Dealing with the dying

We RTs often have to deal with the aging, and all too frequently we have to work with people who are dying. Therefore it's important we know at least a little bit about end of life issues, and how to approach these patients.

This was the topic of an article published in the AARC Times, "Coming of Age: Helping Ease Patient Concerns about the End of Life," (June 2007) by Melaine Giordano (MS, RN, CPFT).

Essentially she writes, "There are no rules one must follow in the journey of dying. It is the person who is dying that charts the course of their death; and the rest of us must respect their wishes and offer our assistance in facilitating their requests. As we care for our dying patients we should remind ourselves that the goal of care that we provide is aligned with the patient's wishes. We should be an advocate for those wishes to the health care team as well as others who are providing care."

Most people who are dying are often:

1. Depressed
2. Fatigued
3. Confused
4. Isolated
5. Scared
6. Suffer side effects of medicines
7. Have to deal with medical terminology and hospitals that they never had to deal with before and may be confused about it

Ah, so it's our job to make sure we not only introduce ourselves properly, and explain what it is that we do, but we also must help to educate the patient. We must make sure they know exactly what we are doing, and why, and how often they will need us.

Giordano describes a common situation where a doctor comes to the bedside, explains something, and the patient has to have her daughter or a nurse explain what the doctor just said. This scenario, although too common, should not play out.

Yet since it does, and we RTs are in the room to give breathing treatments and the like, it's our job to help to clarify their illness and help them to understand what's going on and what to expect in the future.

No, we don't have to relay the bad news, thank goodness, but once they know they are dying, they might ask you. It's your job to help the patient feel better about the "medical world."

Sometime it's just nice to have someone listen to you. I find that many COPD patients tend to like to tell you their whole life stories, as though they want to get it out before they die. Many COPD patients are really friendly and very talkative, and quite often don't want you to ever leave the room.

Therefore I think it's neat when you aren't being rushed so you can sit down on the other bed, or in a chair at eye level, and actually banter with the patient.

It's also neat to know the stages of dying:

1. Pre-active stage of dying: May last for weeks or months. Signs include:

• Withdrawal from their usual activities as well as socialization
• Increase in sleeping times
• Decrease in appetite
• Spending more time in bed
• Agitation and/ or restlessness
• Desire to put things in order
• Reports of seeing people who have already died
• Patient states that he or she is dying

2. The Active phase: Shorter and only lasts a few days but can last a couple week. Signs and symptoms include:

• Heart becomes weaker
• Circulation to extremities decreases (cold or blue fingers, toes and arms), yet often dying don't want additional weight or confinement of blankets
• Decreased mobility. May need pain medicine to move patient.
• Decreased alertness and then have surge of energy right before death
• Death rattle: secretions or saliva in throat due to the loss of ability to swallow. Painless and harmless, although may be difficult for family.
• Cheyne-Stokes breathing: rapid then slower and slower then cessation of breathing then faster and faster and rapid again... It does not cause distress to the patient, but may to the family

For more signs and symptoms check out hospicepatients.org.