End-of-Life Determinations for Newly Admitted Patients

Published on February 4, 2023

Updated on December 25, 2023

Admitting a patient to is a difficult 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 important 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 that can help them identify if the patient is in the transitioning phase or not.

Signs of Transitioning Phase

In this article, we will provide some tips to incorporate into your nursing practice to be able 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 they 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, staff of a “whirl wind” of changes over the last two weeks with almost daily declines. Extremely sudden, unexpected changes have been brought up that occurred in the last two weeks. These changes may include physical, mental, emotional, or spiritual aspects of the patient's condition.
  • Poor appearance: The patient's complexion is dusky, grey, sallow, or otherwise 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 is lethargic or has slurred speech. The patient may also have a blank stare or appear to be in a trance. The patient may also have difficulty recognizing familiar people or places or may become confused or disoriented.
  • Loss of swallowing reflex: If you give the patient something to drink or eat, the liquid or food just roll 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 : The patient is using their hands to manipulate an object or thing 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 may try to get out of bed or remove their medical devices. The patient may also have or and may see or hear things that are not there.
  • event: You ask about the last two weeks and was given the impression the patient had a event as evidenced by a brief of energy that can look like/involve the patient eating more than normal, being more involved, spending more time awake, 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, which is a pattern of alternating fast and slow breaths with periods of apnea. The patient may also have shallow or labored breathing or may gasp for air.
  • Frequent falls: Being told the patient has had multiple falls within a brief period of time. 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 that can worsen 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 to 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 concern 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.

Resources

Multiple Articles on Tips for Nurses

Tips for new nurse — Terminal Restlessness

Providing Comfort During the Last Days of Life with Barbara Karnes RN (YouTube Video)

Preparing the patient, family, and caregivers for a “Good Death”

Velocity of Changes in Condition as an Indicator of Approaching Death (often helpful to answer how soon? or when?)

The Dying Process and the End of Life

The Last Hours of Life

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Gone from My Sight: The Dying Experience

The Eleventh Hour: A Caring Guideline for the Hours to Minutes Before Death

By Your Side , A Guide for Caring for the Dying at Home

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