Elena 
I have been doing a lot of reading this week about dying and the dying process and I came across these helpful articles.
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This is the time during the journey that one begins to sleep most of the time. Disorientation is common and altered senses of perception can be expected. One may experience delusions, sometimes thinking others are trying to hurt them.
The following excerpts come from this book, Palliative Care Perspectives
which I have found to be very helpful. It has huge excerpts available online.
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There may be a brief stage in which the process of losing vision is
troublesome to families. Patients may appear to be “looking right through you.”
This often feels spooky to families. The “look,” as some hospice workers call
it, is often accompanied by predeath visions.
Patients at this stage may be on a different wavelength, as discussed in the
section on altered states in Chapter 7. Families may project all sorts of
meanings onto this look – “He’s ignoring me or mad at me.” It may help to explain
this process (without necessarily trying to explain why, in fact, patients
experience different wavelengths).
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Most dying people then close their eyes and appear to be asleep.
From this point on dying is very mysterious, and we can only infer what is
actually happening. My impression is that this is not coma, a state of
unconsciousness, as many families and clinicians think, but something like a
dream state. Hearing and touch often seem remarkably preserved, suggesting some
degree of consciousness.
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If people ask me how I know this, it is from the many
cases in which a loved one, holding a dying person’s hand, has said “I love
you” and received a soft hand squeeze. In reassuring a dying person who has
anxious respirations by saying “You are doing fine,”
the breathing pattern may slow and becomes peaceful. Families are thus
encouraged to comfort their loved one with words and touch.
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The phase of active dying often
seems more difficult for families than for the dying themselves. Most people
have never witnessed a death before. All sorts of fears, anxieties, and
concerns well up and need to be addressed. Most of all, families need our
support during this difficult, exhausting time. Families, loved ones, and even
clinicians become the patients and look to us for support and guidance.
- I witnessed my grandfather’s death, so I am not totally unfamiliar with the process although not looking forward to seeing it again either. – post by mydomesticchurch
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As the body begins to shut down,
widespread organ dysfunction develops. The accumulation of respiratory
secretions in the lungs (with or without bacterial pneumonia) is just one of
the most visible and audible signs of systemic breakdown.
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Nausea tends to
fade in the actively dying, which is probably related to decreased oral intake.
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Cheyne-Stokes respirations refer to a rhythmic change in respirations wherein breathing becomes shallower and
shallower variably with a slowing in respiratory rate that culminates usually
in complete cessation of breathing for several seconds to more than a minute.
This is followed by progressively stronger respirations
that become exaggerated and quite deep. This pattern is thought to result from
abnormal brainstem responses to CO2 levels in the blood – initially undercompensating
and then overcompensating.
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Morita identified four signs that heralded impending death in 100 cancer
patients: the “death rattle,” respiration with mandibular
movement, cyanosis of the extremities, and lack of radial pulse. He measured
the median time to death from the onset of these signs. They tended to occur in
a rather orderly fashion, with the death rattle preceding respiration with mandibular movement (74% of the time), which in turn
preceded cyanosis and pulselessness (63% of the
time). The median time until death following the death rattle was 57 (+ or –
23, SD) hours, 7.6 (2.5) hours following respiration with mandibular
movement, 5.1 (1.0) hours following cyanosis, and 2.6 (1.0) hour following lack
of radial pulse.3 (I was
struck by this study because until I read about mandibular
movement, I had been unable to see it in my dying patients.)
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The respiratory rate is variably increased and often becomes
irregular, sometimes with frank Cheyne-Stokes respirations. The stethoscope is of minimal use. The
buildup of respiratory secretions in the bronchi and bronchioles makes
localization of underlying alveolar involvement, manifested by rales, difficult, if not impossible, to detect. More useful
is direct palpation of the chest wall for vibrations that represent the buildup
of secretions, a form of fremitus. If such vibrations
occur only in the center of the anterior chest over the trachea, this may
reflect only tracheal secretions and generate a false positive finding for
active dying. These may subsequently clear if cough returns. However,
peripheral fremitus appears to be more suggestive of
terminal retained secretions. Fever is often absent, particularly if steroids
have been used. The pulse may be strong initially but becomes threadier and eventually will not be palpable as blood
pressure falls.
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Despite the lack of fever, peripheral vasodilatation may occur
if there is underlying sepsis. In such cases the pulse initially is rapid and
often hyperdynamic, which can be erroneously read as
a “strong pulse.” Most likely, this pulse results from a widened pulse
pressure, because enhanced cardiac output under adrenergic
stimulation is accompanied by a fall in systemic vascular resistance,
especially if sepsis is present. I have found that feeling the shins for warmth
is useful in evaluating for this. Because the shins have poor vascularization and normally are cool (especially in the
presence of hypotension with reflexive
vasoconstriction), warm shins
conversely suggest vasodilatation. (Note that the sensitivity and specificity
of these suggested examinations have not yet been tested.)
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I have found these signs useful but not infallible. Some
patients with obstructive lung disease, those prone to chronic aspiration such
as stroke, and dementia patients may rattle with retained respiratory
secretions and yet not be actively dying. Cyanosis and mottling of the upper extremities appear more specific for
impending death than do such changes in the lower
extremities, where they commonly reflect peripheral vascular disease. I have
witnessed false positives for mandibular movement in
patients who have obstructive lung disease. The exaggerated use of strap muscles
in breathing may result in jaw movements that mimic true respiration with mandibular movement. I suspect this sign in dying people
results from relaxed muscular tone in the jaw combined with deep breathing.
This might explain additional false positives I have seen for this sign in
patients with benzodiazepine overdoses and amyotrophic lateral sclerosis (two patients each in my
experience), both situations that involve relaxed muscular tone.*
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This phase of dying, variably called the “terminal phase” or
“active dying,” is characterized by a series of changes that affect the dying
person, the family, and clinicians.1 For many dying patients this phase
seems almost anticlimactic. They enter a dreamlike state and seem to progress
peacefully in their dying. Some do have a hard time, and we need to know how to
help them. Families often struggle mightily during this period. Clinicians are
also seriously challenged. Few have been taught about active dying. Most lack
even basic competencies. Clinicians are humbled before death as it becomes so
obvious at a certain point that we are not in charge at all.
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Lay people would be amazed if they knew how little clinicians know
about active dying. They mistakenly think, “You see lots of patients die, you
must know what this is about.” However, in my experience the greatest lack of
clinical knowledge in palliative care exists in this area. D
dyin
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The standard treatment for ovarian cancer is six rounds of chemotherapy with Taxol and a platinum drug (carboplatin or cisplatin). Powerful anti-nausea drugs can dramatically reduce one of the more feared side effects of chemotherapy.
If caught in the earliest stage, ovarian cancer has almost a 90 percent cure rate. One of the best ways to ensure that this cancer is caught early is to pay attention to the early warning symptoms and seek prompt medical attention if the symptoms persist.
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A good article to bookmark. What every woman should know about ovarian cancer.
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Ovarian cancer is relatively rare—only 1.4 percent of women will get it in their lifetimes—but its potential deadliness makes early identification of symptoms a matter of life or death. If caught in the earliest stage, before it has spread beyond the ovaries, almost 90 percent of women will survive, compared to fewer than 30 percent of those whose cancers are caught in the later stages
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While many people think that ovarian cancer is a disease that afflicts mainly high-risk women—women with a family history of breast or ovarian cancer—Goff stresses that it is important for all women to pay attention to these symptoms, since 90 percent of the women diagnosed with ovarian cancer each year have no history of cancer in their families.
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- According to Goff, 57 percent of women with Stage 1 ovarian cancer and 87 percent of women with advanced ovarian cancer experienced one or more of the following symptoms:
- Bloating
- Pelvic or abdominal pain
- Difficulty eating or feeling full quickly
- Feeling a frequent or urgent need to urinate
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“However, if the symptoms are new and persist for more than two to three weeks, they could be a sign of ovarian cancer or other serious conditions, like urinary tract infections or colon cancer,” Goff says. “While the majority of women won’t have ovarian cancer, it’s still critical to see a doctor immediately.”
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Three months ago when we took my mother to the hospital, the possibility of ovarian cancer never crossed our minds! After all she had had two pregnancies and had even had her uterus and one ovary removed back in the 1960s! Her chances of getting ovarian cancer were much reduced. Additionally her mother did not have ovarian cancer nor did any of her aunts. But as it turns out, 90% of the women who develop ovarian cancer will not have any family history of the disease, so all women have to be observant.
Posted from Diigo. The rest of my favorite links are here.