Last Hours Of Life Research Articles

"The Death Rattle" in the Intensive Care Unit After Withdrawal of Mechanical Ventilation in Neurological Patients

The noise produced by oscillatory movements of secretions in the oropharynx, hypopharynx, and trachea during inspiration and expiration in unconscious terminal patients is often described as "the death rattle." The secretions are produced by the salivary glands and bronchial mucosa. These patients are usually too weak to expectorate or swallow the migrating secretions. Sputum usually only accumulates in these areas if there is a significant impairment of the cough reflex, as in deep coma or near death. Reported incidence of death rattle in terminal patients varied between 6 and 92%. Death rattle was most commonly reported in patients dying from pulmonary malignancies, primary brain tumors, or brain metastases, and predicts death within 48 hours in 75% of the patients. After withdrawal of artificial ventilation from the intensive care unit, excessive respiratory secretion resulting in a rattling breathing during the last hours of life is not uncommon, especially not in pulmonary and neurological patients. The distressing experience and negative influence in the bereavement process indicates an ethical demand to treat this symptom from the perspective of others merely than that of the patient.

Ensuring competency in end-of-life care: controlling symptoms

BackgroundPalliative medicine is assuming an increasingly important role in patient care. The Education for Physicians in End-of-life Care (EPEC) Project is an ambitious program to increase core palliative care skills for all physicians. It is not intended to transmit specialty level competencies in palliative care.MethodThe EPEC Curriculum was developed to be a comprehensive syllabus including trainer notes, multiple approaches to teaching the material, slides, and videos of clinical encounters to trigger discussion are provided. The content was developed through a combination of expert opinion, participant feedback and selected literature review. Content development was guided by the goal of teaching core competencies not included in the training of generalist and non-palliative medicine specialist physicians.ResultsWhole patient assessment forms the basis for good symptom control. Approaches to the medical management of pain, depression, anxiety, breathlessness (dyspnea), nausea/vomiting, constipation, fatigue/weakness and the symptoms common during the last hours of life are described.ConclusionWhile some physicians will have specialist palliative care services upon which to call, most in the world will need to provide the initial approaches to symptom control at the end-of-life.

Integrating Palliative Care into Daily Practice: A Nursing Perspective

Education of health care providers has historically been based on the traditional model of curative care. In this model, the curative care focus suddenly ends, substituted by a palliative approach to care, too often only in the last hours of life. Patient goals and wishes may never be clearly established, leaving family and care providers to guess at what the patient's wishes were. If we are to provide quality palliative care, we must equate it with health care providers establishing, acknowledging, and honoring patient and family goals. A major facilitator in accomplishing palliative care goals can arise from the nursing assessment. This article reviews the elements of a comprehensive nursing palliative care assessment (PCA). Although this article focuses on nurses, it has application for all health care professionals. Completion of the PCA provides an opportunity for reflection and evaluation of personal practices that support integrating palliative care into the care of all patients diagnosed with a life-threatening illness, beginning at the time of diagnosis and accelerating in intensity as the disease progresses.

The effect of intravenous fluid infusion on blood and urine parameters of hydration and on state of consciousness in terminal cancer patients.

This prospective study was undertaken to assess the state of hydration in terminal cancer patients with and without intravenous fluids during the last 48 hours of their lives and to correlate various measures of hydration with their state of consciousness. We examined indicators of hydration in the plasma and urine of 68 consecutive patients for whom data were available at 48 hours or less before death. Thirteen of the patients were being treated with intravenous (IV) fluids. Nearly all of the patients studied were found to be dehydrated, as determined by laboratory measurements. State of consciousness correlated inversely with serum sodium (p < 0.001) and urine osmolality (p < 0.02). Patients receiving intravenous fluids were not better hydrated than those without IV therapy, nor was their state of consciousness improved. In light of these findings, which suggest there is no clinical benefit from intravenous infusions, decisions regarding intravenous fluid therapy during the last hours of life should be guided by the preferences of the dying patient and his family.

The relationship of fibroblast translocations to cell morphology and stress fibre density.

Translocation of human fibroblasts in culture was studied using techniques of time-lapse cinemicrography, indirect immunofluorescence, and computer analysis. An inverse relationship between the velocity of cells during the last hour of life and the density of stress fibers seen by immune staining was demonstrated. Translocating cells generally assumed one of two interconvertible morphologies: a triangular tailed shape or tailed fibroblast (TF), and a tailless form that resembled a half-moon, which we call a half-moon fibroblast (HMF). The tail of TFs formed only on regions of substrate that had been previously traversed by cells. The half-moon morphology developed either on previously used or on virgin substrate. Cells adopted the HMF rather than the TF morphology with a four-fold greater frequency. HMFs translocated slightly faster than TFs. The foregoing observation suggest that the fibroblast tail is not an organelle essential for translocation. Since our technique allowed us to distinguish between cells which were cycling and those which had left cycle, we compared their velocities and found them to be similar. Also the average velocities of cells of different population-doubling levels (10th, 30th, 40th) were approximately equal.

The circumstances preceding death from asthma in young people in 1968 to 1969

The circumstances preceding death from asthma were investigated in 52 young persons aged 5 to 34 years dying in Greater London and the South-East Lancashire conurbation between February 1968 and January 1969. Information was gathered at interviews with general practitioners, hospital staff, and relatives or witnesses of the last hours of life. The findings at necropsy were obtained from coroners or hospital pathologists. All the patients were severely affected; most had required regular medication to control their asthma, many had been in hospital for an acute attack and many were deteriorating before death. Despite this, death was regarded as ‘sudden and unexpected’ in at least 79% of patients and it seems probable that the severity of their condition was often not recognized by patients, relatives, and doctors. Several publications have suggested that sudden death has been associated with overdosage by pressure-packed aerosols containing sympathomimetic bronchodilators, and specific enquiries were made about their use. In 11 of 30 cases (37%) in which sufficient information was available the evidence suggested that excessive inhalation of bronchodilators might have contributed to death. Ten of these patients had used a pressure-packed aerosol containing a sympathomimetic bronchodilator and one other patient had inhaled disodium cromoglycate with added isoprenaline. Throughout the period of the investigation the mortality from asthma showed a sharp and continuing decline and it is estimated that less than half the deaths studied (46%) would have been caused by the epidemic factor. Apart from an occasional report of compulsive use, the principal reason for overdosage appears to have been failure to appreciate the lack of a normal response is an indication for a different type of treatment and management and not an indication to increase the dose. No other factor was discovered which might have caused the observed increase in mortality.