A patient needs intensive physical support and emotional comfort as he approaches death. Signs and symptoms of impending death include reduced respiratory rate and depth, decreased or absent blood pressure, weak or erratic pulse rate, lowered skin temperature (although occasional spikes in core temperature may occur), decreased level of consciousness (LOC), diminished sensorium and neuromuscular control, diaphoresis, pallor, cyanosis, and mottling. Emotional support for the dying patient and his family most often means reassurance and your physical presence to help ease fear and loneliness. More intense emotional support is important at much earlier stages, especially for patients with long-term progressive illnesses, who can work through the stages of dying. (See Five stages of dying.)

The patient may have made clear his wishes about extraordinary means of supporting life and may have signed a living will. This document, legally binding in most states, declares the patient’s desire for a death unimpeded by such artificial support as defibrillators, respirators, and life-sustaining drugs. If the patient has signed such a document, you must respect his wishes and communicate the doctor’s “no code” order to all staff members.