Wednesday, December 01, 2004

Symptomatology of Dying 4: Wavering LOC

As a review, some of the symptoms of dying that I have mentioned to some degree in previous posts include:

One to three months prior to death:
-Spiritual Distress

One to two weeks prior to death:
-Picking at Clothes / Tubing

Days or Hours prior to death:
-Fixed stare (Eyes glassy, tearing, half or fully open)
-Death rattle

Next, I want to write about wavering level of consciousness (LOC).

I have had a couple of patients who surprised me by appearing to have slipped into a coma for hours and hours, their breathing became irregular, but they'd then suddenly wake up and be alert and conversant.

Both of the patients I am thinking of in particular tonight had breast cancer that had metastasized to their brains. One of these women, Taneesha, was in her early 30's. The part of her brain that Taneesha's metastasizes was to involved her speech as well as her memory. She would recognize me when I came into her room, but she always thought she knew me from somewhere else.

"Hi Mia, this is my friend Andre," she'd introduce me to one of her visitors, reading my name off my badge. "Andre, this is Mia, she's my neighbor. Hey, I didn't know you worked here!"

I was not Taneesha's neighbor. I assume I looked familiar to her because she'd seen me several times over a period of two days as her nurse.

The next day, Taneesha was sleeping when I came onto shift. The nurse from the day shift reported she'd been sleeping for about 36 hours straight and was not expected to wake up again.

I began talking to Taneesha's mother about what to expect next. What symptoms might suggest that Taneesha was getting ready to leave her body. I sat down on the couch next to Taneesha's mom as we had this solemn and serious talk.

To my surprise, the next morning, as I walked into the room, Taneesha was wide awake and smiling at me.

"Well, what a lovely surprise to come in here and see that beautiful smile of yours!" I declared. Taneesha's face glowed even brighter.

Brain metastases seems to make some of the characteristic predictions of the natural order of death and dying more difficult to predict.

Jane also had breast cancer that had metastasized to her brain. Her partner Rachel never left her bedside. Jane's metastasize had caused considerable swelling in her brain referred to as cerebral edema. With nowhere for the swelling to go, there was increased pressure inside her skulll, referred to as Increased Cranial Pressure (ICP). Jane's primary symptom as a result of this was severe headaches, which would get worse if she moved. So she remained perfectly still in her bed. Rachel didn't want Jane to get "doped up" on too many pain medicines; she wasn't ready to let Jane go yet. But as time went on, Jane faded away more and more. She was sleeping for longer and longer periods of time even with minimal pain medicine. There is a medication that is used for cerebral edema called Mannitol. Though not commonly used in palliative care, Jane had been receiving it when she was in the ICU and thus Rachel was familiar with its purpose and effects and specifically asked for it by name. The doctors agreed to try it and sure enough, Jane woke up out of her evolving coma. And Jane and Rachel were able to enjoy a few more hours together.

Whether drug-induced or not, people at the end of life can slip in and out of an unarousable slumber. This is a very normal part of the dying process. Some palliative care experts, such as Christine Longaker, believe that the long periods of sleep are due to a need for introspection to help people come to terms with their life and how they've lived it, allowing them to let go of this life and to step forward into the unknown. This period of introspection, however, can be very hard for loved ones. They know that the increased sleep is one step closer to saying "goodbye."

1 comment:

dein said...

it is hard to have a family member who is in coma...:-(