CHPN Care at the Time of Death 1 — Questions and Answers
Question 1: Which physiological change is most indicative that death is imminent within hours?
- Elevated blood pressure above baseline
- Mottling extending to the knees and thighs (Correct answer)
- Increased urine output
- Hyperactive bowel sounds
Correct answer: Mottling extending to the knees and thighs
Mottling (livedo reticularis) extending from the extremities toward the trunk indicates severe circulatory failure and is a reliable sign that death is imminent within hours.
Question 2: The 'death rattle' heard in actively dying patients is primarily caused by:
- Aspiration of food or liquid
- Accumulation of secretions in the oropharynx that the patient can no longer clear (Correct answer)
- Bronchospasm from terminal asthma
- Pleural effusion compressing the lungs
Correct answer: Accumulation of secretions in the oropharynx that the patient can no longer clear
The death rattle results from pooled oropharyngeal secretions and relaxation of throat muscles that prevent the patient from clearing secretions through coughing or swallowing.
Question 3: Cheyne-Stokes respirations, commonly seen in the final days of life, are characterized by:
- Rapid, shallow breaths at a consistent rate
- Alternating periods of apnea and hyperpnea in a crescendo-decrescendo pattern (Correct answer)
- Deep, slow respirations with prolonged exhalation
- Labored breathing with audible stridor
Correct answer: Alternating periods of apnea and hyperpnea in a crescendo-decrescendo pattern
Cheyne-Stokes respirations follow a cyclical pattern of gradually increasing depth and rate followed by decreasing depth, then apnea, reflecting brainstem dysfunction and altered carbon dioxide sensitivity.
Question 4: A hospice patient's extremities are cool and cyanotic, with mottling, and respirations are irregular. The family asks how long the patient has to live. The most accurate response is:
- It is impossible to estimate timing of death in any patient
- The patient likely has weeks remaining
- These signs suggest death may occur within hours to a few days (Correct answer)
- The patient is not yet in the active dying phase
Correct answer: These signs suggest death may occur within hours to a few days
Cool, cyanotic extremities with mottling and irregular respirations are classic signs of the active dying phase, which typically precedes death by hours to a few days.
Question 5: Which of the following is considered a late sign of approaching death?
- Decreased appetite and oral intake
- Withdrawal from social interaction
- Mandibular breathing (jaw breathing) (Correct answer)
- Increased sleep duration
Correct answer: Mandibular breathing (jaw breathing)
Mandibular breathing, where only the jaw moves with each breath as chest wall muscles cease functioning, is a very late sign indicating death is typically minutes to hours away.
Question 6: A dying patient's blood pressure is unobtainable, pulse is weak and irregular, and extremities are mottled to the hips. Which term best describes this patient's status?
- Palliative care patient
- Actively dying (Correct answer)
- Terminally ill but stable
- Comfort care only
Correct answer: Actively dying
Unobtainable blood pressure, weak/irregular pulse, and mottling to the hips are hallmarks of the actively dying phase, indicating imminent death.
Question 7: Which change in urinary output is expected and normal in an actively dying hospice patient?
- Polyuria due to loss of ADH secretion
- Hematuria from coagulation failure
- Oliguria or anuria as perfusion to the kidneys decreases (Correct answer)
- Normal urinary output maintained until the moment of death
Correct answer: Oliguria or anuria as perfusion to the kidneys decreases
As cardiac output falls during the active dying phase, renal perfusion decreases dramatically, resulting in oliguria or anuria, which is an expected and normal physiological change.
CHPN Care at the Time of Death 1
Which physiological change is most indicative that death is imminent within hours?