Pain Management

Symptom Management
Common Symptoms:
Bowel Management
Nausea and Vomiting
Terminal Phase
Changing Awareness

Altered Elimination
Respiratory Changes
Agitation or Restlessness
Signs of Impending Death
Caregiver Support
The Terminal Phase of Illness

Four Signs of Impending Death
There are thought to be four signs of impending death that commonly occur in the following order and that are common to most patients. It is important to know these signs and teach the caregivers to understand them as well.

From the HPNA Core Curriculum, 2002:

The “death rattle” occurred before the other symptoms in 74% of patients, occurring approximately twenty-four hours or more before death.

Respirations with jaw movements or “fish out of water” breathing occurred next

Cyanosis of the extremities with or without mottling at the ankle or knee joints.

Finally, pulselessness of the radial artery.

The last three symptoms were observed during the final six hours of life, but this varied among the individual patients, and not all patients experienced the “death rattle.”