Clinical Signs of Death

December 29, 2020
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Dying is a natural process accompanied by declines in function, including neurocognitive, cardiovascular, respiratory, and muscular function.  This process was examined by researchers with regard to cancer patients, and their findings are outlined in this article.

The process of dying varies greatly, and can last up to several weeks in some cases. Actively dying or forthcoming death constitutes the last week of life, and has distinctive clinical signs that are detailed in this article.

The expression of clinical signs differs significantly among patients, but the more of these clinical signs that are shown within an individual, the more likely death is near.

Signs of Active Dying

The determination of a patient transitioning to imminent death is important, so that clinicians can help educate patients and families about the natural dying process.  Furthermore, this helps to inform their necessary decision-making as well as prepare the patient and family for death as much as possible.

Additionally, the care individualized plan is to be updated in order to reflect any changes in the patient’s status, and should include any necessary clinical visits. Please note that a higher level of care may be necessary in specific circumstances of crisis, or symptoms that are not being controlled by initial treatments.

The chart below shows median times that were identified in a study with cancer patients but can be generalized to other causes of death (i.e. heart disease, advanced lung disease, sepsis, and dementia). The following list is not exhaustive but includes some of the more common symptoms.

Days Before Death Clinical Signs
7+ Peripheral edema, delirium, dysphagia of solids, decreased speech, cool/cold extremities
4-6 Abnormal vitals, decreased level of consciousness, dysphagia of liquids
2-3 PPS 20% or less, peripheral cyanosis, decreased response to visual stimuli, drooping of the nasolabial fold, hyperextension of the neck, Cheyne-Stokes breathing, nonreactive pupils, decreased response to verbal stimuli
Less than 2 Death rattle, apnea, respiration with mandibular movement, decreased urine output, pulselessness of radial artery, inability to close eyelids, grunting of vocal cords, fever

Link Between Clinical Signs of Dying and Impending Death

There is a direct relationship between the amount of clinical signs of dying and death:

  • Patients with 2 clinical signs of dying had a 40% chance of dying
  • Patients with 8 clinical signs of dying had more than a 80% chance of dying

The research showed that the more existing clinical signs of death there are, there is a need for an update to the care plan which should include the appropriate interdisciplinary visits.  Ultimately, the process of a natural death results in clinical signs of dying where the more signs that are present increases the likelihood of death.

Involvement of Hospice Interdisciplinary Teams During Clinical Signs of Dying

When clinical signs of dying arise, the hospice interdisciplinary team commences an update to the care plan that will include:

  • Updating the appropriate interdisciplinary team visits
  • Education on the dying process for the patient and family
  • Adjustments to or implementation of medications
  • Ensure that the appropriate medical equipment is in place 

Below, the hospice team roles are described, as they each provide assistance and support in ways that are specific to their discipline and training.

Nurse/nurse practitioner/physician:

  • Discussion regarding the cessation of non-advantageous or troublesome treatments
  • Assure medications and necessary equipment are available to manage symptoms
  • Provide education to the family on utilization of equipment, and explain physiologic changes they may be able to recognize that are associated with the dying process

Social worker/spiritual care coordinator/chaplain:

  • Assist patients and families with exploring and expressing their feelings and navigating their relationships
  • Actively participate in the review of life, including the act of searching for meaningful contributions
  • Facilitate life closure, including forgiveness, addressing regrets, being able to say goodbye, and trying to find acceptance with regard to ongoing losses and death overall

Hospice aides/CNAs are responsible for recognizing the clinical signs of death to then communicate them to the rest of the interdisciplinary team, as well as supporting the patient and family through the dying process in any way they can.

References

Hui, D., Santos, R., Chisholm, G., Bansal, S., Souza Crovador, C., & Bruera, E. (2015). Bedside clinical signs associated with impending death in patients with advanced cancer: Preliminary findings of a prospective, longitudinal cohort study. American Cancer Society Journals, 121 (6), 960-67. https://doi.org/10.1002/cncr.29048

Hui, D., Santos, R., Chisholm, G., Bansal, S., Buosi Silva, T., Kilgore, K., Souza Crovador, C., Yu, X., Swartz, M. D., Perez-Cruz, P. E., Almeida Leite, R., Salete de Angelis Nascimiento, M., Reddy, S., Seriaco, F., Yennu, S., Paiva, C. E., Dev, R., Hall, S., Fajardo, J., & Bruera, E. (2014). Clinical signs of impending death in cancer patients. The Oncologist, 19(6), 681-87. 10.1634/theoncologist.2013-0457

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