THE LAST HOURS OF LIVING

Marcus Smithers is a 70-year-old man with lung cancer diagnosed 6 months ago.
He had radiotherapy to a large mass at the time of diagnosis. He was relatively
well for two months when he developed thoracic back pain. This was secondary to
bone metastases and spinal cord compression. He received further radiation and
morphine for pain control. He is now on 280mg of sustained release morphine
every 12 hours with reasonable pain control. Other symptoms include anorexia and
cachexia, generalized weakness and mild dyspnea. You have followed him
regularly. He lives with his wife Janet in a 2-bedroom condominium. They have 4
married children – 2 sons and 2 daughters – and 6 grandchildren. One son lives in
Texas and the other children live nearby. Marcus worked for a small
manufacturing firm.
Janet who is 60 took early retirement from her civil service job when Marcus
developed cancer. The local home care program is involved and a PSW & nurses
visits twice a week.
Janet and Marcus have discussed the illness with you on multiple visits. He has
indicated that he would like to die at home. Janet calls you one morning.
“I am sorry to bother you. But, you said to call if I had any concerns. I am worried
about Marcus. The last couple of days, he’s been much sicker. He sleeps almost all
the time now. He hardly takes anything – no solid food and only little bits of water.
You told me not to worry about that. But, my son, John, you know the one who
lives in Texas, called and he thinks he should be on intravenous or something or be
sent to hospital so he doesn’t suffer to much. I was wondering if you could visit us
at home today?”

Marcus is a Christian (protestant). He has been a regular churchgoer since his

retirement. He always talks about his Pastor being one of his closest friends, and
when time comes, he will like his Pastor to be present not only to pray for his soul
but to support his wife and family.
Marcus has a written advance directive and on several occasions he has told you
that he wants nothing more done should he die.
Physical Examination
On arrival( 1:30pm), Marcus is lying in bed. He is very drowsy but can be woken
up. He speaks little but says he is not in pain. His oral membranes are quite dry and
his tissue turgor is poor. His blood pressure is 84/56 and he has a regular
tachycardia of 132/min. His respiratory rate is 18/minute with occasional briefs
periods of apnea. He is afebrile. He sounds congested and wheezy. He is quite
pale. His abdomen is normal.
Janet Smithers looks tired, but she seems to be coping so far.

1. What are the signs and symptoms of dying that Marcus is presenting ?
(1point)

2. Using the DAR Method, Document your findings.

(2 points)

Case Scenario Continue

You call your Coworkers who’s an RN and reported to the nurse that Marcus skin
is becoming mottled, and his extremities are cool at touch. And that Marcus is no
longer responding to his wife’s requests.
The nurse determines that Marcus is now in the final stages leading up death.

3. Document these changes using DAR method. (2 points)

A few hours later, there is change to Marcus breathing. He is now showing signs of
Cheyne- Stokes breathing. Janet begins to panic and becomes weepy. Janet insist
that she calls 911 and takes her husband to the hospital.
4. Document these Changes using DAR method. (2points)
Case Scenario Continue
Marcus took his last breath at 8:33pm.

5. Document these findings using DAR method. (2points)

You are now providing post-mortem care to Marcus.

6. How can you ensure you are still providing DIPPS for Marcus. List Specific
Actions. (2points)

7. What is Rigor mortis? What is the main goal for the PSW before Rigor
mortis sets in? (1point)

Post-mortem assignment will be marked in accordance.

1 point for Referencing the textbook

2 point for creativity, relevance, coherence and use of proper full sentences.
References:
University of Toronto and The Temmy Latner Centre For Palliative Care, Mount Sinai Hospital