One common question that both patients (if they are mentally aware) and their loved ones often ask is about the timing of the patient’s passing. While the exact answer lies beyond human knowledge, hospice nurses are crucial in assessing the patient’s journey toward the end of life. This article will explore how to provide a rough estimate using widely followed guidelines.
Comparing the Journey to a Whirlpool
Much like the gradual movement of water in a whirlpool, the approach to death involves changes in the patient’s condition. These changes occur slowly at the outer edges, where one is farther from the end. Similarly, when someone is around six months away from the end, significant changes might occur every four to eight weeks. In contrast, changes happen multiple times each week closer to the center of the “maelstrom,” where death is imminent within two weeks.
Creating a Rough Estimate
Assessing the patient’s journey toward the end involves considering the pace of condition changes. When someone is extremely sick and cannot get better, they may start to show some signs that they are getting closer to death. These signs can help us estimate how much time they have left to live. Different people may have other signs, but there are some common ones that we can look for.
One of the signs is how fast their condition changes. This means how often they have new or old problems get worse. For example, they may have more pain, lose more weight, sleep more, or eat less. These changes can tell us which stage of their dying process. Here’s a simplified breakdown:
Early Stages (Approximately 6 Months or More Away): This is when the changes are slow and not very noticeable. They may happen every month or two. The person may still do things they used to do, like talking, walking, or reading. They may have some good and bad days, but they are not getting much worse.
Approaching the End (Around 3 to 6 Months): This is when the changes are more noticeable and happen more often. They may happen every few weeks. The person may start to have more problems with their body, like breathing, swallowing, or going to the bathroom. They may need more help from others to do things. They may also have more changes in their mood, like feeling sad, angry, or scared.
Nearing the End (About 1 to 3 Months): This is when the changes are fast and happen a lot. They may happen every week or even every day. The person may have more severe problems with their body, like infections, bleeding, or organ failure. They may not be able to do anything by themselves. They may also have more changes in their mind, like seeing or hearing things that are not there, forgetting things, or not knowing where they are.
Imminent Death (Less Than 2 Weeks): This is when the changes are swift and very big. They may happen several times a week or even several times a day. The person’s body is getting ready to stop working. They may have low blood pressure, slow heartbeat, shallow breathing, or cold skin. They may be unable to talk, open their eyes, or respond to anything.
What I’m typically assessing on a hospice admission with discussion among the patient and loved ones is as follows:
In the last 30 days
Increased episodes of generalized pain (hurts all over even to gentle touch) or shortness of breath as evidenced by fast, shallow breathing along with the dates of those events.
How many falls, and what are the dates of each fall?
How many infections took place, and what were the dates of those infections?
How many times was the patient lethargic, and what were the dates?
Has the patient had a new onset of restlessness, agitation, or behavior changes unrelated to an infection? If yes, the dates.
Did the patient experience any changes to mental status outside of lethargy? If yes, please provide the dates of those changes.
How many downward changes to functionality, including activities of daily living (ambulating, feeding themselves, dressing, personal hygiene, continence, toileting)? How close are these changes to one another?
How often did the patient experience dysphagia by date and dietary changes by date?
How much weight loss?
Are there any other changes, including treatments that stopped working, worsening vital signs, etc.? Please provide dates for each.
In the last two weeks
Do you believe there was a whirlwind of downward changes? If so, tell me more.
Assessment Thoughts and Actions Based on a 30-day Review
If there are daily changes (including several times per day) or several changes per week, the patient is EOL-appropriate as death may be imminent.
If the patient has only one change every seven to ten days, the patient should be reassessed for EOL status every visit.
If the patient has one change every other week, the patient should be assessed for EOL status weekly.
And if they are not that close, then how close?
This involves tracking the downward changes and referring to the table below for a general idea of when.
Frequency of Changes in Condition
Frequency of Change
Typically Means Death Within
One every 4 to 8 weeks
Less than 6 months
Every 3 to 4 weeks
Less than 3 months
Every 1 to 2 weeks
Less than 2 months
Once every week
Less than 1 month
Several times per week
Less than 2 Weeks
Every day
Less than 1 Week
Several times per day
Less than 72 hours
When a patient is closer to death, there is often a noticeable increase in the speed at which their condition changes.
Conclusion
Addressing when one will pass away is a complex matter influenced by individual factors. While we cannot provide an exact answer, understanding the general pattern of condition changes can help patients, families, and caregivers prepare emotionally and practically for what lies ahead.
