Recognition of the signs and symptoms that are common in the final hours of life and a basic understanding of how to manage these signs and symptoms are important to helping the patient and family experience a good death in the home setting. The most common signs and symptoms, including pain, dyspnea, and terminal restlessness or delirium, and their management are discussed. Also addressed are other signs and symptoms, such as cardiovascular signs and symptoms including cold extremities, mottling, and changes in vital signs; respiratory signs and symptoms such as changes in breathing pattern, noisy breathing, and mandibular breathing; and neurological signs and symptoms such as disorientation, sensory changes, and semicomatose state. Changes in metabolism such as fatigue, surge of energy, and increased temperature are presented, along with decreased intake, excretion, and communication changes.
Callanan, C., & Kelley, P. (1992). Final gifts. New York: Poseidon.
2.
Campbell, M.L. (2004). Terminal dyspnea and respiratory distress. Critical Care Clinics, 20(3), 403-417.
3.
Carey, T.S., Hanson, L., Garrett, J.M., Lewis, C., Phifer, N., Cox, C.E., et al. (2006). Expectations and outcomes of gastric feeding tubes. American Journal of Medicine, 119(6), 527.e511-527.e526.
4.
Ellershaw, J.E., Kinder, C., Aldridge, J., Allison, M., & Smith, J.C. (2002). Care of the dying: Is pain control compromised or enhanced by continuation of the fentanyl transdermal patch in the dying phase? Journal of Pain and Symptom Management, 24(4), 398-403.
5.
Emanuel, L., Ferris, F.D., von Gunten, C.F., & Von Roenn, J.H. (2006, August 28, 2006). The last hours of living: Practical advice for clinicians. Retrieved September 15, 2006, from http://www.medscape.com/viewprogram/5808_pnt
6.
Fainsinger, R., Miller, M.J., Bruera, E., Hanson, J., & Maceachern, T. (1991). Symptom control during the last week of life on a palliative care unit. Journal of Palliative Care, 7(1), 5-11.
7.
Herr, K., Bjoro, K., & Decker, S. (2006). Tools for assessment of pain in nonverbal older adults with dementia: A state-of-the-science review. Journal of Pain and Symptom Management, 31(2), 170-192.
8.
Kehl, K.A. (2004). Treatment of terminal restlessness: A review of the evidence. Journal of Pain & Palliative Care Pharmacotherapy , 18(1), 5-30.
9.
Lanuke, K., Fainsinger, R.L., & DeMoissac, D. (2004). Hydration management at the end of life. Journal Palliative Medicine, 7(2), 257-263.
10.
Lawlor, P.G. (2002). Delirium and dehydration: Some fluid for thought . Supportive Care in Cancer, 10, 445-454.
11.
Lawlor, P.G., Gagnon, B., Mancini, I.L., Pereira, J.L., Hanson, J., Suarez-Almazor, M.E., et al. (2000). Occurrence, causes, and outcome of delirium in patients with advanced cancer: A prospective study. Archives of Internal Medicine, 160(6), 786-794.
12.
Lichter, I., & Hunt, E. (1990). The last 48 hours of life. Journal of Palliative Care, 6(4), 7-15.
13.
Lugo, R.A., & Kern, S.E. (2002). Clinical pharmacokinetics of morphine. Journal Pain Palliative Care Pharmacotherapeutics, 16(4), 5-18.
14.
Macleod, A. (2006). The management of terminal delirium. Indian Journal of Palliative Care, 12(1), 22-28.
15.
Morita, T., Tei, Y., Tsunoda, J., Inoue, S., & Chihara, S. (2001). Determinants of the sensation of thirst in terminally ill cancer patients. Support Care Cancer, 9(3), 177-186.
16.
Pasero, C., & McCaffery, M. (1999). Opioids by the rectal route. American Journal of Nursing, 99(11), 20.
17.
Periyakoil, V.S., & Hallenbeck, J. (2002). Identifying and managing preparatory grief and depression at the end of life. American Family Physician, 65(5), 883-890.
18.
Reuben, D.B., & Mor, V. (1986). Dyspnea in terminally ill cancer patients. Chest, 89(2), 234-236.
19.
Roth, A.J., & Breitbart, W. (1996). Psychiatric emergencies in terminally ill cancer patients. Hematology-Oncology Clinics of North America, 10(1), 235-259.
20.
Saunders, C. (1989). Pain and impending death. In P. D. Wall & R. Melczack (Eds.), Textbook of pain (2nd ed., pp. 624-631). Edinburgh, UK: Churchill Livingstone.
21.
Solano, J.P., Gomes, B., & Higginson, I.J. (2006). A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. Journal of Pain and Symptom Management, 31(1), 58-69.
22.
Teno, J.M., Clarridge, B.R., Casey, V., Welch, L.C., Wetle, T., Shield, R., et al. (2004). Family perspectives on end-of-life care at the last place of care. Journal of the American Medical Association, 291(1), 88-93.
23.
Thomas, J.R., & von Gunten, C.F. (2003). Management of dyspnea. Journal of Supportive Oncology, 1(1), 23-32.
24.
Ventafridda, V., Ripamonti, C., De Conno, F., Tamburini, M., & Cassileth, B.R. (1990). Symptom prevalence and control during cancer patients' last days of life. Journal of Palliative Care, 6(3), 7-11.
25.
Wilson, G.R., & Reisfield, G.M. (2003). Morphine hyperalgesia: A case report. American Journal of Hospice and Palliative Care, 20(6), 459-461.
