symptoms hours/ minutes before death• Large fixed pupils• Inability to move• Faster but weaker pulse• Lowered blood pressure• Cheyne-Stoke respirations (increasing periods

of time in between breaths)• “Death rattle” (noisy breathing due to collection

of mucus in the throat)www.cerah.lakeheadu.ca

Clinical signs and symptoms of death

• Total lack of response to external stimulus• No muscular movement• No reflexes• No vital signs: breath/pulse/blood pressure

Caring for the Terminally Ill: Honouring the Choices of the People, p. 96

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When death occurs

• What to do if you think death has happened

• Caring for yourself

Caring for the Terminally Ill: Honouring the Choices of the People, p. 96-98

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