NUR3500 Chap.9 Last Days of Life and Compassionate Discharge
Last Days of Life and Compassionate Discharge
Recognising that someone is dying
Nothing else in this chapter works if the dying phase is not recognised, and the signs are individually unremarkable and collectively unmistakable.
They include profound progressive weakness, confinement to bed, long hours asleep, food and drink no longer wanted, swallowing that has become hard, loss of any sense of time with a shortening attention span, low blood pressure that is not from fluid loss, urinary incontinence or retention from weakness, and reduced urine output.
Later come hallucinations involving people who have died, changes in the rate and pattern of breathing including long pauses, noisy breathing from pooled secretions, mottling and cooling of the skin, and a falling blood pressure with a weak rising pulse.
Each of these has an acute-care reading that would be correct in a different patient.
Low blood pressure invites fluids, poor intake invites a feeding tube, restlessness invites investigation. In the dying patient the same findings mean the body is shutting down, and those interventions add burden without benefit.
Recognising the phase is what turns a list of abnormal observations into a plan.
Five symptoms, anticipated rather than discovered
Pain, breathlessness, delirium, seizures and airway secretions account for most of the distress of the last days. Opioids remain the mainstay for pain and are continued by a subcutaneous route once swallowing fails.
Breathlessness is treated with opioids, with oxygen where there is hypoxia, and with moving air from a fan. Delirium is first a search for a cause, including recently added drugs; where it is terminal and irreversible, an antipsychotic or a sedative is used. Seizures need an anticonvulsant with a rectal or subcutaneous option available at home.
Secretions are managed by stopping non-essential fluids and feeds, positioning on the side and using an antisecretory drug.
One warning belongs here. Moaning, groaning and grimacing accompany agitated delirium as often as they accompany pain, and treating every sound with more opioid deepens the delirium. The quiet, drowsy form is the one most often missed altogether.
Skin also changes: a characteristic lesion appears as purple discolouration in a butterfly distribution over areas that are not pressure points and can become a wound within hours, and naming it as part of dying protects the family from believing someone failed to turn their relative.
Compassionate discharge
Compassionate discharge is the arrangement by which a dying patient is transferred out of hospital or hospice to spend their final days and die at home.
Because it is arranged in hours, the preparation happens earlier: the preferred place of death is discussed proactively so coordination becomes a phone call rather than a negotiation. Three conditions must hold together.
The patient has said that home is where they want to die, is expected to live hours to a few days, has comfort as the goal rather than further life sustaining treatment, and has symptoms that can be controlled outside hospital. The community has a home hospice team available.
The family is informed of the prognosis, understands the purpose, is willing and able to give care even if the person outlives the prognosis, can cope emotionally, accepts the risk of death on the journey, and where the case is reportable agrees to call the police if the death occurs at home.
The hours before and the weeks after
The family condition is the one that quietly fails, because willingness and capability are different.
What is taught in the last hour decides whether the plan survives the first night: converting the drug chart to a workable route, leaving anticipatory medicines in the house, rehearsing what the night will look like, settling what happens at the death, and planning the bereavement contact.
Support before and after the death is part of the service, and grief that does not settle needs counselling or specialist input rather than a follow-up call.
What this chapter covers
- 01
Signs of the actively dying patient
- 02
Acute-care readings that mislead in this phase
- 03
Pain, breathlessness, delirium, seizures and secretions
- 04
The three conditions for compassionate discharge
- 05
Preparation at home and bereavement support
Deciding whether to send her home
- 2Test the patient condition against the criteria.
- 2Test the community condition and identify the weak point.
- 3Test the family condition and state your advice.
Key terms
- Actively dying
- The final phase in which weakness, reduced consciousness, poor intake and circulatory changes indicate that death is expected within hours to days.
- Terminal delirium
- Delirium in the dying phase, frequently without a reversible cause, presenting as agitation or as quiet withdrawal.
- Airway secretions
- Noisy breathing late in dying caused by pooled upper airway secretions, managed by stopping fluids, positioning and antisecretory drugs.
- Compassionate discharge
- A rapid transfer arranged so that a dying person can spend their final days and die at home.
- Anticipatory medicines
- Drugs left in the home in advance for pain, breathlessness, agitation and secretions so that treatment is available without delay.
- Preferred place of death
- Where a person has said they wish to die, discussed proactively so that arrangements can be made quickly when needed.
Last Days of Life and Compassionate Discharge FAQ
What happens to oral medication when someone can no longer swallow?
Essential drugs are converted to a route that still works, usually subcutaneous, at an equivalent dose, and anything that no longer contributes to comfort is stopped. Stopping analgesia because tablets cannot be swallowed is the omission that produces uncontrolled pain in the last hours.
Should a dying patient with noisy breathing be given fluids?
Usually not. Reducing non-essential fluids and feeds, positioning on the side and giving an antisecretory drug is what settles the noise, whereas fluids tend to add to it. The family's underlying concern is often thirst, and mouth care is the intervention that addresses that.
Which condition most often prevents a discharge home going ahead?
Family capability rather than willingness. Teaching what is about to happen, leaving anticipatory medication in the house, naming who is called and when, and confirming that the family accepts the risk of death on the journey is what converts willingness into capability.
Exam move
List the signs of the dying phase, then beside each write the acute-care action it would wrongly invite. Rehearse the five symptoms with their first-line management, and write the three discharge conditions as a checklist you could use at a bedside.
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