Interviewing and Observation as part of the assessment

There are observation and interviewing skills you can develop which will help you learn:

• What could cause the current change of condition
• Determining if a patient is having terminal restlessness
• Determining if your patient is within two weeks or less of life to live
• Knowing where your patient is in the dying process

While this article is primarily meant for new nurses, what I’m sharing is also valuable for family members and loved ones as these skills can be honed and developed by anyone with patience and love towards the person being observed and interviewed.

Observation Key Areas

Let us remember our “skin” is the largest organ of our body. As such, when we are sick, the skin is often the first area to change.

• Complexion — ashen, pale/pallor, waxy/glossy looking — all of these are signs that the patient is having a condition change.
• Eyes — is the patient looking at you when you address and talk with them or looking through or past you? Are they seeing beings, objects, and people not present in the room? All of these are indications the patient is having a change of mental status.
• Mottling — red to purple, marbling/splotchy areas that are often first found on the patient’s feet and legs can indicate the person is within days or less of dying.
• Is the patient lethargic — tired on steroids where the patient tries to stay wake, but can barely keep their eyes open, talk (may or may not have slurred speech), etc.
• Is your patient non-responsive?

All the above can indicate the patient is within two weeks or less of life to live.

Interview Key Areas

It is helpful to interview the patient and their loved ones, and any staff (if at a facility). Your goal is to flesh out the following areas:

• Has the patient had any forms of restlessness such as fidgeting, frequent position changes, picking at things not present, appearing to play or interact with objects not present, scratching into their skin without realizing it or other signs of being anxious. This is to flesh out if a patient is having terminal restlessness.
• To what degree are they having trouble with the current texture of their food and liquids? Here you are looking for two things, a medium change where maybe their textures (food and liquid) need to be downgraded for protection against aspiration pneumonia and choking or a notable change such as being told food and liquids are just rolling out of their mouth which is a major indicator for if your patient is within two weeks or less of life to live.
• Is the patient having periods of severe sweating (diaphoresis), acting, or complaining they are too hot or too cold without regard to the actual temperature in the home especially if everyone else is comfortable?
• What has the flow of urine been like? Steady, slowing, almost non-existent and then a splurge out of nowhere? The latter is typically a sign the body is getting ready to give out as in my experience this is a sign of cleansing.
• Has the patient had increasing periods of intractable nausea with emesis and/or loose stools? This can create electrolyte balances pushing the patient faster towards end of life.
• Has the patient had increased periods of confusion including hallucinations? Do any of the hallucinations include people the patient knew that have since died? The latter is a spirit-based sign the patient may be within the last two weeks to one month of life.
• Has the patient had a burst of energy appearing out of nowhere? This can look like being up earlier to eat, eating beyond 100% more than normal, awake far more than normal, and other indicators that make people around the patient question if they are not terminal (i.e. they are having a rally)?
• How fast have the downward changes been taking place? I.e. one medium to major change every four to six weeks? One medium to major change every two to four weeks? One medium to major change per week? Multiple changes per day or week? The more frequent the changes, especially in the last two questions, lead to your patient is within two weeks or less of life to live.

OTHER

Key highlights from the book, Gone from my sight: The Dying Experience by well-known and expert Barbara Karnes, RN:

One to Three Months Before Death

• Withdrawal from the world and people
• Decreased food intake
• Increase in sleep
• Going inside self
• Less communication

One to Two Weeks Before Death

MENTAL CHANGES

• Disorientation
• Agitation
• Restlessness
• Picking at clothes
• Confusion
• Talking with the unseen

PHYSICAL CHANGES

• Decreased blood pressure
• Pulse increase or decrease
• Skin color changes: pale, bluish
• Increased perspiration (clammy)
• Respiration irregularities
• Congestion
• Sleeping but responding
• Complaints of the body being tired and feeling heavy
• Not eating, taking little fluid
• Body temperature: hot, cold
• Decreased urine production — urine becomes tea-colored
• Urine and/or bowel incontinence (writer note — it is common for there to be a release of urine more than anticipated and often stool if even a smear of feces hours to a day or two before death; I view this as the body preparing itself and cleansing itself for death).

Days or Hours to Death

• Intensification of one to two weeks’ signs
• A surge of energy (“Rally”)
• Decrease in blood pressure
• Eyes glassy, tearing, half-open
• Irregular breathing: stop, start (Cheyenne Stokes or Agonal)
• Death Rattle breathing
• Restlessness or no activity
• Purplish, blotchy knees, feet, hands (mottling)
• Pulse week and hard to find
• Decreased urine output
• May wet or stool the bed

Minutes to Death

• “Fish out of water” breathing (Gasping breathing)
• Cannot be awakened