Introduction

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:

  1. 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.
  2. 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.
  3. 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 , 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.
  4. 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 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 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 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 , , or behavior changes unrelated to an infection? If yes, the dates.
  • Did the patient experience any changes to mental status outside of ? 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 by date and dietary changes by date?
  • How much weight loss?
  • Are there any other changes, including treatments that stopped working, worsening , 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 -appropriate as death may be imminent.
  • If the patient has only one change every seven to ten days, the patient should be reassessed for 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 of Condition

Frequency of ChangeTypically Means Death Within
One every 4 to 8 weeksLess than 6 months
Every 3 to 4 weeksLess than 3 months
Every 1 to 2 weeksLess than 2 months
Once every weekLess than 1 month
Several times per weekLess than 2 Weeks
Every dayLess than 1 Week
Several times per dayLess 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 prepare emotionally and practically for what lies ahead.

Resources

Educating families on reporting changes of condition

The importance of caregiver journaling

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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Everything Happens for a Reason: And Other Lies I've Loved

The Art of Dying

Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying

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