What it is: Imminent death means that the older person’s decline in health is irreversible and they are likely to die in the coming hours, days or weeks.
Why it matters: Recognising when death is imminent is difficult but important because it allows the older person to spend time with their friends and family of choice if that is their wish. It also alerts their health care team to the need for terminal care.
What I need to know: The ’typical illness trajectory’ may not hold and giving family a prognosis may not be appropriate. However, the signs of imminent death include:
- profound weakness - totally bed-bound and requiring extensive nursing care
- drowsy, poorly responsive or unconscious with limited response to verbal or physical stimuli
- difficulty with swallowing or inability to swallow
- diminished intake of food and fluids, reduced or no urine output
- changes in breathing pattern including noisy secretions (death rattle) and Cheyne-Stokes (several breaths followed by a long pause)
- skin that is cool to touch or waxy in appearance.
These signs are included in the Residential Aged Care End of Life Care Pathway (RAC EoLCP).
Managing symptoms in the last days of a patient’s life is generally a continuation of what is already being done with attention to symptoms that worsen or new symptoms which develop. This includes pain, dyspnoea, delirium, agitation, respiratory secretions, and functional decline.
Communication may be difficult. Assessment and monitoring can be based on signs such as agitation, restlessness, facial expression, body posture and changes in breathing.
Actions
Contact the GP, multidisciplinary team members, the older person’s substitute decision-maker and family of choice when death is imminent.
Review the person’s wishes and goals of care; this may include reference to an advance care plan (ACP) and/or an advance care directive (ACD) and discussion(s) with a substitute decision-maker, and consideration of discontinuation of treatment.
Provide family and carers with information and guidance on the likely course of the person’s illness and what they can do to provide comfort.
Communication needs to be honest, direct, and compassionate, and allow for the concerns and opinions of the family to be heard and appreciated.
Respect and support the older person’s sense of dignity in relation to symptom care including bowel and bladder function.
Offer emotional and spiritual support appropriate to the older person’s needs and preferences.
Continue to talk calmly with the person and let them know what you are doing – hearing is believed to be the last sense to be lost.