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Fast Fact and Concept #003; Syndrome of Imminent Death

2nd Edition

Author(s): Weissman, D.

Virtually all dying patients go through a stereotypical pattern of symptoms and signs in the days prior to death. This trajectory is often referred to as “actively dying” or “imminent death”. Prompt recognition of this trajectory is key for clinicians to provide the most appropriate interventions for both the patient and family.

1. Stages

Early

Bed Bound
Loss of interest and/or ability to drink/eat
Cognitive changes: increasing time spend sleeping and/or delirium (see Fast Fact #1).

Mid

Further decline in mental status to obtundation (slow to arouse with stimulation; only brief periods of wakefulness)
Death rattle--pooled oral sections that are not cleared due to loss of swallowing reflex;

Late

Coma
Fever: usually from aspiration pneumonia
Altered respiratory pattern—periods of apnea, hyperpnea or irregular breathing
Mottled extremities

2. Time Course

The time to traverse the various stages can be less than 24 hours or as long as 14 days. Patients who enter the trajectory who are nutritionally intact, with no infection (e.g. acute stroke), are apt to live longer than cachectic cancer patients

3. Common Family Concerns

Family members present during the dying process often express the following concerns/questions. Clinicians can best help families by expecting these questions, providing education and reassurance.

Is my loved one in pain; how would we know?
Aren’t we just starving my loved one to death?
What should we expect; how will we know that time is short?
Should I/we stay by the bedside?
Can my loved one hear what we are saying?
What do we do after death?

4. Treatment

Confirm treatment goals; recommend stopping treatments that are not contributing to comfort--pulse oximetry, IV hydration, antibiotics, finger sticks, etc.
Write in progress notes: "patient is dying", not "prognosis is poor".
Treat symptoms/signs as they arise: common among these are: oral secretions (see FF# 109); delirium (FF# 1, 60); dyspnea (FF# 27) and pain (see FF# 53, 54)
Provide excellent mouth and skin care.
Provide daily counseling and support to families

Reference

Rousseau P. Management of symptoms in the actively dying patient. In Principles and Practice of Palliative Care and Supportive Oncology. Berger AM , Portenoy RK and Weissman DE eds; 2 nd Ed, Lippincott; 2002.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007. For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman DE . Syndrome of Imminent Death. Fast Fact and Concept #3; 2 nd Edition, July 2005. End-of-Life Palliative 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

Purpose: Instructional Aid

Audience(s)

	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): Non-pain symptoms & syndromes