Velocity of Changes in Condition as an Indicator of Approaching Death

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See https://nurse.2abraham.com/index.php/2023/04/27/velocity-of-changes-in-condition-as-an-indicator-of-approaching-death/ for the most up to date version of this story.

As a hospice nurse, it is essential to be able to recognize the signs that a patient is nearing the end of their life. One way to do this is by understanding the velocity of changes in their condition. This refers to how quickly their health status is deteriorating.

When a patient is closer to death, there is often a noticeable increase in the speed at which their condition changes. In this article, we will explore how hospice nurses can recognize and interpret the velocity of changes in a patient’s condition as an indicator that they may be approaching the end of their life.

What is the Velocity of Changes in Condition?

The velocity of changes in a patient’s condition refers to the rate at which their health is declining. This can include physical, mental, and emotional changes. In hospice care, it is common for patients to experience a gradual decline in their health over time. However, as they near the end of their life, this decline may become more rapid, and the velocity of changes may increase. This can be an important indicator for hospice nurses to pay attention to as it can signal that a patient is closer to death.

How to Recognize the Velocity of Changes in Condition

Recognizing the velocity of changes in a patient’s condition can take time and experience, but there are several signs that hospice nurses can look for:

  1. Frequent Changes in Vital Signs: As a patient’s health deteriorates, they may experience frequent changes in their vital signs, such as their blood pressure, heart rate, and breathing rate. Hospice nurses should monitor these vital signs regularly to detect any sudden or significant changes. In my experience, the most noticeable change is respiration patterns followed by heart rate. An example of this is having a patient whose respirations are at a regular rate within normal limits who starts having frequent episodes of hyperventilation where the cause cannot be identified as treatable anxiety.
  2. Decline in Functionality: A patient’s ability to perform daily tasks may decline rapidly as they near the end of their life. This can include difficulty with eating, walking, or even talking. Hospice nurses should assess their patient’s functionality regularly and communicate any changes to the interdisciplinary team. An example of this, especially if it is rapid, is a patient who goes from regular texture to mechanical soft to puree within a noticeably short span of time.
  3. Changes in Mental Status: As a patient’s health declines, they may experience changes in their mental status. This can include confusion, agitation, or restlessness. Hospice nurses should be aware of any changes in their patient’s mental status and communicate these changes to the interdisciplinary team.
  4. Increase in Symptoms: Patients may experience an increase in symptoms, such as pain, shortness of breath, or fatigue, as they near the end of their life. Hospice nurses should monitor their patient’s symptoms regularly and communicate any changes to the interdisciplinary team.
  5. Decrease in Response to Treatment: As a patient’s condition deteriorates, they may become less responsive to treatments, such as medications or interventions. Hospice nurses should monitor their patient’s response to treatment and communicate any changes to the interdisciplinary team. An example of this is a congestive heart failure patient who was responding to a given dose of diuretics who then needed increasing doses at more frequent intervals and approximately two weeks before passing, no amount of dosing or the addition of Metolazone helped with symptoms.

By monitoring these signs and symptoms, hospice nurses can get a sense of the velocity of changes in their patient’s condition and recognize when they may be approaching the end of their life. Regarding interpretation of the velocity, in the last month of life we would expect a moderate to significant change of condition once a week. In the last two weeks of life, we would expect a moderate to significant change of condition several times per week. In the last seven days of life, we are expecting moderate to significant changes of condition no less than every other day, possibly daily. In the last 48 hours of life, we are expecting changes of condition, and this is where we do include minimal to moderate to significant several times per day whereas if the changes become more frequent during the day were in the seconds to minutes to hours category

May I recommend that each of you nurses keep a journal that keeps track of moderate to major changes of condition by date that will not only assist you in recertification visits, but in determining the velocity of change?

Conclusion

Recognizing the velocity of changes in a patient’s condition can be an important indicator for hospice nurses that a patient may be approaching the end of their life. By monitoring their patient’s vital signs, functionality, mental status, symptoms, and response to treatment, hospice nurses can recognize the speed at which their condition is deteriorating. This information can be used to make informed decisions about the patient’s care and prepare them and their families for end-of-life care.

Resources

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Peter M. Abraham, BSN, RN

RN experience: cardiology, long-term care, rehab, rural home hospice. Find new articles at https://nurse.2abraham.com/