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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

    Decreasing Fluid Intake, Dehydration

    Signs and Symptoms

    • Most patients also reduce their fluid intake, or stop drinking entirely, long before they die
    • If they are still taking some fluid but are not eating, salt-containing fluids such as soups, soda water, sport drinks, and red vegetable juices can:
      • Help to maintain electrolyte balance

      • Minimize the risk of nausea from hyponatremia
    • Decreased fluid intake usually heightens onlookers’ distress as they worry that the dehydrated patient will suffer, particularly if he or she becomes thirsty
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    Management

    • As with feeding, families and professional caregivers will need support to understand that this is an expected event. It may help families to understand that:
      • Most experts in the field feel that dehydration in the last hours of living
        • Does not cause distress
        • May stimulate endorphin release that adds to the patient’s sense of well being

      • Low blood pressure or weak pulse is part of the dying process and not an indication of dehydration

      • Patients who are not able to move off the bed do not get light-headed or dizzy

      • Patients with peripheral edema or ascites have excess body water and salt and are not dehydrated
    • Parenteral fluids, either intravenously or subcutaneously using hypodermoclysis, are sometimes considered, particularly when the goal is to reverse delirium. However, parenteral fluids may have adverse effects that are not commonly considered:
      • Intravenous lines can be cumbersome and difficult to maintain

      • Moving the angiocatheter can be uncomfortable, particularly if the access site needs to be changed frequently and the patient is cachectic or has no veins

      • Excess parenteral fluids can lead to fluid overload with consequent peripheral or pulmonary edema, worsened breathlessness, cough, and orotracheobronchial secretions, particularly if there is significant hypoalbuminemia

      • They also have the potential to prolong the dying process, which may be undesirable
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    Mucosal/Conjunctival Care

    • To maintain patient comfort and minimize the sense of thirst, even in the face of dehydration, maintain moisture in mucosal membranes with meticulous oral, nasal and conjunctival hygiene
    • Moisten and clean oral mucosa every 15 to 30 minutes with either baking soda mouthwash (1 teaspoon salt, 1 teaspoon baking soda, 1 quart tepid water) or an artificial saliva preparation to minimize the sense of thirst and avoid bad odors or tastes and painful cracking
    • Treat oral candidiasis with topical nystatin or systemic fluconazole (if the patient is able to swallow)
    • Coat lips and anterior nasal mucosa hourly with a thin layer of petroleum jelly to reduce evaporation
    • Avoid perfumed lip balms and swabs containing lemon and glycerin, as these can be both desiccating and irritating, particularly on open sores
    • If eyelids are not closed, moisten conjunctiva with an ophthalmic lubricating gel every 3 to 4 hours, or artificial tears or physiological saline solution every 15 to 30 minutes to avoid painful dry eyes
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