DYING MINDS PAL CARE the ins and outs .pptx

Palliative care: brief intro

1. DYING MINDS DYING MINDS

2. DYING MINDS : OVERVIEW Definition: Study of cognitive and perceptual experiences as death approaches Key areas of focus: Twilight states Terminal lucidity ("lightening before death") Last words Near-death experiences Terminal restlessness

3. Importance of Understanding End-of-Life Experiences

4. ANTICIPATING DYING In patients with irreversible terminal illness, cardiopulmonary resuscitation may prolong, but cannot reverse, the dying process; however, the ineffectiveness of this intervention is often not well understood by patients and their family members. The default care plan that should be presented is to ensure comfort, support for the patient and their family, and vigorous relief of distressing symptoms as the patient is dying. If the patient and/ or their family have the desire or expectation that intensive resuscitative steps be taken (which may include intubation, dialysis, or cardiopulmonary resuscitation), this must be discussed, and an understanding reached in advance of critical deterioration. These conversations are often difficult for medical staff, patients, and family members since they bring focus on the fact that death is close and, consequently, they are frequently avoided until the days just before death. However, these discussions have not been found to change patient or surrogate satisfaction with the clinician. The conversation should focus on what can and will be done for the patient and family as death approaches , emphasizing the critical issues of dignity, comfort, and the relief of distress. These conversations require sensitivity and empathy, allowing time to deal with the questions, concerns, and sometimes strong emotions generated by confronting these issues (Lacey and Sanderson, 2010).

5.     TWILIGHT STATES

6. WHAT IS TWILIGHT STATE The brain undergoes a gradual decline in neuronal activity and function during the dying process [1][2] This constitutes a "first twilight zone" where consciousness is likely lost before complete brain activity suppression [1][2] A "second twilight zone" occurs after the "wave of death", where the brain's outcome becomes uncertain again [1][2] Fenwick P, Brayne S. End-of-life experiences: Reaching out for compassion, communication, and connection. Am J Hosp Palliat Care. 2011;28(1):7-15. 1 Borjigin J, Lee U, Liu T, Pal D, Huff S, Klarr D, et al. Surge of neurophysiological coherence and connectivity in the dying brain. Proc Natl Acad Sci U S A. 2013;110(35):14432-7. 2  Rouleau N, Murugan NJ, Tessaro LWE, Crawley JN, Persinger MA. When is the brain dead? Living-like electrophysiological responses and photon emissions from applications of neurotransmitters in fixed post-mortem human brains. PLoS One. 2016;11(12):e0167231.

7. CHARACTERISTICS OF TWILIGHT STATES Altered consciousness: Fluctuating levels of awareness Periods of lucidity alternating with confusion Difficulty distinguishing between reality and dreams Sensory changes: Visual hallucinations (e.g., seeing deceased relatives, spiritual figures) Auditory hallucinations (hearing voices or music) Tactile sensations (feeling touched or held) Temporal distortions: Altered perception of time (time seeming to slow down or speed up) Mixing of past and present experiences Symbolic language: Use of metaphors related to journeys or transitions References to preparing for departure

8. Heightened emotions: Intense feelings of joy, peace, or love Occasional fear or anxiety Spiritual or transcendent experiences: Sense of connection to a higher power or universal consciousness Feelings of leaving the body or floating Life review: Rapid recall of significant life events Evaluation of one's life and choices Changes in physical needs: Decreased interest in food and drink Altered sleep-wake cycles Increased energy or alertness: Unexpected periods of clarity or energy, often followed by decline Synchronistic events: Seemingly meaningful coincidences Perception of signs or omens

9. Communication with the unseen: Conversations with invisible presences​ Receiving messages or instruction  Physiological changes: Changes in breathing patterns Fluctuations in body temperature Mottling of skin (cutis marmorata) Heightened sensitivity: Increased sensitivity to light, sound, or touch Strong reactions to certain people or objects Sense of impending departure: Expressions of readiness to "go" or "leave" Saying goodbye to loved ones

10. Between alertness and coma are a variety of altered states of consciousness STUPOR :  state of unresponsiveness from which patient may be aroused by vigrous and repeated stimuli     In palliative medicine it is usually a condition which progresses to coma. The moments of lightened awareness lessen, and responsiveness fades. 

11. PERSISTENT VEGETATIVE STATE (PVS)   PVS after severe brain injury consists of wakefulness without awareness.  The eyes open spontaneously in response to verbal stimuli, the sleep–wake cycle exists and autonomic functions are maintained.  No motor or comprehensible verbal output is possible.  The minimal conscious state refers to a similar clinical state in which some semblance of response occurs.  Slow visual tracking gives the appearance of communicating, though this is not able to be sustained.  In the locked- in syndrome, consciousness is preserved but there is an almost complete inability to respond, only eye movements and blinking being preserved.

12. LIGHTENING BEFORE DEATH Halford wrote in 1842 this clinical description of ‘lightening up before death’. This phenomenon is occasionally noted in palliative care units (particularly by nursing staff ). However, this may be less frequent in modern practice because of the increased use of sedatives. It is often associated with delirium, it is a mortal sign and its occurrence seems impossible to predict. Reduced need for analgesic medications and the short burst of increased vitality immediately before death has been reported, and probably refers to the same clinical event.

13. Some people report experiencing a sudden flash of light or lightning-like phenomenon shortly before death * This may be related to a surge of neuronal activity in the brain as it begins to shut down * The exact cause and significance of this phenomenon is still not fully understood The "wave of death" is a characteristic cortical event that marks the complete suppression of brain activity and the entry into the "second twilight zone" - In this phase, the brain's outcome becomes uncertain again, as there is no clear "point of no return" identifiable after the wave of death - A successful resuscitation attempt can trigger the "wave of resuscitation", which signals the recovery of normal brain activity, but the risk of disabling brain sequelae remains

14. HUGHLING JACKSON THEORY

15. NEAR DEATH EXPERIENCES Apparently when dying, or near to death, enhanced perception to light and cognitive powers occur. There are varying reports of types and intensity of lights.  Typical symptom clusters in NDEs :          1. Enhanced speed and clarity of thought and memory,          2. Positive emotions           3. A belief in having left the body and seeing it from above  Th e theories proposed to account for this phenomenon are transcendental, psychological and physiological (and combinations of these). Hypoxia must be a component of the cause. Hughlings Jackson’s concept of hierarchical dissolution of the damaged nervous system and compensatory positive symptoms would appear consistent with the experiences  detailed.

16. Psychological reactions following surviving the near- fatal event must influence how the experience is recalled and processed. Mystical and religious  interpretations are likely to be also relevant. The relationship of NDE and ‘lightening before death’ may be that they are variants of the same process Many people who have been resuscitated from clinical death report vivid experiences and sensations * These may include feelings of peace, out-of-body experiences, and encounters with deceased loved ones * The neurological mechanisms behind near-death experiences are still being investigated. Near-death experiences (NDEs) are powerful, mystical experiences reported by some individuals who have undergone life-threatening events - NDEs often involve common elements such as out-of-body experiences, encountering a bright light, meeting deceased loved ones, and a sense of peace and oneness - While the physiological mechanisms behind NDEs are not fully understood, they appear to be remembered with greater vividness and detail than real or imagined events

17. LAST WORDS It is reported that 30% of patients are alert until moments before death. The very high incidence rates of terminal delirium, coma and medicinal sedation preceding death may suggest this figure is generous.  recent observation reported only 8% awake just prior to death. Notable actual deathbed speeches      are probably rare. ‘Kiss me Hardy’- type exclamations may be, more commonly than not,      mythological.  A quoted medical informant in 1961 claimed to have attended 500 deaths without having heard a single memorable utterance. In the ancient world, before death had been medicalised , such events were described and documented.

18. Some Buddhist traditions hope for full lucidity and awareness at the moment of death as an important component of a satisfactory reincarnation. The Roman Catholic last rite provides a final opportunity to be forgiven for sins committed, and presumes clarity and presence of mind. In its endeavour to relieve the suffering of dying, palliative care may also be altering some of nature’s kind tricks. People's final words or utterances before death can provide insight into their mental state and experiences * Some report coherent, meaningful last words, while others exhibit delirium or confusion * The content and nature of last words is highly variable and can depend on the circumstances of death

19. Common themes and phrases that often emerge as people's last words before death: Expressing Love and Forgiveness Many people use their final moments to express love for their family and friends, or to seek forgiveness. Some common phrases include: "I want to tell you that I love you. "Would you tell me that you love me? "I want to tell you that I forgive you. "Would you give me your forgiveness?

20. Confusion and Delirium Terminal restlessness and delirium are common in the final stages of life for many patients. This can lead to incoherent or confused last words: A patient said "I'm going to die. I know I'm going to die." before passing away shortly after surgery. A nurse heard a patient talking to herself and having conversations with deceased loved ones before she coded.

21. Acceptance and Peacefulness Some people facing death express a sense of acceptance, peace, or even a desire to reunite with deceased loved ones: - A woman regained clarity in her final moments and said "I found Jack," referring to her deceased husband, before passing away. - A hospice patient shared that living was the hard part and dying was much harder than living. - A hospice chaplain shared an experience with a spiritual, non-religious man who saw his deceased brother and his sister Death in the room. He was at peace and died a few days later.

22. Concern for Loved Ones Worrying about loved ones left behind is a common theme in people's last words: - A patient begged a nurse not to let him die, fearing he would leave his daughter alone[2]. - A patient asked a nurse to tell him it was okay to die and find peace, and he passed away shortly after[2].

23. Famous last words and their significance: 1.I am about to -- or I am going to -- die; either expression is correct." - Attributed to French emperor Napoleon Bonaparte, these were reportedly his last words, spoken to his valet as he was dying of stomach cancer in 1821. - Napoleon's last words reflect his pragmatic acceptance of his impending death and his desire to ensure his final utterance was grammatically correct, even in his final moments. 2."I should never have switched from Scotch to Martinis." - Allegedly the last words of actor Humphrey Bogart, spoken to his wife Lauren Bacall in 1957. - Bogart's quip pokes fun at his own drinking habits and suggests he recognized the role alcohol may have played in his esophageal cancer, which ultimately caused his death at age 57.

24. 3."Goodnight my darlings, I'll see you tomorrow." - Reportedly the last words of actress Carrie Fisher in 2016, spoken to her beloved French bulldog Gary.  - Fisher's affectionate farewell to her dog poignantly captures her warm personality and the deep bond she shared with her animal companion, even as she faced her own mortality. 4. "I've had a hell of a lot of fun and I've enjoyed every minute of it." - The last words of actor Errol Flynn in 1959, reflecting on his life and career. - Flynn's unapologetic embrace of life's pleasures and his refusal to dwell on regrets as he faced death at age 50 exemplify a certain devil-may-care Hollywood glamour. 5. "I'm bored with it all." - Allegedly the last words of British Prime Minister William Ewart Gladstone in 1898. - Gladstone's reported final utterance, if true, suggests a certain weariness with the burdens of public life and a longing for the peace of death, though its brevity leaves room for interpretation.

25. How famous last words can reflect cultural attitudes towards death: "Last words as recorded in public documents are often reflections of the social attitude toward death at the time, rather than reports of actual statements." In some cultures, there are specific customs and rituals around death, such as the Filipino practice of cutting a rosary placed in the hands of the deceased.  These cultural practices reflect beliefs about the transition from life to death and honoring the deceased. The examples of famous last words, such as Bogart's quip about switching from Scotch to Martinis or Gladstone's reported weariness, "suggest a certain weariness with the burdens of public life and a longing for the peace of death." [2] These last words provide insight into the individual's personality, values, and state of mind in their final moments. The Western cultural perspective on euthanasia emphasizes individual autonomy and dignity, but a deeper analysis reveals the influence of "family dynamics, social pressures, and communal values" in end-of-life decision making.

26. Impact of last words on grieving process

27. Providing Closure and Comfort  - For some, hearing a final message or farewell from a dying loved one can provide a sense of closure and comfort in the grieving process. Knowing their last words can help loved ones feel a connection to the deceased. Reflecting on the Person's Life and Values - The nature of a person's last words can shed light on their personality, values, and what was most important to them. Reflecting on these final utterances can help the bereaved gain insight into their loved one's life and find meaning in their death. Fueling Speculation and Unresolved Questions - When last words are unclear, unrecorded, or contradictory to how the person lived, it can leave loved ones with unanswered questions and make the grieving process more difficult. Speculation about what was really meant can prolong grief. Reinforcing Cultural Attitudes Towards Death - The way a person faces death, as reflected in their last words, can reinforce cultural beliefs and expectations around mortality. This can shape how the bereaved process the loss within their cultural context.  Providing a Lasting Legacy - For famous individuals, their reported last words can become part of their enduring legacy and how they are remembered. This can be a source of comfort for fans and loved ones alike.

28. Role of last words in shaping the narrative and legacy of persons life

29. ## Reflecting Core Values and Personality - A person's final utterances often reveal their core values, beliefs, and personality. Famous last words like Archimedes' "Do not disturb my circles!" or Jesus' "It is finished" provide insight into what was most important to them. ## Demonstrating Deathbed Redemption  - In Western culture, there is particular attention paid to last words that demonstrate "deathbed salvation" - the repentance of sins and affirmation of faith. This shapes the narrative of the person's life journey. ## Capturing Defining Moments - Last words can encapsulate a defining moment or struggle in a person's life. For example, Eric Garner's repeated "I can't breathe" captured the tragedy of his death and became a rallying cry for the Black Lives Matter movement. ## Shaping Posthumous Reputation - The way a person faces death, as reflected in their last words, can shape how they are remembered and the narrative of their life. Famous last words that are seen as brave, defiant, or redemptive can enhance a person's posthumous reputation. ## Revealing Cultural Attitudes - As recorded in public documents, last words often reflect the social attitudes toward death at the time, rather than actual statements. This provides insight into the cultural context that shaped the person's life narrative.

30. Role of Last words in providing insight into a person's relationship with their faith

31. ## Expressing Faith and Forgiveness - Jesus' words from the cross, such as "Father, forgive them, for they do not know what they are doing" and "It is finished," reveal his unwavering faith in God's plan of salvation and his commitment to forgiveness even in the face of death. ## Seeking Redemption   - Some last words demonstrate a desire for spiritual redemption, like a convicted killer confessing his crime and asking for forgiveness. This reflects a belief in God's mercy and the possibility of salvation. ## Expressing Fear or Rejection of God - In contrast, the last words of those who have rejected God in life, like the actress who refused to have her housekeeper pray for her, can express fear and anger towards God as they face eternity. ## Longing for Heaven and Christ's Return - The last words of some Christians, like John Wesley saying "The best of all is: God is with us!" or D.L. Moody declaring "I see earth receding, and heaven is opening. God is calling me," reveal a joyful anticipation of heaven and Christ's return. ## Affirming Faith in God's Plan - Thomas Becket's last words, "I am ready to die for my Lord, that in my blood the Church may obtain liberty and peace," and the apostle Paul's "I have fought the good fight, I have finished the race, I have kept the faith," demonstrate a strong faith in God's sovereignty and plan, even in the face of martyrdom[3].

32. How a person's last words can reflect their spiritual journey :

33. ## Expressing Faith and Reliance on God - The examples of last words, such as Thomas Becket affirming his readiness to die for the Lord, or the apostle Paul expressing his confidence in God's plan, demonstrate a strong faith and reliance on God, even in the face of death. ## Seeking Spiritual Redemption - Last words can reveal a desire for spiritual redemption, as seen in the case of a convicted killer confessing his crime and asking for forgiveness. This reflects a belief in God's mercy and the possibility of salvation. ## Rejecting or Fearing God - In contrast, the last words of those who have rejected God in life, like the actress who refused to have her housekeeper pray for her, can express fear and anger towards God as they face eternity. ## Anticipating Reunion with God - The last words of some Christians, like John Wesley's joyful declaration about God's presence or D.L. Moody's excited anticipation of heaven, reveal a deep longing for reunion with the divine. ## Entrusting One's Spirit to God - Jesus' final words, "Father, into your hands I commit my spirit," demonstrate a profound trust in God's care and a willingness to surrender one's life to the divine plan, even in the face of suffering. ## Reflecting a Lifetime of Faith - As seen in the example of the author's grandmother, last words can encapsulate a lifetime of devotion to God and serve as a testament to the person's spiritual journey.

34. Last words can have a significant impact on the grieving process for loved ones

35. ## Providing Closure and Comfort - For some, hearing a final message or farewell from a dying loved one can provide a sense of closure and comfort in the grieving process. Knowing their last words can help the bereaved feel a connection to the deceased. ## Reflecting on the Person's Life and Values - The nature of a person's last words can shed light on their personality, values, and what was most important to them. Reflecting on these final utterances can help the grieving loved ones gain insight into their loved one's life and find meaning in their death. ## Fueling Speculation and Unresolved Questions - When last words are unclear, unrecorded, or contradict how the person lived, it can leave loved ones with unanswered questions and make the grieving process more difficult. Speculation about what was really meant can prolong grief. ## Reinforcing Cultural Attitudes Towards Death - The way a person faces death, as reflected in their last words, can reinforce cultural beliefs and expectations around mortality. This can shape how the bereaved process the loss within their cultural context. ## Providing a Lasting Legacy - For famous individuals, their reported last words can become part of their enduring legacy and how they are remembered. This can be a source of comfort for fans and loved ones alike.

36. Last words can have a significant impact on the sense of closure for the bereaved

37. ## Providing Comfort and Meaning - When a person's last words reflect their values, faith, or love for their loved ones, it can provide comfort and a sense of meaning for the bereaved. Knowing their final thoughts and feelings can help the grieving process. ## Offering Closure and Acceptance - Last words that express acceptance of death, gratitude for life, or a peaceful transition can offer the bereaved a sense of closure. This can help them accept the loss and find peace. ## Fueling Unresolved Questions - Unclear, contradictory, or unrecorded last words can leave the bereaved with lingering questions and a lack of closure. Speculation about the true meaning can prolong the grieving process. ## Reinforcing Cultural Narratives - Last words that align with cultural expectations around death and dying can provide a familiar framework for the bereaved to process the loss. This can offer a sense of closure within their cultural context. ## Preserving the Person's Legacy - For public figures, their reported last words can become part of their enduring legacy and how they are remembered. This can be a source of comfort and closure for their fans and loved ones. ## Reflecting Unfinished Relationships - When last words reveal unresolved conflicts or unsaid sentiments, it can leave the bereaved with a sense of incompleteness and a desire for closure that may never be fully achieved.

38. TERMINAL RESTLESSNESS

39. The symptoms include​

40.  The physical signs include :​ ​