While this article is primarily meant for new nurses, what I’m sharing is also valuable for family members and loved ones. Anyone with patience and love toward the person being observed and interviewed can hone and develop these skills.
Observation Key Areas
Let us remember our “skin” is the largest organ of our body. As such, the skin is often the first area to change when we are sick.
Complexion — ashen, pale/pallor, waxy/glossy looking — all of these are signs that the patient has a condition change.
Eyes — is the patient looking at you when you address and talk with them or looking through or past you? Are they seeing beings, objects, and people not present in the room? All of these are indications the patient is changing mental status.
Mottling — red to purple, marbling/splotchy areas often first found on the patient’s feet and legs can indicate the person is within days or less of dying.
Is the patient lethargic — tired on steroids where the patient tries to stay awake but can barely keep their eyes open, talk (may or may not have slurred speech), etc?
It is helpful to interview the patient, their loved ones, and any staff (if at a facility). Your goal is to flesh out the following areas:
Has the patient had any restlessness such as fidgeting, frequent position changes, picking at things not present, appearing to play or interact with objects not present, scratching into their skin without realizing it, or other signs of anxiety? This is to flesh out if a patient is having terminal restlessness.
To what degree are they having trouble with the current texture of their food and liquids? Here, you are looking for two things: a medium change where maybe their textures (food and liquid) need to be downgraded for protection against aspiration pneumonia and choking or a notable change such as being told food and liquids are just rolling out of their mouth which is a significant indicator for if your patient is within two weeks or less of life to live.
Is the patient having periods of severe sweating (diaphoresis), acting, or complaining they are too hot or too cold without regard to the actual temperature in the home, especially if everyone else is comfortable?
What has the flow of urine been like? Steady, slowing, almost non-existent, and then a splurge out of nowhere? The latter is typically a sign the body is getting ready to give out, as in my experience, this is a sign of cleansing.
Has the patient had increasing periods of intractable nausea with emesis or loose stools? This can create electrolyte balances, pushing the patient faster towards the end of life.
Has the patient had increased periods of confusion, including hallucinations? Do any of the hallucinations include people the patient knew that have since died? The latter is a spirit-based sign the patient may be within the last two weeks to one month of life.
Has the patient had a burst of energy appearing out of nowhere? This can look like getting up earlier to eat, eating beyond 100% more than normal, being awake far more than normal, and other indicators that make people around the patient question whether they are not terminal (i.e., they are having a rally).
How fast have the downward changes been taking place? I.e., one medium to significant change every four to six weeks? One medium to major change every two to four weeks? One medium to major change per week? Multiple changes per day or week? The more frequent the changes, especially in the last two questions, the more your patient is within two weeks or less of life to live.
Complaints of the body being tired and feeling heavy
Not eating, taking little fluid
Body temperature: hot, cold
Decreased urine production — urine becomes tea-colored
Urine and bowel incontinence (writer note — it is common for there to be a release of urine more than anticipated and often stool if even a smear of feces hours to a day or two before death; I view this as the body preparing itself and cleansing itself for death).
