SIGNS & SYMPTOMS CLOSE TO TIME OF DEATH OBSERVATIONS OF HOSPICE NURSES
MONTHS NOT WEEKS WEEKS NOT MONTHS
DAYS NOT WEEKS
NEXT FEW DAYS
TODAY OR TOMORROW
BIOLOGICAL & PHYSICAL SIGNS & SYMPTOMS
Weakness & fatigue, ECOG 3, assistance with ADLs Appetite, weight loss ( > 10 % ), bitemporal wasting
Weakness & fatigue, ECOG 4 bedbound, assistance with ADLs Intake, dehydration, some dysphagia, dry skin, skin tenting
Extreme weakness, mouth droop, minimal voluntary movement, no muscle tone
Extreme weakness & fatigue, unable to get up to commode
ACTIVITY
Up & about ECOG 2
Normal, some changes in food likes & dislikes, some weight loss
NUTRITION HYDRATION
Dehydration, dysphagia, emaciated ( dry eyes, pinched nose, ketotic breath )
Dysphagia, no oral intake
Normal, some constipation
No urine, bowel incontinence / diarrhea
ELIMINATION
Constipation
Some bladder incontinence
Bowel / bladder incontinence
Pain, perhaps due to emotional, spiritual causes
PAIN
Usual
Pain
Possible pain
Pain may be or
Peripheral circulation ( mottling, temperature, cyanotic nail beds ) color changes ( jaundice / grey / ashen / pale )
Mottling cyanotic toes, heels, fingers, livedo reticularis
SKIN
Normal
Thin, fragility, bruising
Possible breakdown
Bed & chair existence, may be restless at night Dull, cloudy, looks inward, distant
Responsiveness, frequently unarousable
SLEEP
Some insomnia
> 50 % waking hours in bed
Sleeping
Glazed fixed stare, partly open, fixed or dilated pupils
EYES
Normal
Dull
Glazed, staring, sunken
Dyspneic, possible hypoxia, oxygen may be helpful
Irregular breathing patterns, congestion
Increased congestion, rattle, periods of apnea or Cheyne-Stokes pattern Agitation, no purposeful movement, twitching, ‘near-death awareness’, delirium, non-distressing visual hallucinations
Death rattle, apnea, Cheyne-Stokes pattern
RESPIRATOINS
Normal
Delirium, arousal, unarousable, occasionally a mysterious ‘rally’ or ‘rise before the fall’, sometimes related to out-of-town family
Picking, twitching, seizures, delirium
NEUROLOGICAL
Normal
Normal
Abdominal distension, leg edema, not dehydrated
ASCITES‒EDEM A
Distension, edema Continued distension, edema
or Distension, edema
Distension, edema
38 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024 Adapted from “Markers noted by Home Hospice Nurses Related to Time Remaining in the Dying Process,” Master’s Thesis of Carol McCrann McShane RN, MS, Creighton University Lincoln NE, 1991. Used with Permission
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