From the Guidelines
The clinical signs of impending death typically appear in the final hours to days of life, and healthcare providers should prioritize comfort care, focusing on symptom management rather than life-prolonging interventions. These signs include decreased consciousness with minimal responsiveness, inability to swallow, mottled skin (especially on extremities), irregular breathing patterns such as Cheyne-Stokes respirations (periods of rapid breathing followed by periods of no breathing), noisy respiratory secretions often called the "death rattle," decreased urine output, cool extremities, fixed and dilated pupils, and jaw relaxation 1. Terminal delirium may occur, characterized by restlessness, agitation, or confusion. Vital signs often show decreasing blood pressure, irregular pulse, and decreased oxygen saturation. Patients typically stop eating and drinking as death approaches. These signs result from the body's systems gradually shutting down as circulation decreases, metabolism slows, and neurological function diminishes.
Some key points to consider when managing symptoms in patients nearing death include:
- Monitoring parameters for patient comfort, rather than routine monitoring of vital signs 1
- Adjusting medication dosing based on the patient's condition and previous medication exposure
- Using medications such as morphine for pain and respiratory distress, glycopyrrolate or scopolamine for secretions, haloperidol or other antipsychotics for delirium, and benzodiazepines for anxiety or restlessness
- Prioritizing comfort care and symptom management over life-prolonging interventions, as the focus shifts to improving the patient's quality of life in their final days 1
It's essential to note that the clinical signs of impending death can vary from patient to patient, and healthcare providers should be aware of the individual's unique needs and circumstances when providing care. By prioritizing comfort care and symptom management, healthcare providers can help ensure that patients receive the best possible care in their final days.
From the Research
Clinical Signs of Impending Death
The clinical signs of impending death can be identified through various physical signs and vital signs. According to the studies, the following are some of the common clinical signs of impending death:
- Decreased level of consciousness 2
- Decreased blood pressure 3, 4
- Low oxygen saturation 3, 4
- Increased pulse pressure 4
- Death rattle 2, 4
- Decreased conscious level 4
- Confused mental state 4
- Respiration with mandibular movement 5, 2, 6
- Pulselessness of radial artery 2, 6
- Cheyne-Stokes breathing 2
- Decreased urine output 2
- Apnea periods 2
- Peripheral cyanosis 2
Vital Signs
Vital signs such as heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature can also indicate impending death. The studies found that:
- Systolic blood pressure, diastolic blood pressure, and oxygen saturation decrease significantly in the final three days of life 3
- Heart rate and respiratory rate remain similar in the last three days of life 3
- Temperature increases slightly in the final days of life 3
Prediction Models
Prediction models using physical signs and vital signs can predict death within a certain timeframe. For example:
- A model using pulselessness of the radial artery, respiration with mandibular movement, or a shock index >1.0 can predict death within 7 days with an accuracy of 83.9% 6
- A combination of decreased blood pressure and low oxygen saturation can predict death within 48 hours with a positive predictive value of 95.0% and a negative predictive value of 81.4% 4