doctors--what is terminal agitation
 

My uncle just was diagosed as being in terminal agitation. His kidneys and other organs are failing for the last 6 months and he just declined a step. They gave him a sedative by injection. He will be 91 this Saturday. What does terminal agitation mean and how soon does death follow?

http://www.hospicepatients.org/terminal-agitation.html

http://www.hospiceworld.org/book/terminal-phase.htm

http://www.mywhatever.com/cifwriter/library/58/3404.html

cannot tell you when he will die...
he's close
what is it..
even thou he's dying..he getting 'active/restless'..
engine making noise before the final..cough.
Pt are medicated and thus comfy..
sorry about your Uncle..

Rika

thanks, i tried google and most sites are blocked from work

I could read the last one.

It's what I get at the airport....

Sorry to hear about your uncle. Here is the text of the first link:

Terminal Agitation: A Major Distressful Symptom in the Dying

Many families may be surprised when a terminally ill (and usually calm) family member becomes restless or even agitated. The depth of such restlessness or agitation varies from patient to patient. When moods change or personalities seem to change, family members may be completely bewildered and feel helpless: not knowing what to do. It is common knowledge that individuals who are experiencing even minor illnesses may demonstrate mood changes such as irritability, anger, depression and avoid communication with others. When a terminal illness not only initially strikes, but is now nearing the end, patients may experience profound mood changes. Such mood changes are often difficult for family members to "handle." Causes and treatments for restlessness and agitation are well-known among the palliative care professionals who work with the dying on a regular basis.
What is Terminal Restlessness or Agitation?

Those who work with the dying know this type of restlessness or agitation almost immediately. However, the public and patient's family may have no idea what is going on and often become quite alarmed at their loved one's condition. What does it look like? Although it varies somewhat in each patient, there are common themes that are seen over and over again.

Patients may be too weak to walk or stand, but they insist on getting up from the bed to the chair, or from the chair back to the bed. Whatever position they are in, they complain they are not comfortable and demand to change positions, even if pain is well managed. They may yell out using uncharacteristic language, sometimes angrily accusing others around them. They appear extremely agitated and may not be objective about their own condition. They may be hallucinating, having psychotic episodes and be totally "out of control." At these times, the patient's safety is seriously threatened.

Some patients may demand to go to the hospital emergency room, even though there is nothing that can be done for them there. Some patients may insist that the police be called ... that someone unseen is trying to harm them. Some patients may not recognize those around them, confusing them with other people. They may act as if they were living in the past, confronting an old enemy.
Need to Eliminate Other Obvious Causes of Distress

Just as in all symptoms, other causes must first be ruled out or eliminated. Nurses must make sure that the physician's orders are being followed, that if any other symptoms are not well managed, the physician is contacted or adjustments are made in order to relieve those symptoms. Physicians and nurses must continually re-assess the patient's total overall condition, monitoring every body system's function. Checking vital signs including pain levels is a first step. Is the patient breathing effectively? Is oxygen being given if appropriate for the patient's disease condition? Carefully evaluating, recording and reporting all outward signs must be habitual with those caring for the dying. Any changes must be understood, evaluated and responded to if appropriate.

For example, patients experiencing intense pain may become agitated. The initial thought to use sedatives immediately might make sense if one is not thinking clearly: "... the patient is agitated, I'll use a sedative..." However, that may be a very short-sighted and uneducated approach. Why? Because sedating the patient is not the first action to take. One must first determine what other causes might exist. When pain is severe, sedatives will not eliminate agitation! However, relieving the pain eliminates the agitation. On a more basic level, removing a hard object such as a syringe or catheter tubing that may have drifted underneath the patient may be all it takes to relieve the agitation. Common sense must first be applied!
Questions to be asked

The following are examples of questions that nurses and physicians ask themselves as they approach this problem:

* Is there anything physically interfering with the patient's comfort?
* Does the patient have pain that is not being well-managed? Observing outward facial expressions and body posture are important to evaluate.
* If the patient has a urinary catheter, is it "patent" (meaning open) and is urine flowing freely through it? If it is plugged, that could cause extreme pain from pressure in the bladder.
* Is the patient having regular bowel movements? When was the last bowel movement and what consistency did it have? Could the patient be impacted (blocked)?
* Is there some other sudden change in function that may be causing distress to the patient?
* Is there an infection causing the agitation?
* Is the infection an expected effect of the disease, such as brain cancer?
* Is the patient going through obvious psychological and emotional distress? Has a counselor or minister's services been offered to the patient and family? Is the restlessness purely psychological or is it metabolically based?
* Has a new medication been added? Has a medication dosage been recently increased or decreased? Is this a side-effect from a medication?
* Has the patient entered the pre-active phase of dying?

Universal Metabolic Changes May Cause Restlessness and Agitation

As the terminally ill near death, body organs and systems begin to fail to a greater and greater degree. Kidneys stop producing as much urine and function poorly, the liver and other organs also start to shut down. Waste products from the cells and tissues of the body begin to build up in the tissue spaces and blood stream. Biological and chemical balance is lost. The pH in the blood and other areas may change dramatically. In many patients, these changes alone may account for restlessness and agitation that may be quite severe.
Medications for Terminal Restlessness and Agitation

If, and only if, other obvious causes of restlessness and agitation have already been eliminated, then the physician may directly order medications to reduce the restlessness and agitation. In almost all cases, the physician will have written standing orders for certain medications to be given for these conditions. Such medications include anti-anxiety medications such as Lorazepam (Ativan) and Diazepam (Valium) and anti-psychotic medications such as Haloperidol (Haldol), Chlorpromazine HCl (Thorazine) and others.

The nurse and physician must be extremely careful not to give a medication that might be contraindicated for the patient's condition. It is not appropriate to give all patients Ativan and Morphine, for example, if they become agitated. It they are in pain, then pain medication is appropriate. If their pain is well-managed and they are still agitated, then the other medications may be applied. Certain disease conditions respond well to these medications while others have an opposite or no effect.

Palliative care professionals need to be reading the latest journal articles and research in order to understand when and when not to use these medications. Any nurse or physician who always uses these medications with all patients who are agitated has more to learn about handling these situations.

Palliative care varies according to the patient, the disease, the stage of the disease and the exact situation being encountered. Some believe that palliative care is less demanding than say, acute care in the hospital or intensive care. However, that is not the case. Excellent palliative care requires the same degree of professionalism as in other specialties in health care. Constant patient assessment and re-assessment are necessary.

Knowledge of the latest treatment modalities and options is a sign of the very best palliative care has to offer. Knowledgeable palliative care professionals will be most effective in managing crisis situations such as terminal agitation. If crisis symptoms are not being well handled by staff at the bedside, it is paramount that the physician be consulted about the best course of action to comfort the patient and relieve his or her distress. Terminal agitation is a hospice crisis and meets the criteria for starting the continuous nursing care level of care. (See Continuous Nursing Care in Hospice).

When my father experienced this last summer (not the airport kind), his passing happened about two weeks later. I would suspect that much has to do with the actual disease progression. He got to a point where he wanted to get out of bed and do all kinds of things he was unable to. Some of it was exacerbated by a lot of pain medication.
It was saddening.

I was going to make a joke about the term, but nevermind. Sorry about your uncle Steve.

My father also had this. Final stages of emphysema and he wanted to go home to die. Basically, the family watched him starve to death with a morphine drip. Once the morphine starts, no food can be safely swallowed. It really seemed like doctor assisted suicide. Not a time I like to dwell upon.

We had more of a hospice-assisted termination.
It worked.
I'm thankful to them.

he has 24 care at his home now, his children are with him
sounds like a few days

He has led a very productive life. He was full of vim and vigor.

My dad is last of three brothers. The first died two years ago at 87. All served during WW2, one in Army, one in Navy and this one in Africa with Pan Am.

The stories they told over the years were great.

Sorry to read about your uncle, Steve.

Steve, sorry about your uncle. My grandfather went through this "process" as he began dying. Dying isn't a single event, but the culmination of the entire process a body goes through. Talk to him, comfort him and let him know you're there. My grandfather was concerned about pain and being alone. We managed his pain and were always with him near the end and he made it through and had a peaceful death. It was the best we could do for him...

looking at grandma withering away at this time... 88 , broke her pelvis a month ago... grandpa left now close to 2 years, it's been down hill since, no longer able to live at home, nursing home, not accepting the situation... now the pelvis... weak heart and not really eating anymore...

She had a good long and healthy life, but there's no joy left, and who can blame her...
i was like the 6th kid there, grew up , it was the only real home i knew as a kid, since my parents are the kind that should never have made kids in the first place...

So all i care about now, is how to make it easier for her... whatever the cost... just suggested to the kids (my uncles and aunts), that maybe we could try and get her back into her home.. She never accepted leaving her place for the nursing home (there was no other choice she could not get the care she needed)... If she goes to the terminal care ward in the hospital, (paliatieve we call it, dunno what you call it in English)... there will be somebody from the family with her anyway, day and night... so maybe with home nursing... that might work too , and give her to peace of her own house...

it's a terrible thing this getting old stuff... i seldom feel bad when i hear about somebody crashing in a big ball of fire... one minute you have the time of your life, the next you're charcoal... There is no agonizing wait for death... no years of decline in fysical or mental faculties.. Not having to see yourself become an old person who can't even wipe his own ass , or even keep the crap from coming out till it's supposed to... i'll take the big ball of fire any time over that...

I'm sorry about your uncle Steve, but it sounds like he's lived a full life and ready for the "other side". My 88 yr. old grandmother passed a few weeks ago, and I saw the same in the emergency room a few hours before she passed on. My ex g/f was a hospice nurse, and she recounted the "restlessness" many times as her patients were in their final moments (could be hours or days). Be well, and think of the "good life" he lived...death is as natural as living.

Amazing how the mind knows when the end is near - I guess I would be pissed before I die as well.

he passed last night in his sleep. Best thing that has happened to him this year as his active mind was trapped in the decaying body

He was something. Even untill a few years ago, he and my dad would go fishing along Jensen Beach just to see the girls sunbathing.

thanks for the feedback.

Be well Steve...may your uncle RIP.

he's on the beach now..

the one on left..oh my..'I would so hit that '

Rika

I went through this with our grandmother who we were very very close with. She was driving until she was in her late 80s, was always healthy. Her brain never, ever failed. Even in the hospital close to the end, her memory was better than my mother's. But that last month, where she got the restlessness and everything, it was sad. It wasn't like her at all. Its strange when their passing is actually a good thing. But she was NOT happy with her life at that point- she had been independent up until the last month.

I am glad to hear that your uncle's pain isn't being drawn out any longer. He's in heaven, where the boobies are plentiful and all of our dogs are waiting for us.