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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Module 12: Last Hours of Living
    Part I: Physiological Changes and Symptom Management During the Dying Process

    Weakness/Fatigue
    Decreasing Appetite/Food Intake, Wasting
    Decreasing Fluid Intake, Dehydration
    Decreasing Blood Perfusion, Renal Failure
    Neurological Dysfunction: An Overview
    Pain
    Loss of Ability to Close Eyes
    Changes in Medication Needs

    Loss of Ability to Close Eyes

    • Advanced wasting leads to loss of the retro-orbital fat pad, and the orbit falls posteriorly within the orbital socket
    • As eyelids are of insufficient length to both extend the additional distance backward and cover the conjunctiva, they may not be able to fully appose
    • This may leave some conjunctiva exposed even when the patient is sleeping
    • Eyes that remain open can be distressing to onlookers unless the condition is understood
    • If conjunctiva remains exposed, maintain moisture by using ophthalmic lubricants, artificial tears, or physiological saline as previously discussed

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    Changes in Medication Needs

    • As patients approach the last hour of their lives, reassess the need for each medication and minimize the number that the patient is taking
    • Leave only those medications to manage symptoms such as pain, breathlessness, excess secretions, and terminal delirium and reduce the risk of seizures
    • Choose the least invasive route of administration:
      • The buccal mucosa or oral routes first
      • The subcutaneous or intravenous routes only if necessary
      • The intramuscular route almost never
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