Admitting a patient to hospice services is a complex and sensitive process that requires careful assessment and communication. One of the challenges that hospice nurses face is to determine if the patient is close to the transitioning phase of dying, which is the final stage of life when death is imminent. This phase usually lasts for one to two weeks, and it is essential to prepare the family and provide a plan for increased hospice involvement during this time. However, on admission, hospice nurses do not have the luxury of having visited with the patient over the past several weeks to months to observe the changes that often signal that death is approaching. Therefore, they need to rely on other indicators to help them identify whether the patient is transitioning.
Signs of Transitioning Phase
In this article, we will provide some tips to incorporate into your nursing practice to recognize if the person you are admitting may be in the transitioning phase of dying. These signs are based on clinical experience and observation and may vary from patient to patient. However, they can serve as general guidelines to alert you of the possibility of a fast death.
Some of the signs of the transitioning phase are:
Rapid decline: You hear from loved ones, friends, and staff of a “whirlwind” of changes over the last two weeks, with almost daily declines. Extremely sudden, unexpected changes have occurred in the previous two weeks. These changes may include the patient’s physical, mental, emotional, or spiritual condition.
Poor appearance: The patient’s complexion is dusky, grey, sallow, or ill-looking. The patient may also have signs of dehydration, such as dry skin, lips, or mouth. The patient may also lose weight and muscle mass rapidly.
Reduced alertness: The patient may be lethargic or have slurred speech. The patient may also have a blank stare or appear in a trance. The patient may also have difficulty recognizing familiar people or places or become confused or disoriented.
Loss of swallowing reflex: If you give the patient something to drink or eat, the liquid or food rolls out of their mouth. The patient may also have increased secretions or mucus in their throat, which may cause gurgling or rattling sounds when they breathe. The patient may also cough or choke frequently.
Terminal agitation: The patient uses their hands to manipulate an object or object that is not present. The patient may also pick at things not present, such as their clothes, bed sheets, or air. The patient may also become restless, agitated, or anxious and try to get out of bed or remove their medical devices. The patient may also have hallucinations or delusions and may see or hear things that are not there.
Rally event: You asked about the last two weeks and were given the impression the patient had a rally event as evidenced by a brief surge of energy that can look like/involve the patient eating more than usual, being more involved, spending more time awake, and being more lucid. A rally event is a phenomenon that sometimes occurs before death when the patient seems to improve temporarily and may express a desire to see or talk to certain people or to resolve some unfinished business. However, this event is usually short-lived and followed by a rapid deterioration.
Irregular breathing: The patient’s respirations are very irregular between breaths with or without apnea. Apnea is a pause in breathing that can last from a few seconds to a few minutes. The patient may also have Cheyne-Stokes breathing, a pattern of alternating fast and slow breaths with periods of apnea. The patient may also have shallow or labored breathing or gasp for air.
Frequent falls: Being told the patient has had multiple falls within a brief period. Falls may indicate a loss of balance, coordination, or strength or a change in blood pressure or consciousness. Falls may also cause injuries or complications, worsening the patient’s condition.
Conclusion
In conclusion, hospice nurses need to be aware of the signs of the transitioning phase of dying, which is the final stage of life when death is imminent. These signs can help them determine if the patient they are admitting may be in the transitioning phase or not and plan accordingly for increased hospice involvement and family support. While there should be a post-admission visit within 24 to 48 hours of the admission if you have any concerns the patient may go fast, try to schedule a visit within 24 hours with consideration for even a 3rd visit in a row as it is better to be safe than to miss the opportunity to help the family and caregivers prepare for what may be a fast death.
