Pre-Active

• Withdrawal from active participation in social activities Increased and prolonged periods of sleep
• Hypersensitivity to stimulation (e.g. light, sound, touch)
• Decreased appetite and PO intake
• Increased restlessness, confusion, agitation

Active

• Circulation
  • Blood pressure goes down, heart rate faster, pulse weaker
  • Cold extremities, profound mottling of skin, cyanosis
• Fluids and metabolism
  • Inability to tolerate enteral nutrition
  • Decreased energy requirements
  • Notable decrease in urine and stool output, bowel or bladder incontinence
• Respiratory
  • Changes in breathing pattern
    • Cheyne-Stokes breathing
    • Agonal breathing
    • Prolonged periods of apnea
  • Inability to close mouth or constant breathing through mouth
  • Difficulty managing secretions, gurgling/noisy breathing (“death rattle”)
• Neurologic
  • Unresponsive or responsive only to significant stimulation
  • Limited purposeful movement
  • Decreased muscle tone
  • May experience a sudden unexplained surge of energy
  • “Terminal Agitation” severe multifactorial distress
    • Rule out other confounding variable:
      • Urinary retention, Constipation, Medication toxicity
  • Unable to speak despite appearing awake
• Senses
  • Hearing may remain intact until death
    • Be cognizant of what is said around patient
  • Vision is blurred