Sunday, February 25, 2024

Signs Of Deterioration In Cancer Patients

Confusion Restlessness Or Agitation


Sometimes a person may become confused, restless or agitated. Your loved one may not know where they are or who is with them. Or they may fidget, or want to move about even if theyre not able to. You may want to reassure them by reminding them of who you are and what is going on around them.

They may describe speaking to someone who has died or they may see things that arent there. If theyre not upset, its fine to talk to them about what they can see or hear. Some people may be frightened staying near them, gently touching them and reassuring them may help. A calm room with quiet music and familiar items like photos nearby can also help.

It can be upsetting for you if your family member is confused or agitated. There could be different reasons for why it is happening, so speak to the doctor or nurse. They will look for anything that is causing it, like pain, problems with their bladder or bowels, or issues with their medicines. They may recommend giving medicine to relax and calm them. Or they may suggest putting in a catheter . This will stop the bladder getting full and causing discomfort. If you are worried that your family member may be in pain, the doctor or nurse can help with this.

Physical Changes As You Near The End Of Life

This is written for the person with cancer, but it can be helpful to the people who care for, love, and support someone with advanced cancer, too. This information may help you find answers to your questions and concerns during this very sensitive and difficult time.

These are some things a person may experience during the last stage of life, usually as death gets closer. It’s important to know that each person’s experience is different. Its not always normal to feel bad, and there are often things that can be done to help you feel better. We also give some tips on how to manage these symptoms.

Communication with the people who are helping to care for you is key. Be sure to check in and tell your health care team how you are doing. If it’s difficult or tiring for you to communicate, be sure your loved one or caregiver can help you to pass on information your health care team needs to know.

How You Might Feel

You are likely to feel some very strong emotions when your relative or friend is dying. You might feel that you want to try and change what is happening. All you can do is give them a lot of support and comfort during this difficult time.

You might need support and help yourself, when someone close to you is dying. It could help to speak to:

  • the doctor or nurses on the ward
  • a religious leader
  • close friends and relatives

Try not to worry that you are going to do something wrong. Being with your loved one and letting them know you love and care for them is the most important thing.

  • National Institute for Health and Clinical Excellence , 7 December 2016

  • On Death and DyingE Kubler-RossScribner, 2014

  • Early and late signs that precede dying among older persons in nursing homes: the multidisciplinary teams perspective

    H Åvik Persson and others

    BMC Geriatrics 18, 134

  • End-of-Life Care: Managing Common Symptoms

    R Albert

    American Family Physician, 2017 Mar 15 95:356-361

  • Tipping point: When patients stop eating and drinking in the last phase of their life

    D Blum and others

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Stage 4 Cancer Final Weeks

Its tough to know what to expect when ones life nears the end. Providing care at home instead of a hospital or hospice facility may entail additional obligations. In any case, the health care team will deliver the best care possible. They will also make the dying person as comfortable as possible.

Caring For Patients In The Last Days Of Life

Cutaneous lupus erythematosus mimicking radiation dermatitis in a ...

Many clinicians find themselves at a loss as to what to do when patients approachthis phase of their illness particularly if they have not been trained or exposed topalliative care. It is important, however, to be able to manage this phase of lifewell because a great deal of suffering can occur at this time, not only for thepatient, but also for those who love and care about the person who is dying. DameCicely Saunders, who was the founder of the modern hospice movement said, Howpeople die lives on in the memories of those who live on. Hence, all cliniciansshould feel a sense of obligation to their patients to ensure that beyond all theinterventions that have been exhausted, there will always be hope in a peaceful anddignified death.

In general, there are four key areas of concern when managing patients who areapproaching the last days of life. If clinicians are able to put these four keyareas into perspective at the time when patients are approaching their last days,this may help as a practical guide to better care at the end of life.

The four key areas of concern include:

  • Recognizing the dying phase
  • Communication with the patient, family and loved ones
  • Provision of symptom management
  • Ethical decision making.
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    A Number Of Physical Changes Are Common When The Patient Is Near Death

    Certain physical changes may occur in the patient at the end of life:

    • The patient may feel tired or weak.
    • The patient may pass less urine and it may be dark in color.
    • The patients hands and feet may become blotchy, cold, or blue. Caregivers can use blankets to keep the patient warm. Electric blankets or heating pads should not be used.
    • The heart rate may go up or down and become irregular.
    • Blood pressure usually goes down.
    • Breathing may become irregular, with very shallow breathing, short periods of not breathing, or deep, rapid breathing.

    However, these signs and changes don’t always occur in everyone. For this reason, it may be hard to know when a patient is near death.

    What To Expect When A Person With Cancer Is Nearing Death

    This information has been written for the caregiver, but many patients want this same information for themselves. It gives some signs that death may be close and gives the caregivers some ideas about ways they may be able to help.

    The signs of death being near can be different for each person. No one can really predict what may happen at the end of life, how long the final stage of life will last, or when death will actually happen. Sometimes death comes quickly due to an unexpected event or problem. Other times the dying process moves slowly and the patient seems to linger.

    If possible, its important to have a plan for what to do just following a death, so that the caregivers and other people who are with the patient know what to do during this very emotional time. If the patient is in hospice, the hospice nurse and social worker will help you. If the patient is not in hospice, talk with the doctor so that you will know exactly what to do at the time of death.

    Just like the timing of the dying process cannot be predicted, it’s also hard to predict what exactly will happen in the final stage of life and especially near death. The following symptoms are examples of what may happen in some people with cancer who are dying. While not all may happen, it may help you to know about them.

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    Center On Aging Care Sheets

    Recognition of approaching death is a critical skill required of all clinicians who provide care for patients at risk of dying. This skill enables the clinicians to consider a number of important issues. They include whether palliative care and hospice care are needed whether to hospitalize the patient or whether to perform cardiopulmonary resuscitation vs. allowing natural death.

    Identification of impending death also enables the clinician to inform the patient and family about the prognosis when this information is desired, allowing them to identify goals, priorities, and expectations for their future. It also allows individuals to address existential and spiritual issues as well as to prepare for the end of life.

    While there is no precise method for determining prognosis, most healthcare workers tend to be overly optimistic about prognosis. This over-optimism can generate false hope and deprive patients and families of the opportunity to use their remaining time in ways that would be most meaningful to them. The online tool ePrognosis can facilitate the clinical application of prognostic indices and improve decision-making.


    Patients May Not Want To Eat Or Drink In The Final Days Or Hours

    3 Soft signs of deterioration

    In the final days to hours of life, patients often lose the desire to eat or drink, and may not want food and fluids that are offered to them. The family may give ice chips or swab the mouth and lips to keep them moist. Food and fluids should not be forced on the patient. This can make the patient uncomfortable or cause choking.

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    Possible Changes In Consciousness

    • More sleeping during the day
    • Hard to wake or rouse from sleep
    • Confusion about time, place, or people
    • Restless, might pick or pull at bed linen
    • May talk about things unrelated to the events or people present
    • May have more anxiety, restlessness, fear, and loneliness at night
    • After a period of sleepiness and confusion, may have a short time when they are mentally clear before going back into semi-consciousness

    Care Decisions In The Final Weeks Days And Hours Of Life

    In This Section
    • Receipt of cancer-directed therapy in the last month of life .
    • Total number of admissions to the pediatric ICU .

    Pediatric care providers may want to consider the factors listed above to identify patients at higher risk of dying in an intensive inpatient setting, and to initiate early conversations about goals of care and preferred place of death.

  • Earle CC, Neville BA, Landrum MB, et al.: Trends in the aggressiveness of cancer care near the end of life. J Clin Oncol 22 : 315-21, 2004.
  • Setoguchi S, Earle CC, Glynn R, et al.: Comparison of prospective and retrospective indicators of the quality of end-of-life cancer care. J Clin Oncol 26 : 5671-8, 2008.
  • Ho TH, Barbera L, Saskin R, et al.: Trends in the aggressiveness of end-of-life cancer care in the universal health care system of Ontario, Canada. J Clin Oncol 29 : 1587-91, 2011.
  • Fang P, Jagsi R, He W, et al.: Rising and Falling Trends in the Use of Chemotherapy and Targeted Therapy Near the End of Life in Older Patients With Cancer. J Clin Oncol 37 : 1721-1731, 2019.
  • Johnson LA, Ellis C: Chemotherapy in the Last 30 Days and 14 Days of Life in African Americans With Lung Cancer. Am J Hosp Palliat Care 38 : 927-931, 2021.
  • Wright AA, Zhang B, Ray A, et al.: Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 300 : 1665-73, 2008.
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    No Further Escalation Of Care

    Patients with advanced cancer are often unprepared for a decline in health status near the end of life and, as a consequence, they are admitted to the hospital for more aggressive treatments. This complicates EOL decision making because the treatments may prolong life, or at least are perceived as accomplishing that goal. At that point, patients or families may express ambivalence or be reluctant to withdraw treatments rather than withhold them.

    Conversely, some situations may warrant exploring with the patient and/or family a time-limited trial of intensive medical treatments. The patient or surrogates may choose to withdraw all LST if there is no improvement during the limited trial. From an ethical standpoint, withdrawing treatment is equivalent to withholding such treatment. Both actions are justified for unwarranted or unwanted intensive care.

    Anticipating The End Of Life

    Chapter 1
    In This Section

    For more information, see the Symptoms During the Final Months, Weeks, and Days of Life section.

    Encouraging family members who desire to do something to participate in the care of the patient may be helpful. In the final days to hours of life, patients often have limited, transitory moments of lucidity. Family members should be prepared for this and educated that this is a natural aspect of the dying process and not necessarily a result of medications being administered for symptoms or a sign that the patient is doing better than predicted. Despite their limited ability to interact, patients may be aware of the presence of others thus, loved ones can be encouraged to speak to the patient as if he or she can hear them.

    For patients who die in the hospital, clinicians need to be prepared to inquire about the familys desire for an autopsy, offering reassurance that the body will be treated with respect and that open-casket services are still possible, if desired.

  • Lorenz K, Lynn J, Dy S, et al.: Cancer care quality measures: symptoms and end-of-life care. Evid Rep Technol Assess : 1-77, 2006.
  • Lamont EB, Christakis NA: Prognostic disclosure to patients with cancer near the end of life. Ann Intern Med 134 : 1096-105, 2001.
  • Hui D, Kilgore K, Nguyen L, et al.: The accuracy of probabilistic versus temporal clinician prediction of survival for patients with advanced cancer: a preliminary report. Oncologist 16 : 1642-8, 2011.
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    When Is A Patient At The End Of Life And What Is End

    Clinicians, researchers and healthcare policy makers often try to compartmentalizecare into neat definitions with clear-cut time frames so as to identify needs anddefine roles. However, with end-of-life care , is there a time frame to definewhen this should occur? At present, there is no consensus on the definition or timeframe for the end of life. Generally, many consider end of life to be the last fewdays to 12 weeks of life. In the UK, the General Medical Council guidancerefers to patients approaching the end of life when they are likely to die withinthe next 12 months . In the USA, Medicare defines the needfor hospice care at the end of life as the last 6 months of life . Many of the definitions using a time frame arebased on the survival duration of a patient however, survival is something that cannever be predicted with great accuracy and is really a retrospective outcome. Hence,if a clinician were to use such definitions to identify patients requiring EOLC theywould need a crystal ball or a clairvoyant in order to ensure the right patientreceived appropriate care. Therefore, when we focus on a rigid definition, using themodel of dichotomous intent , many patients requiring EOLC will be missed and a lot of physical,psychosocial and spiritual needs unmet.

    Model of dichotomous intent.

    Integrated curativepalliative model.

  • Pain and symptom management: requires attention to the physicaldistress caused by the illness at the end of life
  • Signs Of Dying From Cancer

    Cancer is one of the leading causes of death in the United States. Although mortality rates are dropping, cancer is common enough that most people in the United States know someone who has had cancer in their lifetime.

    However, not as much is known about the end-of-life signs of cancer, and what one should expect at the end. Furthermore, many are unaware of the ways in which hospice can help patients in dealing with the stages of death from cancer.

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    The Dying Person And Intractable Suffering

    In This Section
    • Conclude the discussion with a summary and a plan.
  • Ruijs CD, Kerkhof AJ, van der Wal G, et al.: Symptoms, unbearability and the nature of suffering in terminal cancer patients dying at home: a prospective primary care study. BMC Fam Pract 14: 201, 2013.
  • Williams AL, McCorkle R: Cancer family caregivers during the palliative, hospice, and bereavement phases: a review of the descriptive psychosocial literature. Palliat Support Care 9 : 315-25, 2011.
  • Meeker MA, Waldrop DP, Schneider J, et al.: Contending with advanced illness: patient and caregiver perspectives. J Pain Symptom Manage 47 : 887-95, 2014.
  • Hebert RS, Arnold RM, Schulz R: Improving well-being in caregivers of terminally ill patients. Making the case for patient suffering as a focus for intervention research. J Pain Symptom Manage 34 : 539-46, 2007.
  • Maltoni M, Scarpi E, Rosati M, et al.: Palliative sedation in end-of-life care and survival: a systematic review. J Clin Oncol 30 : 1378-83, 2012.
  • George R: Suffering and healing–our core business. Palliat Med 23 : 385-7, 2009.
  • Elsayem A, Curry Iii E, Boohene J, et al.: Use of palliative sedation for intractable symptoms in the palliative care unit of a comprehensive cancer center. Support Care Cancer 17 : 53-9, 2009.
  • Putman MS, Yoon JD, Rasinski KA, et al.: Intentional sedation to unconsciousness at the end of life: findings from a national physician survey. J Pain Symptom Manage 46 : 326-34, 2013.
  • When Is The Right Time To Use Hospice Care

    Deteriorating Patient Condition

    Many people believe that hospice care is only appropriate in the last days or weeks of life. Yet Medicare states that it can be used as much as 6 months before death is anticipated. And those who have lost loved ones say that they wish they had called in hospice care sooner.

    Research has shown that patients and families who use hospice services report a higher quality of life than those who dont. Hospice care offers many helpful services, including medical care, counseling, and respite care. People usually qualify for hospice when their doctor signs a statement saying that patients with their type and stage of disease, on average, arent likely to survive beyond 6 months. More information about hospice can be found below in the Related Resources section of this fact sheet.

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    How To Cope In The Final Hours

    In the hours before a person dies, their organs shut down and their body stops working. At this time, they may want their loved ones to be around them.

    A person caring for a dying loved one in their last hours should make them feel as comfortable as they can.

    It is a good idea to keep talking to a dying person right up until they pass away. They can often still hear what is going on around them.

    If a dying person is attached to a heart rate monitor, those around them will be able to see when their heart has stopped working, meaning that they have died.

    Other signs of death include:

    4 sourcescollapsed

    • Hui, D., Dos Santos, R., Chisholm, G., Bansal, S., Souza Crovador, C., & Bruera, E. . Bedside clinical signs associated with impending death in patients with advanced cancer: Preliminary findings of a prospective, longitudinal cohort study. Cancer, 121, 960967

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