Death and Dying / Care of the Deceased

Source: https://www.harborlighthospice.com/blog/what-are-the-3-stages-of-dying/

For many people, death is an unfamiliar process. Terminally-ill patients and their caregivers may wonder what to expect during this stage and how to make this time more comfortable. Having a better understanding of what happens during this process can help everyone involved to better prepare for this transition and each of the stages of dying.

3 Main Stages Of Dying

There are three main stages of dying: the early stage, the middle stage and the last stage. These are marked by various changes in responsiveness and functioning. However, it is important to keep mind that the timing of each stage and the symptoms experienced can vary from person to person. Outlined below is a general look at what to expect during each stage.

Early Stage Of Dying

In the early stage of dying, a patient will begin eating and drinking markedly less. This period can last anywhere from a few days to several weeks.

What You Will See

The first sign of this stage of dying will be a noticeable drop in interest in food. For many patients, eating becomes more of a burden than a joy at this point. They may also occasionally choke on their fluids and will start to feel full rather quickly.

What Is Actually Happening

During this stage, the body starts conserving energy and does not need as much nourishment as it did in the past. Although it may be troubling to witness, it does not cause the patient any pain or suffering. This is a natural process where the body shuts down hunger, and artificial feeding at this time does not prevent death and can even lead to physical distress.

To provide comfort, loved ones can offer patients bits of food, sips of fluid or ice chips, but it is important to respect the patient’s wishes when it comes to eating and drinking.

Middle Stage Of Dying

The middle stage of dying is marked by changes in the patient’s physical appearance that could last a few hours or several days.

Signs You Will Notice

The person will become increasingly less responsive to their surroundings and those around them, to the point where they will eventually become unable to speak or move at all. This is typically seen during the last days of life.

What Is Occurring In Stage 2

As the body’s circulation slows down, blood is reserved for helping major internal organs function. The patient’s hands and feet might feel cold and could become darker in appearance.

During this stage, loved ones can offer blankets to increase comfort as the patient’s circulation changes. However, heating pads and electric blankets are not advised because the patient will be unable to judge if they are becoming too hot.

The detachment from their surroundings and relationships is the body’s physical and spiritual response to the process of dying and is perfectly normal.

Loved ones should assume the patient can hear everything they say. Experts suggest speaking softly to the patient and touching them gently only if they normally like being touched. This is a good time for prayer or meditation. It is not recommended to ask the patient questions that require answers.

Last Stage Of Dying

During the final stage of dying, disorientation and restlessness will grow. There will be significant changes in the patient’s breathing and continence.

What You Will Notice

The patient’s bowel movements may stop entirely, or they may become incontinent. Their breathing may become shallow and irregular, with long pauses that grow frequent as death approaches. There may also be sounds of chest congestion and throat rattling in the last hours.

What Their Bodies Are Doing

The restlessness noted in this stage is attributed to changes in metabolism, while the kidney and bowel functions are affected by decreasing circulation. Relaxing muscles can lead to incontinence. The slowing of blood circulation to internal organs causes the lungs to lose their power to clear out fluids as well as the relaxation of the throat muscles.

When a patient enters the final stage of dying, it is helpful to talk to them reassuringly. Again, gentle touch is acceptable if the patient likes being touched. Even when they are not responsive, the patient might be able to hear those around them, so it is important to speak respectfully. Although this can be a distressing time for loved ones, it is best to try to stay calm.

Some patients may need medication for restlessness, diapers, a catheter or underbody pads. At this point, administering oxygen will not help. However, it may be useful to elevate the head of the patient’s bed or use pillows to help lift their head; turning the patient on their side may also increase comfort.

• Death is usually an easy diagnosis. If death is uncertain, lack of pulse, breath sounds, and heartbeat will usually suffice.

• Occasionally, the clinician may be fooled by a prolonged respiratory pause, as occurs in Cheyne-Stokes respirations. If in doubt, observation of respirations for several minutes is advised.

• Such common practices as shining a bright light into the pupils, or “assessing for pain” with a sternal rub are unnecessary and to be avoided if possible.

• Death pronouncement is a solemn ritual, the importance of which transcends the business of certification. If family is present, pronouncement may formally give permission for loved ones to grieve. As a rule, families should not be asked to leave during pronouncement, although some may wish to do so. In the process of pronouncement, condolences can be offered and the bereaved consoled.

• Even if no one else is present, pronouncement provides an opportunity for clinicians to say goodbye, to reflect on care delivered, and to bear witness to the passing of another human being (Hallenbeck 2003).

Death Pronouncement

If called to pronounce someone unknown to you:

• Inquire as to the circumstances of the death (anticipated or not)

• Inquire as to whether family is present and, if present, their condition (quietly grieving, dazed, angry, etc.)

In entering the room of the deceased:

• First, calm yourself

If family are present:

• Assess their initial reaction (actively grieving – anxious waiting for your evaluation).

• Do NOT ask them to leave – you should be able to do a brief examination with family present – pulse, respirations, and heartbeat.

• Clearly communicate that the person has died and offer condolences.

• Pause for their acute grief reaction; remain quiet, yet available; do not speak too much.

Respond simply to immediate reactions and questions:

• Console as you feel is appropriate to your relationship.

• Give permission for them to take some time prior to next steps such as autopsy requests or notification of others.

In departing, model saying goodbye to the deceased, as seems appropriate to the circumstances.

Source: https://www.ncbi.nlm.nih.gov/books/NBK545144/

Certain prerequisites should be present before the determination of brain death, including:

1. Evidence of an etiology of coma should be known. Confounding conditions should be excluded, including severe metabolic, endocrinal, and acid-base derangements. If a drug intoxication is suspected, five half-lives of drug clearance should be waited, with adjustment to renal and hepatic functions.

2. Core body temperature should be more than 36 degrees C. Warming blankets are an option.

3. Achieve systolic blood pressure (SBP) more than 100 mmHg, often accomplished using vasopressors or vasopressin.[11]

Brain death can be assessed by physical examination, the apnea test, and ancillary tests.

I. Physical Examination

This includes the response to pain and assessment of brain stem reflexes. Loss of response to central pain occurs in brain death. Central pain assessment can be by the application of noxious stimuli to certain areas as the supraorbital notch, the ankle of the jaw, upper trapezius, the anterior axillary fold, and the sternum. Neither eye response nor motor reflexes are detectable in brain death. It is important to note that some spinal reflexes can be present in patients with brain death. Saposnik et al. studied spinal reflexes in 107 patients with brain death and noted the following reflexes:

• Undulating toe flexion response, which is repetitive flexion and extension of toes triggered by plantar tactile stimulation

• Triple flexion reflex, which is flexion of thigh, leg, and foot triggered by plantar tactile stimulation

• The plantar response, which is plantar flexion triggered by plantar stimulation

• Pronator extension reflex triggered by head-turning

• Quadriceps flexion triggered by local noxious stimuli

• Facial myokymia, which is repetitive twitching of facial muscles

• Lazarus sign, which is bilateral arm flexion, shoulder adduction, and hand raising to the chest/neck, triggered by head flexion and sternal stimulation

• Myoclonus of arm and leg

• Muscle fasciculations

Brain death can be confirmed if brain stem reflexes are lost, including:[12][13]

• CN II: Loss of pupillary reflex (light reflex), pupils should be mid dilated 4 to 9 mm, and not reactive to light.

• CN III, IV, VI: Eye motion is lost in reaction to head movement (doll’s eyes).

• CN V, VII: Loss of corneal reflex.

• CN VIII: Loss of oculovestibular reflex (Caloric test): With irrigation of each by 60 ml of ice water, the eye won’t move toward the irrigated ear.

• CN IX: Loss of gag reflex.

• CN X: Loss of cough reflex

II. Apnea Test

The apnea test is used to assess the brain's ability to drive pulmonary function in response to the rise of CO2. Before the performance of the apnea test, the mechanical ventilator should be adjusted to obtain PCO2 within 35 to 45 mmHg and PO2 above 200 mmHg, using a positive end-expiratory pressure (PEEP) of 5 to 8 cm H2O. During the test, oxygen should be supplemented using a cannula connected to the endotracheal tube at 6 L/min, or T piece at 12 L/min, or using CPAP of 5 to 10 cm H2O. In the case of loss of respiratory drive, CO2 is expected to rise 5 mmHg every minute in the first 2 minutes, then by 2 mmHg every minute after. Repeat arterial blood gas (ABG) after 8 to 10 minutes showing CO2 of 60 mmHg or the rise of CO2 more than 20 mmHg above baseline is consistent with brain death. If the patient develops hypotension with SBP below 90 mmHg or cardiac arrhythmias, the test should terminate, and arterial blood gases are drawn. For patients on extracorporeal membrane oxygenation (ECMO) machines, oxygenation can be maintained while performing the apnea test by decreasing the gas sweep flow rate to 0.5 to 1.0 L/min and using an oxygenation source through the endotracheal (ET) tube.

III. Ancillary Tests

These tests are considerations if there is any uncertainty of diagnosis of brain death or if the apnea test cannot be performed (as in cases of chronic CO2 retainers).

*Ancillary tests used for detection of cessation of cerebral blood flow:

• Cerebral angiography: Four vessel angiography is considered the gold standard for tests that evaluate cerebral blood flow. It can confirm brain death when it shows cessation of blood flow to the brain. Limitations include invasiveness of the test and transferring the patient to the radiology suite. Also, the contrast may induce nephrotoxicity affecting the donor's kidney. False-negative tests can occur when ICP becomes lowered by surgery, trauma, or ventricular shunts.

• Transcranial ultrasound: Can be used to assess pulsations of middle cerebral arteries, vertebral and basilar arteries bilaterally, also anterior cerebral arteries or ophthalmic arteries if possible. The transcranial US can confirm brain death by showing small peaked systolic pulsations or the absence of diastolic pulsations. Test limitations include the performer's expertise, the presence of unsuitable windows due to thick temporal bones, as well as lowered ICP by surgery or ventricular shunts giving false-negative tests.

• Computed tomogram (CT) brain angiography and MR angiography showing cessation of cerebral blood flow.

• Radionuclide brain imaging: This can be done using a 99mTc-labeled hexamethyl propylene amine oxime (HMPAO) isotope tracer then imaging by single-photon emission computed tomography (SPECT) brain scintigraphy. The absence of a tracer in the brain circulation (the hollow skull phenomenon) is consistent with brain death. The test may show false-positive results if imaging is done in one plane only instead of 2 planes (anterior and lateral).

*Ancillary tests used for detection of loss of bioelectrical activity of the brain:

• Somatosensory evoked potentials: Patients with brain death show no somatosensory evoked potentials in response to bilateral median nerve stimulation and no brain stem evoked potentials in response to auditory stimuli. SSEPs can confirm EEG findings, as it is less affected by drug intoxication; however, it still can be affected by hypothermia.[11][14][15]

Last updated May 2017

Ref: (a) NHCP Instruction 5360.1N (31OCT2012). (b) NHCP Instruction 6510.2D (28APR2015). (c) NHCP Instruction 6010.5M (01MAY2000) reviewed 2012.

Physician/Provider Responsibilities

1.) Complete NAVMED 6320/5 and ensure it is delivered to patient administration and/or the Decedent Affairs Officer within 1 hour of death. After hours, assure delivery to the OOD / CDO.

2.) Notify San Diego Medical Examiner (ME) at 858-694-2905 for any death at NHCP. This may be completed by the OOD / CDO or Decedent Affairs. The Medical Examiner may wave jurisdiction and should provide a waiver number that subsequently needs to be documented in the medical record along with the name of the person granting the waiver.

3.) The remains should not be altered or moved until ME notification has occurred. Only the ME can authorize movement of the body.

4.) Assume care of the deceased in accordance with Ref (a).

Coroner (Medical Examiner) Notification

1. Active Duty deaths aboard military installations are not reportable to the San Diego County Medical Examiner. Refer to "notification" section of Ref (a).

2. All other deaths must be reported to the San Diego County Coroner at the number above.

3. The following instances or circumstances of death should be communicated to the San Diego Coroner's Office

   1. Violent, sudden, or unusual death

   2. Unattended death

   3. Decedent has not been attended by a physician in the last 20 days

   4. Self-induced death (suicide) or criminal abortion

   5. Known or suspected homicide, suicide, or accidental poisoning

   6. Deaths resulting from an old or recent accident (either wholly or in part)

   7. Deaths from:

      1. Drowning

      2. Fire

      3. Hanging

      4. Gunshot

      5. Stabbing

      6. Cutting

      7. Exposure

      8. Starvation

      9. Acute alcoholism

      10. Drug addiction

      11. Strangulation

      12. Aspiration

      13. Suspicion of sudden infant death syndrome (SIDS)

   8. Known or suspected criminal cause

   9. Deaths associated with known or alleged rape or crime against nature

   10. Deaths occurring in prison

   11. Death due to contagious disease and constitute a public health hazard

   12. Deaths from occupational diseases or occupational hazards

FYSA

Charge Nurse Responsibilities

1.) Immediately notify the quarterdeck (725-1888) and the Decedent Affairs Officer at (cell) 760-390-9032 during normal working hours. After normal working hours, weekends, and holidays, the Decedent Affairs Officer can be reached at (cell) 760-390-9032 and the Officer of the Day or Command Duty Officer (OOD or CDO) can be reached at (cell) 760-685-3537. The nurse of the day (NOD) can be reached at (cell) 760-685-3468.

2.) Notify Lifesharing at 1-888-423-6667 of all deaths and all imminent deaths (regardless of determined viability and possibility of donation). At the time of referral, have the chart available and provide the following information: Name and MRN, Age/Sex/Race, weight and height, time and cause of death (for cardiac death).

3.) Notify Social Worker and Chaplain.

a.) Social Work Office Phone: 760-725-1318

b.) Social work after hours: 760-696-8727

c.) NHCP Chaplain duty phone: 760-613-7364 (OR 760-293-1503)

d.) MCB Pendleton Duty Chaplain 760-470-7077

4.) Assure pertinent information is entered into the NOD report

5.) Assume care of the deceased in accordance with Ref (A.) as above.

Inpatient Order Set, under ZHANG, GREGORY: imsd-MED Comfort Care Order Set. Taken from NMCSD ICU.

• Ensure Life Sustaining Treatment (LST) and code status updated

• Consider consult w/ Social Work for home hospice if desired

• D/c unnecessary orders / monitoring

• Eating and Drinking to patient comfort

• Consider consult to spiritual care / Chaplain

• D/C unnecessary meds and labs

• Minimize disruptive / distressing interventions.

• Symptoms to consider:

  • Pain / Dyspnea / Air Hunger - Morphine pushes, consider PCA / drip

  • Agitation - Ativan

  • Delirium - Haldol

  • Secretions - Glycopyrrolate

  • Nausea - Scopolamine patch, Zofran PRN

  • Constipation - Senna for no bowel obstruction, Bisacodyl suppository of there is an obstruction.

  • Fever - Tylenol, ibuprofen, Toradol IV.