Physiology of dying

This chapter discusses the physiological changes that occur in the last weeks and days of life, and how this understanding can help in providing better care for patients and families. Starting in the last months of life with an accelerating course in the last several weeks, patients with advanced illnesses typically develop a characteristic decline in their physical function, nutritional status, respiratory function, and cognition as a result of progressive cancer and acute symptomatic complications. These changes correspond with worsening performance status, anorexia-cachexia, breathlessness, and delirium, which are prognostic factors in patients with advanced illnesses. In the last days of life, other physiological changes involving the neurological, neuromuscular, cardiovascular, and respiratory systems become apparent. The presence of telltale signs such as non-reactive pupils, Cheyne–Stokes breathing, inability to close eyelids, grunting of vocal cords, respiration with mandibular movement, death rattle, drooping of nasolabial fold, pulselessness of radial artery, hyperextension of neck, and decreased urine output significantly increase the likelihood of impending death within 3 days, although the absence of these signs cannot rule out impending death. Physiological monitoring such as vital signs, phase angle, cardiac electrophysiology, and bispectral index may provide further insights into the dying process.

Clinical Practice Guideline for End-of-Life Care in Patients with Cancer: A Modified ADAPTE Process

PurposeThis study seeks to adapt a guideline for end-of-life care in patients with cancer to be used by healthcare teams.MethodsThis methodological study was conducted by modifying the ADAPTE process and adding to it a qualitative study and consensus ratings by a multidisciplinary panel of experts. A qualitative study was thus performed to identify the end-of-life needs of patients with cancer. Then, the source guidelines and the results of the qualitative study were used to draft the initial version of the guideline, with 85 adaptation recommendations. A multidisciplinary panel of healthcare experts performed the external review of the recommendations based on the four criteria of relatedness, comprehensibility, usefulness, and feasibility and scored them on a scale of 1-9. The mean score of each recommendation was calculated, and the recommendations were classified into three categories: Appropriate (mean score of 7-9), uncertain (mean score of 4-6.99), and inappropriate (mean score of 1-3.99).ResultsAll the recommendations were approved, as they all had a mean score of 7 or higher, and were then categorized into 11 dimensions: Communication management; participatory and evidence-based decision-making management; pain management; dyspnea management; nausea and vomiting management; anorexia and cachexia management; constipation management; death rattle management; management of delirium, anxiety, and restlessness; hydration management; and pharmacological considerations.ConclusionThe adaptation of the guideline for end-of-life care in patients with cancer in Iran was performed by modifying the ADAPTE process with the participation of multidisciplinary stakeholders and based on the local needs.

Featural dynamics in morphosyntactic change

This chapter examines Icelandic Dative Substitution (DS) and argues that two of its diachronic side effects, referred to as Person-Specific Retention and an Elsewhere Condition Death Rattle, are explained by the way in which formal features constrain the trajectory of morphosyntactic change. The study is based on naturally occurring data and a recent language acquisition experiment and the analysis draws on weighted grammatical rules as well as Yang’s Tolerance Principle. It is argued that DS does not necessarily involve a change in the syntax, but should rather be viewed as a change in the interpretation of syntactic information at the interface with morphology, resulting in variability on the surface. The results are analyzed in the context of recent theories on specialization in linguistic change and the dynamics of variation in individuals.

Palliative care physicians’ perspectives of management for terminally ill cancer patients with death rattle: a nationwide survey

Death rattle occurs during the last days of life, and relatives of those afflicted frequently report that it is very distressful. However, there is no effective treatment for it. The purpose of this study was to investigate the perceptions of Japanese palliative care physicians in clinical practice in Japan. We conducted a nationwide survey of 268 physicians via an anonymous, self-report questionnaire. We assessed pharmacological and non-pharmacological management and anticholinergic agent choice. One hundred eighty-nine physicians (70.5%) returned the questionnaires. Fifty-five participants (29.1%) treating patients with Type-1 (real death rattle) and 36 participants (19%) treating patients with Type-2 (pseudo-death rattle) death rattle reported that they would frequently administer an anticholinergic agent. One-fourth would administer scopolamine butylbromide or scopolamine hydrobromide. In conclusion, more Japanese palliative care physicians thought that anticholinergic agents might be effective for treating Type-1 death rattle rather than Type-2. Further clinical trials of these agents are needed.