By Joseph Shega, MD, Chief Medical Officer, VITAS Healthcare Show
Dying is a natural process accompanied by decrements in neurocognitive, cardiovascular, respiratory, and muscular function. The dying process is highly variable and can last up to several weeks in some instances. Actively dying or imminent death represents the last week of life and has characteristic clinical signs detailed in the table below. The expression of clinical end-of-life signs varies substantially between patients, but a greater number of clinical signs present within an individual increases the likelihood of death. End-of-Life Stages TimelineThe identification of a patient transitioning to imminent death is important, so that clinicians can help educate patients and families about the natural dying process to inform decision-making as well as prepare the patient and family for death as much as feasible. In addition, the care plan should be updated to reflect the change in the patient’s status, including any necessary clinical visits. A higher level of care may be needed on occasion for a period of crisis or uncontrolled symptoms not responding to initial treatments. The table below demonstrates what to generally expect at each stage of death. 7+ Days Before Death
4-6 Days Before Death
2-3 Days Before Death
Less Than 2 Days Before Death
Clinical signs are based upon study in cancer patients but are generalizable to other causes of death (e.g. heart disease, advanced lung disease, sepsis, and dementia). The list is not exhaustive but includes some of the more common end-of-life symptoms. Link Between Clinical Signs of Dying and Impending DeathA direct relationship exists between the number of clinical signs of dying and death:
Therefore, the more clinical signs of death that are present necessitates a care plan update including necessary discipline visits. The likelihood of death increases with the number of present end-of-life signs. How Long Does the Active Stage of Dying Last?The active stage of dying generally only lasts for about 3 days. The active stage is preceded by an approximately 3-week period of the pre-active dying stage. Though the active stage can be different for everyone, common symptoms include unresponsiveness and a significant drop in blood pressure. What Are the Emotional Signs of Death?There are many forewarning signs that death is near besides clinical indicators and symptoms. Analyzing emotional signs can also shed light on a patient’s end-of-life status. Some of these signs include:
Hospice Team Involvement During Stages of DyingWhen clinical signs of dying emerge, the hospice interdisciplinary care team initiates a care plan update that includes:
The hospice team provides support in a variety of ways, specific to each team member's discipline. Nurse, nurse practitioner, and/or physician:
Social worker and chaplain:
Hospice aides:
How to Help Families Cope After a Loved One Has DiedAfter a patient dies, family members need time to process their feelings. They should not be subjected to additional stress with the logistics of legal forms or removal of the body. Be empatheticMedical professionals and care teams should keep in mind that the time, setting, and specific events surrounding a loved one’s death shape lasting memories for their family members—solemn moments that deserve to be respected and honored.
Honor ritualsHonor families’ needs for specific rituals at the time of or shortly after death, such as private family time with the body, bathing of the body, recitation of prayers, or dressing of their loved one in special clothing or garments.
Encourage a healthy grieving processRemind family members and caregivers that each person’s grief is unique and will ebb and flow over the following day, weeks, months, and years. If the patient was on hospice care, Medicare-certified hospices provide up to a year of grief and loss counseling for their family following the patient’s death.
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