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second level
third level
fourth level
fifth level
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/div>
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le
E
C
Module 12=
: Last
Hours of Living
© EPEC Project, 2003
Permission to reproduce for educational purposes granted
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![](3D"master07_background.gif")
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E
P
E
C
P
E
C
La=
st
Hours of Living
Module 12
![](3D"master06_background.gif")
![](3D"master06_image003.gif")
Last hours of living
•E=
veryone
will die
< 10% suddenly
> 90% prolonged illness
•L=
ast
opportunity for life closure
•L=
ittle
experience with death
exaggerated sense of dying process
Preparing for the last hours
of life . . .
. . .
Preparing for the last hours
of life
•C=
aregivers
awareness of patient choices
knowledgeable, skilled, confident
rapid response
•L=
ikely
events, signs, symptoms of the dying process
E
P
E
C
P
E
C
Physiologic Changes, Symptom Management
Objectives
•Assess,
manage the pathophysiologic changes of dying
Physiologic changes during
the dying process
Weakness / fatigue
•D=
ecreased
ability to move
•J=
oint
position fatigue
•I=
ncreased
risk of pressure ulcers
•I=
ncreased
need for care
activities of daily living
turning, movement, massage
Decreasing appetite / food
intake
•F=
ears:
“giving in,” starvation
•R=
eminders
food may be nauseating
anorexia may be protective
risk of aspiration
clenched teeth express desires, control
•H=
elp
family find alternative ways to care
Decreas=
ing
fluid intake . . .
•O=
ral
rehydrating fluids
•F=
ears:
dehydration, thirst
•R=
emind
families, caregivers
dehydration does not cause distress
dehydration may be protective
.
. . Decreasing fluid intake
•P=
arenteral
fluids may be harmful
fluid overload, breathlessness, cough, secretions
•M=
ucosa
/ conjunctiva care
Decreasing blood perfusion
<=
span
style=3D'font-weight:normal'>•Parenteral fluids will=
not
reverse
Neurologic dysfunction
<=
span
style=3D'font-weight:normal'>•Decreasing level of
consciousness
•Communication with the=
unconscious
patient
2 roads to death=
Restless
Confused
Tremulous
Hallucinations
Mumbling
Delirium
Myoclonic
Jerks
Sleepy
Lethargic
Obtunded
Semicomatose
Comatose
Seizures
![](3D"slide0052_image004.gif")
![](3D"slide0052_image005.gif")
![](3D"slide0052_image006.gif")
![](3D"slide0052_image007.gif")
![](3D"slide0052_image008.gif")
![](3D"slide0052_image009.gif")
![](3D"slide0052_image010.gif")
![](3D"slide0052_image011.gif")
![](3D"slide0052_image012.gif")
![](3D"slide0052_image013.gif")
![](3D"slide0052_image014.gif")
=
=
=
=
THE USUAL ROAD<=
/span>
![](3D"slide0052_image015.gif")
=
=
=
=
THE DIFFICULT ROAD<=
/span>
![](3D"slide0052_image016.gif")
![](3D"slide0052_image017.gif")
![](3D"slide0052_image018.gif")
=
=
=
=
Normal
![](3D"slide0052_image019.gif")
=
=
=
=
Dead
![](3D"slide0052_image020.gif")
![](3D"slide0052_image021.gif")
Decreasing level of <=
span
style=3D'position:absolute;top:51.8%;left:1.09%;width:97.36%;height:49.39%=
'>consciousness
Communication
with the unconscious pati=
ent .
. .
<=
span
style=3D'font-weight:normal'>•Assume patient hears
everything
. . . Communication with the unconscious patient
•C=
reate
familiar environment
•I=
nclude
in conversations
assure of presence, safety
•G=
ive
permission to die
•T=
ouch
Terminal delirium
•“The
difficult road to death”
•Medical
management
benzodiazepines
lorazepam, midazolam
neuroleptics
haloperidol, chlorpromazine
•Seizures
•Family
needs support, education
Changes in
respiration . . .
respiration . . .
•A=
ltered
breathing patterns
diminishing tidal volume
apnea
Cheyne-Stokes respirations
accessory muscle use
last reflex breaths
. .
. Changes in respi=
ration
•F=
ears
suffocation
•M=
anagement
family support
oxygen may prolong dying process
breathlessness
Loss of ability to swallow
•L=
oss
of gag reflex
•B=
uildup
of saliva, secretions
scopolamine to dry secretions
postural drainage
positioning
suctioning
Loss of sphincter control
<=
span
style=3D'font-weight:normal'>•Family needs knowledge,
support
Pain . . .
•F=
ear
of increased pain
•A=
ssessment
of the unconscious patient
persistent vs fleeting expression
grimace or physiologic signs
incident vs rest pain
distinction from terminal delirium
. . .=
Pain
•M=
anagement
when no urine output
stop routine dosing, infusions of morphine
breakthrough dosing as needed (prn)
least invasive route of administration
Loss of ability to
close eyes
close eyes
•L=
oss
of retro-orbital fat pad
•I=
nsufficient
eyelid length
•C=
onjunctival
exposure
increased risk of dryness, pain
maintain moisture
Medications
•L=
imit
to essential medications
•C=
hoose
less invasive route of administration
buccal mucosal or oral first, then consider
rectal
subcutaneous, intravenous rarely
intramuscular almost never
E
P
E
C
P
E
C
=
Expected
Death
Objectives
•Prepare,
support the patient, family, caregivers
As expected death approaches
. . .
•D=
iscuss
status of patient, realistic care goals
role of physician, interdisciplinary team
•W=
hat
patient experiences ¹ what onlookers see
. . .
As expected death appro=
aches
•Reinforce
signs, events of dying process
•Personal, cultural,
religious, rituals, funeral planning
•Family support through=
out
the process
Signs that death has =
occurred
. . .
<=
span
style=3D'font-weight:normal'>•Absence of heartbeat,
respirations
. . .
Signs that death has occurr=
ed
•M=
uscles,
sphincters relax
release of stool, urine
eyes can remain open
jaw falls open
body fluids may trickle internally
What to do when death occurs
After expected death =
occurs
. . .
•Care
shifts from patient to family / caregivers
• Different loss for
everyone
<=
span
style=3D'font-weight:normal'>•Invite those not prese=
nt
to bedside
=
. . .
After expected death occurs=
•Take
time to witness what has happened
•Create a peaceful,
accessible environment
• When rigor mortis sets
in
• Assess acute grief
reactions
Moving the body
•P=
repare
the body
•C=
hoice
of funeral service providers
•W=
rapping,
moving the body
family presence
intolerance of closed body bags
Other tasks
•N=
otify
other physicians, caregivers of the death
stop services
arrange to remove equipment / supplies
•Se=
cure
valuables with executor
•D=
ispose
of medications, biologic wastes
Bereavement care
•B=
ereavement
care
•A=
ttendance
at funeral
•F=
ollow
up to assess grief reactions, provide support
•A=
ssistance
with practical matters
redeem insurance
will, financial obligations, estate closure
Dying in institutions
•H=
ome-like
environment
permit privacy, intimacy
personal things, photos
•C=
ontinuity
of care plans
•A=
void
abrupt changes of settings
•C=
onsider
a specialized unit
E
P
E
C
P
E
C
=
Module
12, Part 3 <=
span
style=3D'font-size:225%;color:yellow;display:none'>
Loss, Grief, Bereavement
Objectives
•Identify,
manage initial grief reactions
Loss, grief with life-threatening
illness . . .
•H=
ighly
vulnerable
•F=
requent
losses
function / control / independence
image of self / sense of dignity
relationships
sense of future
. .
. Loss, grief with life-threatening
illness
•C=
onfront
end of life
high emotions
multiple coping responses
Loss, grief, coping
•G=
rief
=3D emotional response to loss
•C=
oping
strategies
conscious, unconscious
avoidance
destructive
suicidal ideation
Normal grief
•P=
hysical
hollowness in stomach,
tightness in chest, heart palpitations
•E=
motional
numbness, relief, sadness,
fear, anger, guilt
•C=
ognitive
disbelief, confusion,
inability to concentrate
Complicated grief . . .
•C=
hronic
grief
normal grief reactions over very long periods
of time
•D=
elayed
grief
normal grief reactions are suppressed or
postponed
. . .
Complicated grief
•E=
xaggerated
grief
self-destructive behaviors eg, suicide
•M=
asked
grief
unaware that behaviors are a result of the
loss
Tasks of the grieving
l1. Accept the reality of the loss
l=
2. Experience the pain caused by the loss
l=
3. Adjust to the new environment after the
loss
l4. Rebuild a new life
Assessment of grief
•R=
epeated
assessments
anticipated, actual losses
emotional responses
coping strategies
role of religion
•I=
nterdisciplinary
team assessment, monitoring
Grief management
•If
reactions, coping strategies appropriate
monitor
support
counseling
rituals
•If
inappropriate, potentially harmful
rapid, skilled assessment, intervention
![](3D"slide0061_image022.gif")
Summary =
Key
Issues
1. If managed well, the last hours can lead to
significant personal
and family growth. If managed poorly, life closure may be
=
incomplete, suffering may occur unnecessarily, family distress
=
may continue long after the patient’s death, and those who=
3;
watch may worry that their own death will be similar.
2. During the last hours of their lives, patients
usually need
skilled care around the clock. The environment must allow
=
family and friends ready access to their loved one in a setting
=
;
conducive to privacy and intimacy
![](3D"slide0068_image023.gif")
Summary =
Key
Issues
3. Advance preparation and education of professional=
s,
family, and volunteer caregivers is essential. They should
=
also be knowledgeable about the potential time course,
signs and symptoms of the dying process and their
potential management. Help families to understand that
what they see may be very different from the patient’s
experience.
4. The physiologic changes of dying are complex. To&=
#13;
control each symptom effectively, physicians need to
have an understanding of its cause, underlying
pathophysiology, and the appropriate pharmacology to
use.
![](3D"slide0067_image024.gif")
Summary =
Key
Issues
5. At the end of life, fatigue need not be resisted =
and
most
treatment to alleviate it can be discontinued.
6. Most patients lose their appetite and reduce food
intake long
before they reach the last hours of their lives. Anorexia may
<=
/b>
be protective, and the resulting ketosis can lead to a greater
=
sense of well-being and diminish pain.
7. Most patients also reduce their fluid intake, or =
stop
drinking
entirely, long before they die. Dehydration in the last hours
<=
/b>
of living does not cause distress and may stimulate
=
endorphin release that adds to the patient’s sense of well=
3;
-being.
Potential pitfall: Maintaining parent=
eral
fluids. They may have =
adverse
effects that are not commonly considered![](3D"slide0066_image025.gif")
Summary =
Key
Issues
8. Maintain moisture in mucosal membranes with
=
meticulous oral, lip, nasal, and conjunctival hygiene and
<=
/span>
lubrication.
9. The majority of patients experience increasing=
3;
drowsiness, sleep most if not all of the time, and
<=
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eventually become unarousable. Absence of eyelash
reflexes indicates a profound level of coma equivalent to
<=
/span>
full anesthesia.
10. Presume that the unconscious patient hears
everything.
![](3D"slide0065_image026.gif")
Summary =
Key
Issues
11. Moaning, groaning, and grimacing accompanying &#=
13;
agitation=
and
restlessness are frequently
misinterp=
reted
as pain. Terminal delirium may be
occurring.
While a t=
rial
of opioids may be beneficial in the
unconscio=
us
patient who is difficult to assess,
benzodiaz=
epines
or sedating neuroleptics may be
needed to
manage terminal delirium.
If
benzodiazepines have a paradoxical exciting effect.
These pat=
ients
require neuroleptic medications to
control t=
heir
delirium.
![](3D"slide0064_image027.gif")
Summary =
Key
Issues
12. Diminished hepatic function and renal perfusion
may
change
pharmacology of chronically administered
medications.
13. Secretions from the tracheobronchial tree
frequently
accumulat=
e.
Scopolamine or glycopyrrolate will
effective=
ly
reduce the production of saliva and other
&=
nbsp;
secretions.
![](3D"slide0063_image028.gif")
Summary =
Key
Issues
14. Institutional dying presents particular challeng=
es.
Prioritie=
s and
care plans at the very end of life differ
from thos=
e for
life prolongation and cure.
15. Planning discussions should cover personal,
cultural,
and relig=
ious
traditions, rites, and rituals that may
dictate h=
ow
prayers are to be conducted, how a
person=
217;s
body is to be handled after death, and&nb=
sp;
when/how =
the
body can be moved.
Pearl: Know the signs of the dying process.
<=
/i>
16. When expected death occurs, the focus of care sh=
ifts
to
the famil=
y and
those who provided care.
![](3D"slide0062_image029.gif")
Summary =
Key
Issues
18. To deal with loss of any kind, individuals must&=
#13;
complete =
each
task of the grieving process.
a.
Accept the reality of loss
b.
Experience the pain caused by the loss
c.
Adjust to the new environment after the
=
;
loss
d.
Rebuild a new life
![](3D"slide0071_image030.gif")
Summary =
Key
Issues
19.
Physicians need to be able to recognize grief and assist with appropriate interventions. Some grief-coping
strategies (eg,
increased smoking/alcohol/medication intake,
overworking, and suicidal ideation) may accelerate a=
nd
even become destructive.
=
;
20. Based on media dramatization and vivid imaginati=
ons,
many people have develo=
ped
an exaggerated sense and fear of what d=
ying
and death are like.
21. For the bereaved person who is emotionally
distraught and now f=
eels
very lonely and abandoned, each task of the grieving process may seem insurmountable and may
take
months or even years to resolve.
E
P
E
C
P
E
C
End of Module 12:
Last Hours of Living
Review Fast Facts
Complete Module 12 Post Assessment
‹header›
‹date/time&=
#8250;
Click to edit Master text styles
Second level
Third level
Fourth level
Fifth level
‹footer›
‹#›
The last hours of living are imp=
ortant
not only for the comfort of the patient, but for all
who are bereaved by, or simply witness, the death. Normal death is
explained in this
module, as are the key tasks that need to be accomplished before, at, and
after the death.
Management of the patient’s distress is critica=
l,
particularly issues associated with feeding and hydration, changes in
consciousness, delirium, pain, breathlessness, and secretions. Preparation=
and
education of the family are important. Normal grief and bereavement are
discussed as well as complicated grief.
Key words
bereavement, breathing changes, complicated grief, coroner, decreased
appetite, decreased mobility, decreased perfusion, decreased thirst, delir=
ium,
expectations, eyes, fatigue, imminent death, moving the body, neurological
dysfunction, normal grief, pain, rigor mortis, sphincter control, swallowi=
ng,
tasks of caring
Every one of us will die. A few =
of us
(<10%) will die suddenly. Most of us (>90%) will die after a long pe=
riod
of illness with gradual deterioration until an active dying phase at the e=
nd.
The last hours of our lives may be some of our most significant. They prov=
ide
the last opportunity to finish our business, create final memories, give f=
inal
gifts, find spiritual peace, and say good-bye.
Those who provide care =
have
one opportunity to get it right. There is no second chance. If managed wel=
l,
the last hours can lead to significant personal and family growth. If mana=
ged
poorly, life closure may be incomplete, suffering may occur unnecessarily,
family distress may continue long after the patient’s death, and tho=
se who
watch may worry that their death will be similar.
Most of us have litt=
le
or no experience with the dying process or death. While many professionals
have seen a dead body, lay people rarely have. Most of us have neither wat=
ched
someone die nor provided care during the last hours of life.
Based on
media dramatization and our vivid imaginations, most people have developed=
an
exaggerated sense of what dying and death are like. However, with appropri=
ate
management, it is possible to provide smooth passage and comfort for the p=
atient
and all onlookers.
During the last hours of their l=
ives,
all patients require skilled care around the clock. This can be provided in
any setting as long as the professional, family, and volunteer caregivers =
are
appropriately prepared and supported throughout the process. The environme=
nt
must allow family and friends access to their loved one around the clock w=
ithout
disturbing others and should be conducive to privacy and intimacy. Medicat=
ions,
equipment,
and supplies need to be available in anticipation of proble=
ms,
whether the patient is at home or in a health care institution. As the
patient’s condition and the family’s ability to cope can change
frequently, both must be reassessed regularly and the plan of care modifie=
d as
needed. As changes can occur suddenly and unexpectedly, caregivers must be
able to respond quickly. This is particularly important when the patient i=
s at
home, if unnecessary readmission is to be avoided.
If the last hours of a person=
217;s
life are to be as rewarding as possible, advance preparation and education=
of
professional, family, and volunteer caregivers is essential, whether the
patient is at home, in an acute care or skilled nursing facility, a hospic=
e or
palliative care unit, prison, etc. Everyone who participates must be aware=
of
the patient’s health status, his or her goals for care and the
parents’ goals if the patient is a child, advance directives, and pr=
oxy
for decision making. They should also be knowledgeable about the potential
time course, signs and symptoms of the dying process and their potential
management.
Help families to understand that what they see may be very
different from the patient’s experience. If family members and
caregivers feel confident, the experience can provide a sense of final gift
giving. For parents of a dying child, confidence can leave a sense of good
parenting. If unprepared and unsupported, they may spend excessive energy
worrying how to handle the next event. If things do not go as hoped for,
family members may
live with frustration, worry, fear, or guilt that t=
hey
did something wrong or caused the patient’s death.
Physicians wi=
ll
need to establish in advance whether potential caregivers, including profe=
ssionals
who work in institutions, are skilled in caring for patients in the last h=
ours
of life. Do not assume that anyone, even a professional, knows how to perf=
orm basic
tasks. Those who are inexperienced in this particular area will need speci=
fic training
including, for instance, knowledge about body fluid precautions. Written m=
aterials
can provide additional support to caregivers when experts are not
present.
Although we often sense that death will either come quickly o=
ver
minutes or be protracted over days to weeks, it is not possible to predict
when death will occur. Some patients may appear to wait for someone to vis=
it,
or for an important event such as a birthday or a special holiday, and then
die soon afterward. Others experience unexplained improvements and live lo=
nger
than expected. A few seem to “decide to die” and do so
very
quickly, sometimes within minutes. While we may give families or professio=
nal caregivers
an idea of how long the patient might live, always advise them about the i=
nherent
unpredictability of death.
Essential skill for physicians
As virtually all physicians will care for dying patients and their familie=
s,
the approaches to care in the last hours of life are essential skills for
physicians. This module discusses the specialized care required during the
last hours of life in 3 parts. These specialized approaches are applicable
whether the patient is at home or in an institutional setting:
·
part 1 discusses the physiologic changes that occur as patients are dying =
and approaches
to the management of associated symptoms.
· part 2 discusses preparation for expected death and what to =
do
when death occurs.
· part 3 discusses loss and the assessment and management of normal=
and
complicated grief reactions.
As a person dies, many different
physiologic changes present as signs and symptoms. Each one can be alarmin=
g if
it is not understood. To control each symptom effectively, physicians need=
to
have an understanding of its cause, underlying pathophysiology, and the
appropriate pharmacology to use.
Weakness and fatigue usually inc=
rease as
the patient gets closer to death. In the last hours of life, it is likely =
that
the patient will not be able to move around in the bed or raise his or her
head. Joints may become uncomfortable if they are not moved. Continuous
pressure on the same area of skin, particularly over bony prominences, will
increase the risk of skin ischemia and the development of pressure ulcers.
These may become painful or
odoriferous if they become infected. They are more easily prevented t=
han
treated.
At the end of life, fatigue need not be resisted and most treatment to
alleviate it can be discontinued (see Module 10: Common Physical Symptoms).
Patients who are too fatigued to move and have joint position fatigue may
require passive movement of their joints every 1 to 2 hours. To minimize t=
he
risk of pressure ulcer formation, turn the patient from side to side every=
1
to 1.5 hours and protect areas of bony prominence with hydrocolloid dressi=
ngs
and special supports. A draw sheet can assist caregivers to turn the patie=
nt
and minimize pain and shearing forces to the skin. If turning is painful,
consider a pressure-reducing surface (eg, air mattress or airbed). As the =
patient
approaches death, the need for turning lessens as the risk of skin breakdo=
wn becomes
less important.
Intermittent massage before and after turning,
particularly to areas of contact, can both be comforting and reduce the ri=
sk
of skin breakdown by improving circulation and shifting edema. Avoid massa=
ging
areas of erythema or actual skin breakdown.
Most patients lose their appetit=
e and
reduce food intake long before they reach the last hours of their lives. T=
here
are many causes, most of which become irreversible close to death.
Fam=
ilies
and professional caregivers often interpret cessation of eating as
“giving in.” They frequently worry that the patient will
“starve to death.” Physicians can help families understand that
loss of appetite is normal at this stage. Remind them that the patient is =
not
hungry, that food either is not appealing or may be nauseating, that the p=
atient
would likely eat if he or she could, and that clenching of teeth may be the
only way for the patient
to express desires.
Educate families about the studies that demonstrate that parenteral or ent=
eral
feeding of patients at the end of their lives neither improves symptom con=
trol
nor lengthens life. Help them to understand that anorexia may be protectiv=
e,
as the resulting ketosis can lead to a greater sense of well-being and
diminish pain.
Whatever the degree of acceptance of these facts, it is
important for physicians to help families and caregivers realize that food
pushed upon the unwilling patient may cause problems such as aspiration and
increase tensions. Above all=
, help
them to find alternate ways to provide appropriate physical care and emoti=
onal
support to the patient so that they can continue to participate and feel
valued during the dying process.
Most patients also reduce their =
fluid
intake, or stop drinking entirely, long before they die. If they are still
taking some fluid but are not eating, salt-containing fluids such as soups,
soda water, sport drinks, and red vegetable juices can help to maintain el=
ectrolyte
balance and minimize the risk of nausea from hyponatremia.
Decreased f=
luid
intake usually heightens onlookers’ distress as they worry that the =
dehydrated
patient will suffer, particularly if he or she becomes thirsty. As with fe=
eding,
families and professional caregivers will need support to understand that =
this
is an expected event. It may help families to understand that most experts=
in
the field feel that dehydration in the last hours of living does not cause
distress and may stimulate endorphin release that adds to the patient̵=
7;s
sense of well-being. Low blood pressure or weak pulse is part of the dying
process and not an indication of dehydration. Patients who are not able to
move off the bed do not get lightheaded or dizzy. Patients with peripheral
edema or ascites have excess body water and salt and are not dehydrated.&#=
13;Parenteral
fluids, either intravenously or subcutaneously using hypodermoclysis, are =
sometimes
considered, particularly when the goal is to reverse delirium. However, pa=
renteral
fluids may have adverse effects that are not commonly considered. Intraven=
ous
lines can be cumbersome and difficult to maintain. Moving the angiocatheter
can be uncomfortable, particularly if the access site needs to be changed =
frequently
and the patient
is cachectic or has no accessible veins.
Excess parenteral fluids can lead to fluid overload with consequent periph=
eral
or pulmonary edema, worsened breathlessness, cough, and orotracheobronchia=
l secretions,
particularly if there is significant hypoalbuminemia. They also have the p=
otential
to prolong the dying process, which may be undesirable.
Mucosal/conjunctival care
To maintain patient comfort and minimize the sense of thirst, even in the =
face
of dehydration, maintain moisture in mucosal membranes with meticulous ora=
l,
nasal, and conjunctival hygiene. Moisten and clean oral mucosa every 15 to=
30
minutes with either baking soda mouthwash (1 teaspoon salt, 1 teaspoon bak=
ing
soda, 1 quart tepid water) or an artificial saliva preparation to minimize=
the
sense of thirst and avoid bad odors or tastes and painful cracking. Treat =
oral
candidiasis with topical nystatin or systemic fluconazole if the patient is
able to swallow. Coat lips and anterior nasal mucosa hourly with a thin la=
yer
of petroleum jelly to reduce evaporation. Avoid perfumed lip balms and swa=
bs
containing lemon and glycerin, as these can be both desiccating and
irritating, particularly on open sores. If eyelids are not closed, moisten=
conjunctiva
with an ophthalmic lubricating
gel every 3 to 4 hours, or artificial t=
ears
or physiologic saline solution every 15 to 30 minutes to avoid painful dry
eyes.
As cardiac output and intravascu=
lar
volume decrease toward the end of life, there will be evidence of diminish=
ed
peripheral blood perfusion. Tachycardia, hypotension, peripheral cooling,
peripheral and central cyanosis, and mottling of the skin (livedo reticula=
ris)
are normal. Venous blood may pool along dependent skin surfaces. Urine out=
put
falls as perfusion of the kidney diminishes. Oliguria or anuria is normal.=
Parenteral
fluids will not
reverse this circulatory shut-down.
The neurologic changes associate=
d with
the dying process are the result of multiple concurrent nonreversible fact=
ors,
including hypoxemia, metabolic imbalance, acidosis, toxin accumulation due=
to
liver and renal failure, adverse effects of medication, sepsis, diseaserel=
ated
factors, reduced cerebral perfusion, etc.
The neurologic changes
associated with the dying process may manifest in 2 different patterns that
have been described as the “2 roads to death” (see figure belo=
w).
The “usual road” that most patients follow presents as decreas=
ing
level of consciousness that leads to coma and death. The “difficult
road” that a few patients follow presents as an agitated delirium du=
e to
central nervous system (CNS) excitation, with or without myoclonic jerks&#=
13;that
leads to coma and death. Based on clinical observation, it is likely that =
the
risk of focal or grand mal seizures is increased along the “difficult
road,” particularly when cerebral metastases are present.
As reprinted in: Advance plannin=
g. In:
Ferris FD, Flannery JS, McNeal HB, Morissette MR,
Cameron R, Bally GA,
eds. Module 4: Palliative care. In: A Comprehensive Guide for the
Care of
Persons with HIV Disease. Toronto, Ontario: Mount S=
inai
Hospital and Casey House Hospice Inc;
1995:118-120. Originally published in: Freemon FR. Delirium and organ=
ic
psychosis.
In: Organic Mental Disease. Jamaica, NY: SP Medical and Scientific
Books; 1981:81-94.
The majority of patients travers=
e the
“usual road to death.” They experience increasing drowsiness,
sleep most if not all of the time, and eventually become unrousable. Absen=
ce
of eyelash reflexes on physical examination indicates a profound level of =
coma
equivalent to full anesthesia.
Families will frequently find th=
at their
decreasing ability to communicate is distressing. The last hours of life a=
re
the time when they most want to communicate with their loved one. As many
clinicians have observed, the degree of family distress seems to be in ver=
sely
related to the extent to which advance planning and preparation occurred. =
Time
spent preparing families is likely to be very worthwhile.
While we do =
not
know what unconscious patients can actually hear, experience suggests that=
at
times their awareness may be greater than their ability to respond. Given =
our
inability to assess a dying patient’s comprehension and the distress
that talking “over” the patient may cause, it is prudent to
presume that the unconscious patient hears everything.
Advise families=
and
professional caregivers to talk to the patient as if he or she were consci=
ous.
Encourage
families to create an environment that is familiar and pleasant. Surround =
the
patient with the people, children, pets, things, music, and sounds that he=
or
she would like. Include the patient in everyday conversations. Encourage
family to say the things they need to say. At times, it may seem that a
patient may be waiting for permission to die. If this is the case, encoura=
ge
family members to give the patient permission to “let
go” and die in a manner that feels most comfortable to them.=
3;
The physician or other
caregivers might suggest to family members other words like:
· I know that you are dying, please do so when you are ready.&=
#13;
· I love you. I will miss you. I will never forget you. Please do w=
hat
you need to do when you are ready.
· Mommy and Daddy love you. We will miss you, but we will be
OK.
As touch can heighten communication, encourage family members to show
affection in ways they are used to. Let them know that it is okay to lie
beside the patient in privacy to maintain as much intimacy as they feel
comfortable with.
Delirium may be the first sign t=
o herald
the “difficult road to death.” It frequently presents as
confusion, restlessness, and/or agitation, with or without day-night rever=
sal.
It may result from any of the standard causes of delirium listed in DSM-IV=
(American
Psychiatric Association, 1994) that can accompany the dying process.
Agitated terminal delirium can be very distressing to family and professio=
nal caregivers
who do not understand it. Although previous care may have been excellent, =
if
the delirium goes misdiagnosed or unmanaged, family members will likely re=
member
a horrible death “in terrible pain” and may worry that their o=
wn
death will be the same. In anticipation of the possibility of terminal
delirium, educate and support family and professional caregivers to unders=
tand
its causes, the finality and irreversibility of the situation, and approac=
hes
to its management. It is particularly important that all onlookers underst=
and
that what the patient experiences may be very different from what they see.
If delirium presents and the patient is not perceived to be actively
dying, it may be appropriate to evaluate and try to reverse treatable
contributing factors. However, if the patient is close to the last hours of
his or her life, this is only effective in a minority of cases
If death is imminent, it will not be possible to reverse the underlying
causes. Focus on the management of the symptoms associated with the termin=
al
delirium and settle the patient and the family.
When moaning, groaning,
and grimacing accompany agitation and restlessness, they are frequently
misinterpreted as pain. However, it is a myth that pain suddenly develops
during the last hours of life when it has not previously been out of contr=
ol. While
a trial of opioids may be beneficial in the unconscious patient who is
difficult to assess, physicians must remember that opioids may accumulate =
and
add to delirium when renal
Benzodiazepines may excite some patients and not have the desired settling
effect. These patients require neuroleptic medications to control their
delirium. Haloperidol (0.5–2.0 mg q hs to q 6 h to start and titrate=
d)
given intravenously, subcutaneously, or rectally may be effective. A more
sedating alternative is chlorpromazine (10–25 mg po q hs to q 6 h to
start and titrated) given intravenously or rectally.
Seizures may be managed with high doses of benzodiazepines. Other
antiepileptics such as phenytoin pr or IV, fosphenytoin SC, or phenobarbit=
al,
60 to 120 mg pr, IV, or IM q 10 to 20 min prn, may become necessary until
control is established.
clearance is poor.
Rarely, the trial of increas=
ed
opioids does not relieve the agitation or makes the delirium worse by
increasing agitation or precipitating myoclonic jerks or seizures. If so, =
then
pursue alternate therapies directed at
suppressing the symptoms associated with the delirium.
Benzodiazepines are used widely as they are anxiolytics, amnestics, skelet=
al
muscle relaxants, and antiepileptics. Oral lorazepam, 1 to 2 mg as an elix=
ir,
or the tablet predissolved in 0.5 to 1.0 mL of water and administered agai=
nst
the buccal mucosa q 1 h prn will settle most patients with 2 to 10 mg/24 h=
. It
can then be given in divided doses, q 3 to 4 h, to keep the patient
settled.
For a few extremely agitated patients, high doses of lorazep=
am,
20 to 50+ mg/24 h, may be required. A midazolam infusion of 1 to 5 mg SC o=
r IV
q 1 h, preceded by repeated loading boluses of 0.5 mg q 15 min to effect, =
may
be a rapidly effective alternative.
Changes in a dying patient’=
;s
breathing pattern may be indicative of significant neurological compromise.
Breaths may become very shallow and frequent with a diminishing tidal volu=
me.
Periods of apnea and/or Cheyne-Stokes pattern respirations may develop.
Accessory respiratory muscle use may become prominent. A few, sometimes ma=
ny,
last reflex breaths may signal death.
Families and professional caregi=
vers
frequently find changes in breathing patterns to be one of the most
distressing signs of impending death. Many fear that the comatose patient =
will
experience a sense of suffocation. Knowledge that the unresponsive patient=
may
not be experiencing breathlessness or “suffocating,” and may n=
ot
benefit from oxygen which may actually prolong the dying process, may be v=
ery
comforting. Low doses of opioids
or benzodiazepines are appropriate to manage any perception of
breathlessness
In the last hours of life, weakn=
ess and
decreased neurologic function frequently impair the patient’s abilit=
y to
swallow. The gag reflex and reflexive clearing of the oropharynx decline a=
nd
secretions from the tracheobronchial tree accumulate. These conditions may
become more prominent as the patient loses consciousness. Buildup of saliva
and oropharyngeal secretions may lead to gurgling, crackling, or rattling
sounds with each breath.
Some have called this the “death
rattle,” a term frequently disconcerting to families and caregivers.=
For
unprepared families and professional caregivers, it may sound like the pat=
ient
is choking.
Once the patient is unable to swallow, cease oral intake. =
Warn
families and professional caregivers of the risk of aspiration. Scopolamin=
e,
0.2–0.4 mg SC q 4 h or 1 to 3 transdermal patches q 72 h or 0.1 to 1=
.0
mg/h by continuous IV or SC infusion, or glycopyrrolate, 0.2 mg SC q 4 to =
6 h
or 0.4 to 1.2 mg/d by continuous IV or SC, will effectively reduce the
production of saliva and other secretions. They will minimize or eliminate=
the
gurgling and crackling sounds, and may be used prophylactically in the
unconscious dying patient. Anecdote suggests that the earlier treatment is
initiated, the better it works, as larger amounts of secretions in the upp=
er aerodigestive
tract are more difficult to eliminate. However, premature use in the patie=
nt
who is still alert may lead to
unacceptable drying of oral and pharyng=
eal
mucosa. While atropine may be equally effective, it has an increased risk =
of
producing undesired cardiac and/or CNS excitation.
If excessive fluid accumulates in the back of the throat and upper airways=
, it
may need to be cleared by repositioning the patient or postural drainage.
Turning the patient onto one side or a semiprone position may reduce gurgl=
ing.
Lowering the head of the bed and raising the foot of the bed while the pat=
ient
is in a semiprone position may cause fluids to move into the oropharynx, f=
rom
which they can be easily removed. Do not maintain this position for more t=
han
a few minutes at a time, as stomach contents may also move
unexpectedly.
Oropharyngeal suctioning is not recommended. It is frequently ineffective,=
as
fluids are beyond the reach of the catheter, and may only stimulate an
otherwise peaceful patient and distress family members who are watching.&#=
13;
Fatigue and loss of sphincter co=
ntrol in
the last hours of life may lead to incontinence of urine and/or stool. Both
can be very distressing to patients and family members, particularly if pe=
ople
are not warned in advance that these problems may arise. If they occur,
attention needs to be paid to cleaning and skin care. A urinary catheter m=
ay minimize
the need for frequent changing and cleaning, prevent skin breakdown, and r=
educe
the demand
on caregivers. However, it is not always necessary if urine
flow is minimal and can be managed with absorbent pads or surfaces. If
diarrhea is considerable and relentless, a rectal tube may be similarly
effective.
While many fear that pain will s=
uddenly
increase as the patient dies, there is no evidence to suggest this
occurs.
Though difficult to assess, continuous pain in the semiconscio=
us
or obtunded patient may be associated with grimacing and continuous facial
tension, particularly across the forehead and between the eyebrows. The
possibility of pain must also be considered when physiologic signs occur, =
such
as transitory tachycardia that may signal distress. Do not overdiagnose pa=
in
when fleeting forehead tension comes and goes with movement or
mental
activity (eg, dreams or hallucinations). Do not confuse pain with the rest=
lessness,
agitation, moaning, and groaning that accompany terminal delirium. If the
diagnosis is unclear, a trial of a higher dose of opioid may be necessary =
to
judge whether pain is driving the observed behaviors.
Knowledge of opioid pharmacology=
becomes
critical during the last hours of life. The liver conjugates codeine,
morphine, oxycodone, and hydromorphone into glucuronides. Some of their
metabolites remain active as analgesics until they are renally cleared,
particularly morphine. As dying patients experience diminished hepatic
function and renal perfusion, and usually become oliguric or anuric, routi=
ne dosing
or continuous infusions
of morphine may lead to increased serum
concentrations of active metabolites, toxicity, and an increased risk of
terminal delirium. To minimize this risk, discontinue routine dosing or
continuous infusions of morphine when urine output and renal clearance
stop.
Titrate morphine breakthrough (rescue) doses to manage expressio=
ns
suggestive of continuous pain. Consider the use of alternative opioids with
inactive metabolites such as fentanyl or hydromorphone.
Advanced wasting leads to loss o=
f the
retro-orbital fat pad, and the orbit falls posteriorly within the orbital
socket. As eyelids are of insufficient length to both extend the additional
distance backward and cover the conjunctiva, they may not be able to fully
appose. This may leave some conjunctiva exposed even when the patient is
sleeping. Eyes that remain open can be distressing to onlookers unless the
condition is understood.
If conjunctiva remains exposed, maintain mois=
ture
by using ophthalmic lubricants, artificial tears, or physiologic saline as
previously discussed.
As patients approach the last ho=
ur of
their lives, reassess the need for each medication and minimize the number
that the patient is taking. Leave only those medications to manage symptoms
such as pain, breathlessness, excess secretions, and terminal delirium and
reduce the risk of seizures. Choose the least invasive route of administra=
tion:
the buccal mucosa or oral routes first, the subcutaneous or intravenous ro=
utes
only if necessary, and the intramuscular route almost never.
No matter how well families and
professional caregivers are prepared, they will often find a prolonged dea=
th
to be draining, particularly if the patient is intermittently restless or
agitated. As death approaches, review the status of the patient and answer=
questions.
Families may need to hear gentle repetition and clarification of the
goals of care, the futility of life-prolonging therapies, and the
irreversibility of unfolding events. Advance discussion should ensure that
everyone is aware of personal, cultural, and religious traditions, rites, =
and
rituals that may dictate how prayers are to be conducted, how a personR=
17;s
body is to be handled after death, and when/how the body can be moved. To
expedite arrangements for the funeral, memorial services, burial, or crema=
tion,
suggest that the patient and/or family contact the funeral home in advance.
Throughout the last hours of life, particularly as death approaches,
families will benefit from repeated contact with their physicians and/or o=
ther
members of the interdisciplinary team. To minimize confusion and unnecessa=
ry
telephone calls, clarify the role of the physician and members of the
interdisciplinary care team and their contact information in advance.
=
Families
will settle best if questions are answered calmly and their concerns addre=
ssed
promptly. To be effective, ensure that a knowledgeable physician, or other
health care professional, is available by telephone 24 hours per day, 7 da=
ys
per week. Delays in communication only heighten anxiety and may leave fami=
lies
frustrated that the care provided was not the best that was possible.
As expected death approaches, an=
swer
questions and review the signs and potential events that may occur as the
patient dies. The heart stops beating; breathing stops; pupils become fixe=
d;
body color becomes pale and waxen as blood settles; body temperature drops;
muscles and sphincters relax, urine and stool may be released; eyes may re=
main
open; the jaw can fall open; and observers may hear the trickling of fluid=
s internally.
If the patient dies at home, rem=
ind
families and caregivers that there is no need to call 911. If a home hospi=
ce
program is involved, have the family call the hospice. If a home hospice is
not involved, determine in advance who should be notified.
Make certain
that family and professional caregivers understand that there are no rules=
that
govern what happens as soon as the patient dies. Unless death is unexpecte=
d,
or malice is suspected, involvement of the coroner’s office is usual=
ly
not required, although local regulations may vary. If the patient has not
requested organ donation or made an anatomic gift to a medical school, the
physician or other health care professional need not attend quickly to wit=
ness
what has occurred. Presence may be helpful if family members are distressed
and need immediate support with their acute grief reactions.
When expected death occurs, the =
focus of
care shifts from the patient to the family and those who provided care.
Everyone present will have a different experience and a different sense of
loss. Even though the loss has been anticipated for some time, no one will
know what it feels like until it actually occurs, and indeed it may take h=
ours
to days to weeks or even months for each person to realize the full
effect.
Encourage all who are present, including caregivers, to take t=
he
time they need to realize what has happened and say their good-byes. There=
is
no need to rush, even in the hospital or other care facility. Allow everyo=
ne
to touch, hold, and even kiss the person’s body as they feel most
comfortable. Be sensitive to the limits allowed by personal, cultural, or
religious practices. Maintain universal body fluid precautions. The time s=
pent
with the
body will help people through their acute grief. It will help
them to develop a new sense of awareness of what has happened. It will ben=
efit
everyone as the event becomes more distant and family members start to ada=
pt
to the absence of their loved one.
To facilitate the acute grieving
process, professional caregivers may wish to create a visually peaceful and
accessible environment when family members are ready. A few moments spent
alone in the room positioning the patient’s body, disconnecting any =
lines
and machinery, removing catheters, and cleaning up any mess will allow the=
family
closer access to the patient’s body. If eyes remain open, eyelids ca=
n be
manually held closed for a few minutes and will usually remain closed once
they dry. If they remain open, a small amount of surgical tape or a short
Steri-strip will hold them closed for longer without pulling on eyelashes =
when
they are removed. If the jaw falls open as muscles relax, a rolled-up towel
placed under the chin of an elevated head will usually hold
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return href.substring(0, Start)=20
else=20
return href.substring(0, End)=20
}
return '';
}
function GetTags(base,tag)
{
if(g_supportsPPTHTML) return base.all.tags(tag);
else return base.getElementsByTagName(tag);
}
function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP=
refix+GetHrefObj( gCurSld ).mNtsHref ) }
function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() }
function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() }
function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() }
function SetHasNts( fVal )
{
if( gHasNts !=3D fVal ) {
gHasNts=3DfVal
UpdNavPane()
}
}
function ToggleOtlText()
{
gOtlTxtExp=3D!gOtlTxtExp
UpdOtlPane()
}
function ClearMedia()
{
// Clear any sounds playing before launching another browser window. Other=
wise,
// in fullscreen mode, you'll continue to hear the sound in the frames mod=
e.
if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0;
}
function FullScreen()
{=20
if ( PPTSld.g_animUseRuntime )
PPTSld.document.body.pause();
ClearMedia();
var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF =
: FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref;
if(PPTNav.event.ctrlKey) {
var w =3D (window.screen.availWidth * 1.0) / 2.0
var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW
win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top=
=3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
else
{
win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
}
function ToggleVNarration()
{
rObj=3DPPTSld.document.all("NSPlay")
if( rObj && !PPTSld.g_animUseRuntime ) {
if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) )
rObj.Play()
else if( rObj.playState =3D=3D 2 )
rObj.Pause()
else
return;
}
else if( PPTSld.g_animUseRuntime )
{
narObj =3D PPTSld.document.all("narrationID")
if( narObj )
narObj.togglePause()
}
}
function GetCurSldNum()
{ =20
obj=3DGetHrefObj(gCurSld)
if( obj.mOrigVis =3D=3D 1 )
return obj.mSldIdx
else =20
return gCurSld
}
function GetNumSlds()
{ =20
if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 )
return GetSldList().mNumVisSlds;
else
return GetSldList().mList.length
}
function GetSldNum( href )
{
for(ii=3D0; ii 1 )
PopSldList();
else if( !IsFramesMode() ) {
if( gLoopCont )
GoToFirst()
else
EndShow()
}
}
function GoToPrevSld()
{
ii=3DgCurSld-1
if( ii > 0 ) {
obj=3DGetHrefObj(ii)
while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) )
obj=3DGetHrefObj(--ii)
if( ii =3D=3D 0 ) ii=3D1
GoToSldNum(ii)
}
}
function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) }
function GoToLast()
{
ii=3DGetSldList().mList.length
if( ii !=3D gCurSld )
GoToSld( GetHrefObj(ii).mSldHref )
}
function GoToSldNum( num )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
obj =3D GetHrefObj( num )
obj.mVis=3D1
gPrevSld=3DgCurSld
gCurSld =3D num;
PPTSld.location.replace(MHTMLPrefix+obj.mSldHref)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function GoToSld( href )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
GetHrefObj( GetSldNum(href) ).mVis=3D1
PPTSld.location.replace(MHTMLPrefix+href)
}
function SldUpdated( id )
{
if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return
gPrevSld=3DgCurSld
gCurSld=3DGetSldNum(id)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) }
function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO=
bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) }
function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) }
function CloseWindow() {
if( HideMenu() ) return;
=09
var event =3D PPTSld.event;
if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D=
=3D32 || event.type=3D=3D"click" ) )
window.close( self );
CatchNumKeys( self, event );
}
function Unload() { gIsEndShow=3D0; }
function SetupEndShow() {
gIsEndShow=3D1;
PPTSld.document.body.scroll=3D"no";
PPTSld.document.onkeypress=3DCloseWindow;
PPTSld.document.onclick=3DCloseWindow;
PPTSld.document.oncontextmenu=3D_CM;
}
function EndShow()
{
if( IsFramesMode() ) return
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
doc=3DPPTSld.document
var dir =3D doc.body.dir
if( dir !=3D "rtl" ) dir =3D "ltr";
doc.open()
doc.writeln(' 0) {
PushSldList(sldList,fEnd);
gCurSld =3D 1;
}
else
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
}
function PushSldList(arr,fEnd) {
var ii =3D gSldStack.length;
gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd);
GoToSld( gSldStack[ii].mList[0].mSldHref );
}
function PopSldList() {
if (gSldStack[gSldStack.length-1].fEndShow)
EndShow()
else {
gCurSld =3D gSldStack[gSldStack.length-1].mCurSld;
gSldStack[gSldStack.length-1] =3D null;
gSldStack.length--;
var sldList =3D gSldStack[gSldStack.length-1];
GoToSld( sldList.mList[gCurSld - 1].mSldHref );
}
}
var custShowList=3Dnew Array();
/*********************************************
Navigation button implementation
There are 2 types of buttons: ImgBtn, TxtBtn
implemented as function objects. They share
a similiar interface so the event handlers
can call SetActive, for example, on a button=20
object without needing to know exactly=20
what type of button it is.
**********************************************/
//----------------------------------
function ImgBtn( oId,bId,w,action )
//----------------------------------
{
var t=3Dthis
t.Perform =3D _IBP
t.SetActive =3D _IBSetA
t.SetInactive=3D _IBSetI
t.SetPressed =3D _IBSetP
t.SetDisabled=3D _IBSetD
t.Enabled =3D _IBSetE
t.ChangeIcon =3D null
t.UserAction =3D action
t.ChgState =3D _IBUI
t.mObjId =3D oId
t.mBorderId=3D bId
t.mWidth =3D w
t.mIsOn =3D t.mCurState =3D 0
}
function _IBSetA()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _IBSetI()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0=20
}
}
function _IBSetP()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 )
obj.style.posLeft+=3D1; obj.style.posTop+=3D1
}
}
function _IBSetD()
{ =20
obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 )
obj.style.posTop=3D0=20
}
function _IBSetE( state )
{
var t=3Dthis
GetObj( t.mBorderId ).style.visibility=3D"visible"
if( state !=3D t.mIsOn ) {
t.mIsOn=3Dstate
if( state )
t.SetInactive()
else
t.SetDisabled()
}
}
function _IBP()
{
var t=3Dthis
if( t.mIsOn ) {
if( t.UserAction !=3D null )
t.UserAction()
if( t.ChangeIcon ) {
obj=3DGetObj(t.mObjId)
if( t.ChangeIcon() )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth
else
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth
}
t.SetActive()
} =20
}
function _IBUI( clr1,clr2,nextState )
{
var t=3Dthis
SetBorder( GetObj( t.mBorderId ),clr1,clr2 )
obj=3DGetObj( t.mObjId )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj=
.style.posTop
t.mCurState=3DnextState
return obj
}
//-----------------------------------------
function TxtBtn( oId,oeId,action,chkState )
//-----------------------------------------
{
var t=3Dthis
t.Perform =3D _TBP
t.SetActive =3D _TBSetA
t.SetInactive=3D _TBSetI
t.SetPressed =3D _TBSetP
t.SetDisabled=3D _TBSetD
t.SetEnabled =3D _TBSetE
t.GetState =3D chkState
t.UserAction =3D action
t.ChgState =3D _TBUI
t.mObjId =3D oId
t.m_elementsId=3D oeId
t.mIsOn =3D 1
}
function _TBSetA()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gHiliteClr,gShadowClr,0,0 )
}
function _TBSetI()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
}
function _TBSetP()
{
if( this.mIsOn )
this.ChgState( gShadowClr,gHiliteClr,1,1 )
}
function _TBSetD()
{ =20
this.ChgState( gFaceClr,gFaceClr,0,0 )
this.mIsOn =3D 0
}
function _TBSetE()
{
var t=3Dthis
if( !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
else
t.ChgState( gShadowClr,gHiliteClr,1,1 )
t.mIsOn =3D 1
}
function _TBP()
{
var t=3Dthis
if( t.mIsOn ) {=20
if( t.UserAction !=3D null )
t.UserAction()
if( !t.GetState )
return
if( t.GetState() )
t.SetPressed()
else
t.SetActive()
} =20
}
function _TBUI( clr1,clr2,lOffset,tOffset )
{
SetBorder( GetObj( this.mObjId ),clr1,clr2 )
Offset( GetObj( this.m_elementsId ),lOffset,tOffset )
}
function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle=
ft }
function SetBorder( obj, upperLeft, lowerRight )
{
s=3Dobj.style;
s.borderStyle =3D "solid"
s.borderWidth =3D 1=20
s.borderLeftColor =3D s.borderTopColor =3D upperLeft
s.borderBottomColor=3D s.borderRightColor =3D lowerRight
}
function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] }
function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() }
function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() }
function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() }
function BtnOnUp()
{
b=3DGetBtnObj()
if( b !=3D null )
b.Perform()
else
Upd()
}
function GetNtsState(){ return parent.gNtsOpen }
function GetOtlState(){ return parent.gOtlOpen }
function GetOtlTxtState(){ return parent.gOtlTxtExp }
function NtsBtnSetFlag( fVal )
{
s=3Ddocument.all.item( this.m_flagId ).style
s.display=3D"none"
if( fVal )
s.display=3D""
else
s.display=3D"none"
}
function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etActive() }
function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etInactive() }
function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S=
etPressed() }
function _BSetA_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]=20
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _BSetI_BorderImg()
{=20
b =3D gBtnArr[this.mBorderId]
if( b !=3D null && this.mIsOn && !b.GetState() ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0
}
}
var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"=
THREEDFACE"
var gBtnArr =3D new Array()
gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan=
e,GetOtlState )
gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt=
lPane,GetOtlState )
gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN=
tsPane )
gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg;
gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg;
gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.=
ToggleNtsPane,GetNtsState )
gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To=
ggleNtsPane,GetNtsState )
gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n=
b_prevBorder",30,parent.GoToPrevSld )
gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n=
b_nextBorder",30,parent.GoToNextSld )
gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent=
.FullScreen )
gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa=
rent.FullScreen,null )
gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent=
.FullScreen,null )
gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border;
gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border;
gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice=
","nb_voiceBorder",18,parent.ToggleVNarration )
gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT=
xt","nb_otlTxtBorder",23,parent.ToggleOtlText )
gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts"
gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag
gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState
/*********************************************
Context menu implementation
_CM() is the function that's hooked up to
the oncontextmenu event. Once we're asked to
show the menu, we first build it by creating
DIVs on-the-fly. Then we position it=20
within the screen area so it doesn't get
clipped.
Creating the DIVs using createElement() means
we don't have to write out any extra HTML
into the slide HTML files.
**********************************************/
var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr=
row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval"
function ShowMenu()
{
BuildMenu();
var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y=
=3DPPTSld.event.clientY+doc.scrollTop
m =3D PPTSld.document.all.item("ctxtmenu")
m.style.pixelLeft=3Dx
if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) )
m.style.pixelLeft=3Dx-m.scrollWidth
m.style.pixelTop=3Dy
if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) )
m.style.pixelTop=3Dy-m.scrollHeight
m.style.display=3D""
}
function _CM()
{
if( !parent.IsFullScrMode() ) return;
if(!PPTSld.event.ctrlKey) {
ShowMenu()
return false
} else
HideMenu()
}
function BuildMenu()
{
if( PPTSld.document.all.item("ctxtmenu") ) return
var mObj=3DCreateItem( PPTSld.document.body )
mObj.id=3D"ctxtmenu"
mObj.style.visibility=3D"hidden"
var s=3DmObj.style
s.position=3D"absolute"
s.cursor=3D"default"
s.width=3D"120px"
SetCMBorder(mObj,"menu","black")
var iObj=3DCreateItem( mObj )
SetCMBorder( iObj, "threedhighlight","threedshadow" )
iObj.style.padding=3D2
CreateMenuItem( iObj,sNext,M_GoNextSld,M_True )
CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld )
=09
CreateSeparator( iObj )
CreateMenuItem( iObj,sEnd,M_End,M_True )
mObj.style.visibility=3D"visible"
}
function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa=
lue=3Dfalse }
function Highlight() { ChangeClr("activecaption","threedhighlight") }
function Deselect() { ChangeClr("threedface","menutext") }
function Perform()
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() )
e.Action()
else
PPTSld.event.cancelBubble=3Dtrue
}
function ChangeClr( bg,clr )
{
e=3DPPTSld.event.srcElement
if( e.type=3D=3D"menuitem" && e.IsActive() ) {
e.style.backgroundColor=3Dbg
e.style.color=3Dclr
}
}
function M_HasPrevSld() { return( parent.HasPrevSld() ) }
function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() }
function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();=
PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() }
function M_True() { return true }
function M_End() { window.close( self ) }
function CreateMenuItem( node,text,action,eval )
{
var e=3DCreateItem( node )
e.type=3D"menuitem"
e.Action=3Daction
e.IsActive=3Deval
e.innerHTML=3Dtext
if( !e.IsActive() )
e.style.color=3D"threedshadow"
e.onclick=3DPerform
e.onmouseover=3DHighlight
e.onmouseout=3DDeselect
s=3De.style;
s.fontFamily=3DsFont
s.fontSize=3D"9pt"
s.paddingLeft=3D2
}
function CreateSeparator( node )
{
var sObj=3DCreateItem( node )
SetCMBorder(sObj,"menu","menu")
var s=3DsObj.style
s.borderTopColor=3D"threedshadow"
s.borderBottomColor=3D"threedhighlight"
s.height=3D1
s.fontSize=3D"0px"
}
function CreateItem( node )
{
var elem=3DPPTSld.document.createElement("DIV")
node.insertBefore( elem )
return elem
}
function SetCMBorder( o,ltClr,rbClr )
{
var s=3Do.style
s.backgroundColor=3D"menu"
s.borderStyle=3D"solid"
s.borderWidth=3D1
s.borderColor=3DltClr+" "+rbClr+" "+rbClr+" "+ltClr
}
------=_NextPart_01C7D841.152FDA80
Content-Location: file:///C:/DECCB227/Module12LastHoursofLiving_files/fullscreen.htm
Content-Transfer-Encoding: quoted-printable
Content-Type: text/html; charset="us-ascii"
Module 12
------=_NextPart_01C7D841.152FDA80--
the jaw closed until muscles stiffen some 4 to 6 hours later.
Caregivers who have not been present for the death can assess how family
members are handling their loss by listening to a recounting of how things
went leading up to the death and afterward. Spiritual advisors or other
interdisciplinary team members may be instrumental in orchestrating events=
to
facilitate the transition that those present are experiencing. Grief react=
ions
beyond cultural norms suggest a risk of significant ongoing or delayed gri=
ef
reactions.
When the immediate family is ready, invite others who have been close to t=
he
patient, including caregivers, to come to the bedside to witness what has
happened before the person’s body is moved. When letting people know
what has happened, follow the guidelines for communicating bad news. Try to
avoid breaking unexpected news by telephone, as communicating in person
provides much greater opportunity for assessment
and support. As additional visitors arrive, sp=
end a
few minutes to remind them of the changes in body color, temperature, and =
the
scene they will see. This can reduce the surprise and make the transition a
little easier for
everyone.
Once family members have had the=
time
they need to witness what has happened, deal with their acute grief reacti=
ons,
and observe their customs and traditions, then preparations for burial or
cremation and a funeral or memorial service(s) can begin. Some family memb=
ers
may find it therapeutic to help bathe and prepare the person’s body =
for
transfer to the funeral home or the hospital morgue. For many, such ritual=
s will
be their final act of direct caring.
Once ready, family members or
professional caregivers at the request of the family may call a chosen fun=
eral
service provider and arrange to move the person’s body. Most funeral
services are available to transfer the body 24 hours per day, 7 days per w=
eek,
and will attend at home within a short time of the call. If the patient is=
in
a health care institution, the funeral home will deal directly with the
institution.
Depending on local regulations and arrangements, some fun=
eral
directors will insist on the completed death certificate being present bef=
ore
they pick up the body. All will require a completed death certificate to
proceed with any body preparation and registration of the death. To avoid
delaying the process, ensure that the physician who will complete the
certificate has ample warning that one will be required. Usually, the phys=
ician
does
not need to be called at the moment of the death just to do this.
=
;
At home, once the body has been =
removed
and family members are settled, professional caregivers can offer to assist
them with some of their immediate tasks. They may notify other physicians =
and
caregivers that the death has occurred. They may notify health care service
agencies so that services can be stopped and equipment removed from the ho=
me
when it is convenient for the family. They may suggest how to secure
valuables. They
may dispose of medications, particularly opioids, in t=
he
toilet, and they may dispose of biological wastes. Caregivers should be cl=
ear
about local regulations governing ownership of medications after a death a=
nd
waste disposal.
When family members are ready, professional caregivers=
can
let the family know how to reach them, then leave them to have some privacy
together.
Immediately after the death, tho=
se who
survive will need time to recover from their stress and fatigue, and resto=
re
their environments back to normal.
A bereavement card and attendance at
the patient’s funeral may be appropriate. For many physicians and
members of the professional team, encouraging follow-up visits from family
members to assess the severity of their grief reactions to their recent lo=
ss and
coping strategies and to provide support is a part of their professional d=
uty
of care.
Professional members of the interdisciplinary team can also o=
ffer
to assist family members, when ready, to deal with outstanding practical
matters, secure documents to redeem insurance, find legal counsel to execu=
te
the will, meet financial obligations, close the estate, etc.
This discussion about preparatio=
n for
expected death and what to do when the patient dies is relevant to patients
dying in any setting (eg, at home, in hospital, in nursing homes, other
extended care facilities, jails, etc). However, a few remarks are warranted
regarding the particular challenges of ensuring a comfortable death in an =
institution
whose culture is not focused on end-of-life care.
As many patients approach the end of their lives, they prefer to remain wi=
th
the caregivers they know, rather than be transferred to another facility.
Institutions should make the environment as home-like as possible. To help
ensure privacy, move the patient to a private room where family can be pre=
sent
continuously and intimate with the patient if they would choose to do so.
Encourage the family to surround the patient with a few personal
thing=
s or
photos. Prepare the professional staff and encourage continuity of care pl=
ans across
nursing shifts and changes in house staff. Avoid changing settings abruptl=
y simply
because the patient is dying. For instance, transferring from a nursing ho=
me
to hospital or vice versa can be very disruptive and distressing to
everyone.
Priorities and care plans at the end of life differ consider=
ably
from those for life prolongation and cure. It is frequently challenging for
physicians and other health care professionals to incorporate both into a =
busy
hospital or skilled nursing facility. If the provision of end-of-life care
proves to be difficult in these settings, consider a specialized unit where
patients and families can be assured of the environment and the skilled
care
they need.
As patients and families confront
life-threatening illness, they are vulnerable to many different anticipate=
d,
if not actual, losses. These include: loss of functional capabilities,
control, independence, body image, dignity, relationships, sense of future=
, etc.
As illness progresses, the risk of losing control over fundamentally impor=
tant
aspects of their lives increases, at times dramatically.
Grief reactio=
ns,
the emotional reactions to loss, frequently run very high as everyone conf=
ronts
the possibility of the end of the patient’s life and the change death
will bring.
Multiple coping strategies may o=
ccur
simultaneously. Some will be helpful. Others may become destructive.
T=
o be
effective in end-of-life care, physicians need to be able to recognize gri=
ef
and assist with appropriate interventions.
Normal grief reactions include a=
whole
range of physical, emotional, and cognitive behaviors.
The bereaved may
note feelings of hollowness in the stomach, tightness in the chest, heart
palpitations, weakness, lack of energy, gastrointestinal disturbances, wei=
ght
gain or loss, or skin reactions. Many say they feel emotional numbness,
relief, sadness, fear, anger, guilt, loneliness, abandonment, despair, or
ambivalence. They may be concerned about cognitive symptoms such as disbel=
ief,
confusion, inability to concentrate, and preoccupation with or dreams of t=
he
deceased. All of these are normal grief reactions to any type of loss.
=
;Some
people will make a conscious effort to deal with the loss. Others will deny
what is happening and avoid dealing with the loss. Some coping strategies =
(eg,
increased smoking/alcohol/medication intake, overworking, and suicidal
ideation) may accelerate and even become destructive, especially in the fa=
ce
of seemingly insurmountable loss.
Recently bereaved may seek assistance
from their physicians for these symptoms. Recognition of the cause is
important if useless or misleading investigations or medication trials are=
to
be avoided.
When grief reactions occur over =
long
periods of time, are very intense, or interfere with the survivor’s
physical or emotional well-being, they become symptoms of complicated grie=
f.
There are 4 categories of complicated grief reactions. Chronic grief is
characterized by normal grief reactions that do not subside and continue o=
ver
very long periods of time.
Delayed grief is characterized by normal gr=
ief
reactions that are suppressed or postponed. The survivor consciously or
unconsciously avoids the pain of the loss. In exaggerated grief, the survi=
vor
may resort to self-destructive behaviors such as suicide. Finally, in mask=
ed
grief, the survivor is not aware that the behaviors that interfere with no=
rmal
functioning are a result of the loss.
The physician needs to be attune=
d to
behaviors that might indicate complicated grief, especially if these conti=
nue
beyond 6 to 12 months. The survivor may not be able to speak of the deceas=
ed
without experiencing intense sadness. Themes of loss may continue to occur=
in
every topic during a clinical interview. Minor events may unexpectedly tri=
gger
intense grief and sadness. The survivor may be unwilling to move possessio=
ns
belonging to the deceased. Sometimes the survivor will develop symptoms
similar to those of the deceased. When complicated grief is suspected, ref=
erral
for specialized help
is warranted.
After a major loss, there are ty=
pically
4 tasks the bereaved must complete before they will effectively deal with
their loss. These tasks apply to the many losses that precede the death, as
well as to the death itself. While the tasks are interdependent, they are =
not
necessarily completed in sequence.
For many, realization and acceptance
that the loss or death has actually occurred can be a major hurdle. If such
individuals spent little or no time at the bedside after the death realizi=
ng
what happened, they may continue for months to deny that anything has
occurred.
Denial can be unwavering. Some bereaved may even continue to
look for the person, waiting for his or her telephone call and/or return.
Until such people realize that the person has died, they cannot begin to
resolve what has happened and move on.
Knowing that the death has
occurred is not enough. To be able to move on, the bereaved need to experi=
ence
the pain caused by their loss. As this can be very distressing, many who a=
re
bereaved try to avoid the pain, and physicians frequently try to blunt it =
with
medication. While this may be necessary for temporary management of
destructive reactions, if overdone, medication may prolong both the grief
reactions and the pain associated with the loss.
Once they have realiz=
ed
what has happened and the pain that the loss has caused, the bereaved need=
to
recognize the significance of their losses and the changes to their lives.=
Finally,
as grief proceeds, the bereaved need to reinvest their energy into new act=
ivities
and relationships.
All of these tasks may seem relatively straightforw=
ard
to the inexperienced onlooker. However, for the person who is emotionally
distraught and now feels very lonely and abandoned, each task may seem
insurmountable and may take months or even years to resolve.
While sup=
port
from family and caregivers may be intense for the first few days or weeks
after the death, the degree of support inevitably diminishes as others les=
s affected
get on with their lives. If the person who has suffered the greatest loss =
is unable
to move on and dwells on his or her loss, impatience for change may create=
a rift
and increase tensions between the bereaved and other members of the family=
/caregivers.
To effectively anticipate and re=
duce the
grief reactions of our patients and families, physicians must repeatedly
assess their anticipated and actual losses, emotional responses, and coping
strategies. Gentle inquiry may provide support to the bereaved, and help t=
he
physician understand how the survivor is coping.
Other professionals, =
such
as hospice nurses, social workers, and chaplains, can greatly facilitate t=
he
assessment and monitoring of grief. While religion may be an important com=
ponent
of coping, it is beyond the scope of this module to discuss it in any deta=
il. Use
a chaplain or pastoral care professional to help determine and understand =
the religious
background and framework held by each family member.
If the loss, grief reactions, an=
d coping
strategies appear to be appropriate and effective, the situation can be
monitored and supportive counseling provided. Survivors may feel they are
“going crazy” or “losing their mind.” Permit them =
to discuss
their feelings. Reinforce that grief is painful and prolonged, but normal.=
Encourage
the survivor to talk about what it is like to live without the deceased. E=
ncourage
participation in rituals such
as attending the funeral or memorial services, or identifying personal
rituals.
Explain that the length of time needed for the grief process will vary with
each person and situation. There is no “right” way to grieve. =
Each
person will have his/her own way. In general, most people who are bereaved=
are
able to reenter the world after 1 to 3 weeks. However, active grieving can=
go
on for a year or more. Sadness can continue for much longer but typically =
does
not intrude on or prevent new life.
If loss, grief reactions, and copi=
ng
strategies appear to be inappropriate or ineffective and/or they have the
potential to cause harm (eg, destructive behaviors or suicide), they will =
need
to be assessed quickly. Consult someone who is skilled in loss, grief, and
bereavement care so that therapy can be instigated quickly to reduce the r=
isk
of harmful/destructive activities.
Competence, teaching, and calm, =
empathic
reassurance are critical to helping patients and families in the last hour=
s of
living. These important hours often leave lasting memories for families, as
well as for caregivers and professionals. For the majority of dying patien=
ts,
physiologic changes occur that are predictable, including loss of appetite=
and
thirst, decreased blood perfusion, neurologic dysfunction, changes in resp=
iration,
loss of
ability to swallow, and loss of ability to close the eyes.
Knowledge of metabolism at the end of life is important for medical
management, especially if pain or terminal delirium occurs. Suggestions ab=
out
how to manage dying in institutional settings include making room for priv=
ate
visits, cultural observance, and communication. When death approaches, be =
sure
the family knows what to do and what to expect, including matters such as
when
rigor mortis sets in, how to call the funeral home, say goodbye a=
nd
move the body. Care does not end until the physician has helped the family
with their grief reactions and helped those with complicated grief to get
care.
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Content-Location: file:///C:/DECCB227/Module12LastHoursofLiving_files/script.js
Content-Transfer-Encoding: quoted-printable
Content-Type: application/javascript; charset="us-ascii"
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var sld=3DGetObj("SlideObj")
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if( MakeNotesVis() ) return
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=09
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parent.SldUpdated(GetSldId())
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g_origW=3Dsld.style.posWidth
g_scaleHyperlinks=3D(document.all.tags("AREA").length>0)
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InitHLinkArray()
if( g_scaleInFrame||(IsWin("PPTSld") && parent.IsFullScrMode() ) )
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_RSW()
if( IsWin("PPTSld") && parent.IsFullScrMode() )
FullScrInit();
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MakeSldVis();
ChkAutoAdv()
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if( document.all("NSPlay") )
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if( sld.filters && sld.filters.revealtrans )
setTimeout( "document.body.start()", sld.filters.revealtrans.duration * =
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else
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function MakeSldVis()=20
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var fTrans=3Dg_showAnimation && SldHasTrans()
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parent.SetHasNts(0)
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parent.SetHasNts(1)
}
return 1
}
function ChkAutoAdv()
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function IsSldOrNts() { return( IsWin("PPTSld")||IsWin("PPTNts") ) }
function SupportsPPTAnimation() { return( navigator.platform =3D=3D "Win32"=
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if( !g_supportsPPTHTML || IsNts() ||
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cltHeight=3Ddocument.body.clientHeight-padding
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if( cltHeight < g_origH*factor )
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newSize =3D g_origSz * factor
if( newSize < 1 ) newSize=3D1
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s.fontSize=3DnewSize+"px"
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s.posHeight=3Dg_origH*factor
s.posLeft=3D(cltWidth-s.posWidth+padding)/2
s.posTop=3D(cltHeight-s.posHeight+padding)/2
if( g_scaleHyperlinks )
ScaleHyperlinks( factor )
}
function _InitAnimations()
{
animRuntimeInstalled =3D ''+document.body.localTime !=3D 'undefined';
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g_animUseRuntime =3D g_showAnimation && animRuntimeInstalled && !(isFullSc=
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if( g_animUseRuntime ) {
collSeq =3D document.all.tags("seq");
if( collSeq !=3D null ) {
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' + ENDSHOW_MESG + '
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