The Nuts and Bolts of Dying

1. The Nuts and Bolts of Dying

2. �Is there any meaning in life that the inevitability of death does not negate?�-The Death of Ivan Ilych

3. What is Death? physical end anxiety-producing threat to existence transformation punishment reckoning relief inevitable

4. Dying is a Sacred Art The final ritual Last chance to find meaning/purpose Marking of path What does it mean to be �ready� to die? Convictions about the process Practical methods for sacred passage

5. Diagnosis: The Beginning shock, disbelief, missing details �chemo brain� shift in consciousness many options in response planning paralysis/inertia

6. Remember� you are choosing to snuggle up abnormal in living is normal in dying body is preparing itself to stop simultaneous shifts in consciousness

7. Recommendations from the medical perspective Alleviate physical and emotional symptoms Support function/autonomy to preserve dignity Guard against inappropriate aggressive care Make time spent EOL precious Ensure QOL Minimize financial burdens Educate patients about insurance limitations Help the family with bereavement

8. ACS says� Pain Fatigue Constipation Dyspnea Nausea & vomiting Sleep disturbances Depression Anxiety Confusion Restlessness Anorexia/cachexia

9. Causes of Pain in Terminal Cancer bone mets neuropathic pain neurological pain psychosocial pain constipation decubitous ulcers and more

10. Pain Management Thorough and consistent assessment �round the clock treatment Dispell myths of addiction Teach and encourage reporting of side effects Heat, cold, massage, relaxation, distraction

11. Causes of Constipation in Terminal Cancer opioids immobility altered nutrition chemo iron supplements bowel obstruction

12. Dyspnea increasing tumor size/lung mets comorbidities pleural effusion pain or fatigue anxiety

13. Dyspnea Management Pursed lip breathing Use of can or open window for facial cooling Frequent mouth care Humidified oxygen Elevate head of bed

14. Nausea and Vomiting electrolyte imbalances (hypercalcemia, etc) bowel obstruction brain mets visceral distention altered taste gastric stasis

15. Stages of Dying not all pts go through all stages stages vary in length predictions are guidelines mind/body/spirit can affect process nothing to �do�

16. �Pre-active� and �Active� Dying Pre-active lasts roughly 2 weeks more aware organs function swelling begins acknowledge dying �unfinished business� slow or non-healing Active lasts about 3 days generally not aware very minimal function swelling persists settles into dying abnormal breathing hallucinations

17. Pre-active Dying restlessness, confusion, agitation inability to be made comfortable withdrawal from social interaction increased sleep/lethargy increased apnea decreased intake states that he/she is dying seeing people who have died tying up �loose ends� inability to heal wounds swelling in extremities

18. Active Dying coma-like severe agitation departure from normal personality longer apnea respiratory congestion/fluid �death rattle� states that he/she will die cyanosis stiffening/frozen not taking any food by mouth can�t speak even if awake open mouth incontinence dark urine dramatic BP drop cold extremities complains can�t feel feet/hands

19. Terminal Agitation subtle signals from the body (basic physiology) intuition �knowing�

20. Terminal Agitation panic sweating muttering concern with details questions reassurance repeating

21. What does it look like? demand to move/transfer complaints of discomfort accusations/yelling out hallucinations/stories may not recognize others speak quickly/disconnected repetitive actions shuddering limbs

22. Why? hypoxia decreased brain circulation metabolic changes things we can�t measure

23. Terminal Agitation Steps Are all sx are addressed? pain breathing bedding comfort (if pain, sedative will not help; pain med can alleviate agitation if pain is cause)

25. Non-pharmaceutical Options Alpha and theta-wave entrainment Christian monastic death prep music Bio-energy interventions Reiki, Healing Touch, Quantum Touch Guided visualization, prayer, meditation Aromatherapy anxiety, confusion, pain relief, breathlesness Gentle massage hands, feet, brow and head, ears Environment of quiet and serenity low light, no TV, slow approach, co-breathing Soothing tone of voice Hand holding under the hand

26. Breakdown Begins Muscles in organs relax Decreased blood flow/oxygenation kidneys, liver and pancreas first Heart and lungs are focus heat in trunk and upper body arms and legs grow cold

27. Breakdown Continues kidneys decrease urine output liver does not process as much waste overall capacity of major organs blood PH shifts (toxicity) circulation decreases sleeping increases (patterns like infancy) *current medical thinking suggests that artificial nutrition and hydration actually make the process of dying more uncomfortable

28. The person dies.

29. sit down.ritual bathing?family sharing?What�s here?

30. What is rigor mortis? body-wide stiffening facial muscles affected first within 10 minutes to a few hours of death Maximum rigidity at 12-24 hours lasts about 72 hours

31. Rigor Mortis muscle membranes become more permeable to calcium living muscle uses energy to transport calcium to the outside of the cells calcium promotes the actin/myosin bridge contraction results ATP stores are used up actin and myosin remain linked until decomposition begins