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== Introduction ==

== Introduction ==

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Symptoms and signs which indicate the definite death of the patient is called ''arishta''. By seeing flower, smoke and cloudy weather one can expect fruit, fire and rain respectively. In the same way certain symptoms which appear before the death of the person are called ''arishta''.(Sushruta, [[Sutra Sthana]].28/3) Sometimes ''arishtas'' are not recognized by ignorant ''vaidya'' due to their minuscule nature or misunderstanding or by carelessness because ''arishta'' develops instantaneously before the death of an individual. Once the symptoms developed death is certain.  

Symptoms and signs which indicate the definite death of the patient is called [[arishta]]. By seeing flower, smoke and cloudy weather one can expect fruit, fire and rain respectively. In the same way certain symptoms which appear before the death of the person are called [[arishta]].[Su. Sa. Sutra Sthana 28/3]<ref>Sushruta. Sushruta Samhita. Edited by Jadavaji Trikamji Aacharya. 8th ed. Varanasi: Chaukhambha Orientalia;2005.</ref> Sometimes [[arishta]] are not recognized by ignorant [[vaidya]] due to their minuscule nature or misunderstanding or by carelessness because [[arishta]] develops instantaneously before the death of an individual. Once the symptoms developed death is certain.  

The dying process usually begins well before death. As that process begins, person starts on a mental path of discovery, comprehending that death will indeed occur and believing in their own mortality. Death is a personal journey that each individual approaches in their own unique way. Nothing is concrete, nothing is set in stone. There are many paths one can take on this journey but all lead to the same destination. The journey ultimately leads to the physical departure from the body. There are milestones along this journey. Some may hit only a few while another may stop at each one, taking their time along the way. Some may take months to reach their destination, others will take only days. This chapter discusses what has been observed in research by ancient scientists which predicts the impending death. The patient afflicted with these signs and symptoms does not survive more than 3 days or 7 days. A variety of physiological changes occur in the last day and hours of life.

The dying process usually begins well before death. As that process begins, person starts on a mental path of discovery, comprehending that death will indeed occur and believing in their own mortality. Death is a personal journey that each individual approaches in their own unique way. Nothing is concrete, nothing is set in stone. There are many paths one can take on this journey but all lead to the same destination. The journey ultimately leads to the physical departure from the body. There are milestones along this journey. Some may hit only a few while another may stop at each one, taking their time along the way. Some may take months to reach their destination, others will take only days. This chapter discusses what has been observed in research by ancient scientists which predicts the impending death. The patient afflicted with these signs and symptoms does not survive more than 3 days or 7 days. A variety of physiological changes occur in the last day and hours of life.

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The patient of painful and fully manifested ''vatasthila'' (hard tumor caused by vitiated ''vata'') in the cardiac region if, suffers from intense thirst, then he instantly dies.[4]  

The patient of painful and fully manifested [[vatasthila]] (hard tumor caused by vitiated [[vata]]) in the cardiac region if, suffers from intense thirst, then he instantly dies.[4]  

If patient develops laxity in the calf muscles and irregularity in the structure of the nose due to the movement of abnormal ''vata'' all over the body, then he instantly dies. [5]

If patient develops laxity in the calf muscles and irregularity in the structure of the nose due to the movement of abnormal [[vata]] all over the body, then he instantly dies. [5]

If the eye brows of patient are dislocated (drooped) and severe burning sensation in the body develops, and  patient suffers from hiccup, he instantly dies.[6].  

If the eye brows of patient are dislocated (drooped) and severe burning sensation in the body develops, and  patient suffers from hiccup, he instantly dies.[6].  

Diminution of blood and flesh in a patient, who is suffering from distension of both the ''manyas'' (carotid regions of the neck) by the abnormal ''vata'' moving upwards leads to death. [7]  

Diminution of blood and flesh in a patient, who is suffering from distension of both the ''manyas'' (carotid regions of the neck) by the abnormal [[ vata ]] moving upwards leads to death. [7]  

If a weak patient develops suffering in the groin region due to sudden aggravation of ''vata'' between the anus and the umbilicus, then he instantly dies. [8]

If a weak patient develops suffering in the groin region due to sudden aggravation of [[ vata ]] between the anus and the umbilicus, then he instantly dies. [8]

Stretching of the tip of ribs by the aggravated ''vata'' afflicting the chest of a patient, whose eyes are dilated and who feels ''staimitya'' (as if covered with a wet cloth) leads to instant death. [9]

Stretching of the tip of ribs by the aggravated [[ vata ]] afflicting the chest of a patient, whose eyes are dilated and who feels ''staimitya'' (as if covered with a wet cloth) leads to instant death. [9]

Congestion/constriction of both heart and anus by strongly aggravated ''vata'' in a weak patient leads to instant death. [10]

Congestion/constriction of both heart and anus by strongly aggravated [[ vata ]] in a weak patient leads to instant death. [10]

If a patient develops severe dyspnea due to congestion/constriction of both groins and anus by strongly aggravated ''vata'', he dies instantly. [11]

If a patient develops severe dyspnea due to congestion/constriction of both groins and anus by strongly aggravated [[ vata ]], he dies instantly. [11]

If a patient develops severe cutting pain in umbilicus, urination, top of urinary bladder, defecation caused by strongly aggravated ''vata'', he dies instantly. [12]   

If a patient develops severe cutting pain in umbilicus, urination, top of urinary bladder, defecation caused by strongly aggravated [[ vata ]], he dies instantly. [12]   

If a patient suffering from pricking pain in the groin region caused by the vitiated ''vata'' develops diarrhea and thirst, he dies instantly. [13]  

If a patient suffering from pricking pain in the groin region caused by the vitiated [[ vata ]] develops diarrhea and thirst, he dies instantly. [13]  

The patient whose entire body is already pervaded by aggravated ''vata'', if suffers from diarrhea and thirst, dies instantly. [14]

The patient whose entire body is already pervaded by aggravated [[ vata ]], if suffers from diarrhea and thirst, dies instantly. [14]

The patient whose body is swollen because of ''vata'' dominant ''Shotharoga'' and suffers from diarrhea and thirst, dies instantly [15]

The patient whose body is swollen because of [[ vata ]] dominant [[shotha]] and suffers from diarrhea and thirst, dies instantly [15]

The patient having cutting pain originated from ''Amashaya'' (stomach including the small-intestine) suffers from diarrhea and thirst, dies instantly. [16]

The patient having cutting pain originated from [[amashaya]] (stomach including the small-intestine) suffers from diarrhea and thirst, dies instantly. [16]

The patient having cutting pain originated from ''Pakvashaya'' (large intestine) suffers from thirst and severe anal spasm, dies instantly. [17]

The patient having cutting pain originated from [[pakvashaya]] (large intestine) suffers from thirst and severe anal spasm, dies instantly. [17]

If abnormal ''vata'' having its site of manifestation in ''Pakvashaya'' (large intestine) causes unconsciousness and develops stertorious breathing (obstruction of breathing by ''Kapha'') in the throat, the patient dies instantly. [18] Appearance of teeth as if adhered with mud, face as if covered with ashes and excessive perspiration, are signs of the patient who will die soon. [19]

If abnormal [[ vata ]] having its site of manifestation in [[pakvashaya]] (large intestine) causes unconsciousness and develops stertorious breathing (obstruction of breathing by [[kapha]]) in the throat, the patient dies instantly. [18]  

Appearance of diarrhea in a patient having thirst, dyspnea, ''Shiroroga'' (headache), unconsciousness, debility and groaning sound from the throat are signs of the patient who will die soon. [20]

 

Appearance of diarrhea in a patient having thirst, dyspnea, [[shiroroga]] (headache), unconsciousness, debility and groaning sound from the throat are signs of the patient who will die soon. [20]

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=== Summary ===

=== Summary ===

== Tattva Vimarsha (Fundamental Principles) ==

== Tattva Vimarsha (Fundamental Principles) ==

*Excessively vitiated ''vata'' can cause immediate death.

*Excessively vitiated [[vata]] can cause immediate death.

*Disorders associated with excessive thirst and diarrhea indicating severe dehydration can cause immediate death.

*Disorders associated with excessive thirst and diarrhea indicating severe dehydration can cause immediate death.

Physical Symptoms and Their Management- Great emphasis has been placed on addressing dying patient’s pain. Some institutions have made pain assessment a fifth vital sign to emphasize its importance. The most common physical and psychological symptoms among all terminally ill patients include pain, fatigue, insomnia, anorexia, dyspnea, depression, anxiety, and nausea and vomiting. In the last days of life, terminal delirium is also common. Assessment of patients with advanced cancer has shown that patients experienced different physical and psychological symptoms.

Physical Symptoms and Their Management- Great emphasis has been placed on addressing dying patient’s pain. Some institutions have made pain assessment a fifth vital sign to emphasize its importance. The most common physical and psychological symptoms among all terminally ill patients include pain, fatigue, insomnia, anorexia, dyspnea, depression, anxiety, and nausea and vomiting. In the last days of life, terminal delirium is also common. Assessment of patients with advanced cancer has shown that patients experienced different physical and psychological symptoms.

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===Table 1: Signs of Impending Death<ref> Transition to Death - End of Life Curriculum - Stanford University;

=== Signs of impending death and interventions ===

http://endoflife.stanford.edu/M06_last48hr/signs_imp_death.htm </ref>===

 

The following signs [table 1] are observed contemporarily<ref>Transition to Death - End of Life Curriculum - Stanford University;

Available from http://endoflife.stanford.edu/M06_last48hr/signs_imp_death.htm </ref> and can be related with signs enlisted in this chapter. Accordingly suitable interventions can be done in critical conditions.

 

{| class="wikitable"

{| class="wikitable"

! rowspan="1" style="background: lightyellow;"| Physiologic Changes

! rowspan="1" style="background: lightyellow;"| Physiologic Changes

! rowspan="1" style="background: lightyellow;"| Signs/Symptoms

! rowspan="1" style="background: lightyellow;"| Signs/Symptoms

| Decreased blood perfusion || Skin may become mottled and discolored. Mottling and cyanosis of the upper extremities appear to indicate impending death versus such changes in the lower extremities. || Provide good skin care. Turn patient every 2-3 hours if this does not cause discomfort. Lotion to back and extremities. Support extremities with soft pillows.  

| Decreased blood perfusion || Skin may become mottled and discolored. Mottling and cyanosis of the upper extremities appear to indicate impending death versus such changes in the lower extremities. || Provide good skin care. Turn patient every 2-3 hours if this does not cause discomfort. Lotion to back and extremities. Support extremities with soft pillows.  

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| Decreased cerebral perfusion || Decreased level of consciousness or terminal delirium.Drowsiness/disorientation|| Orient patient gently if tolerated and this is not upsetting. Allow pt. to rest.  

| Decreased cerebral perfusion || Decreased level of consciousness or terminal delirium. Drowsiness/disorientation|| Orient patient gently if tolerated and this is not upsetting. Allow pt. to rest.  

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| Decrease in cardiac output and intravascular volume || Tachycardia Hypotension Central and peripheral cyanosis and peripheral cooling. || Comfort measures. Space out activities.  

| Decrease in cardiac output and intravascular volume || Tachycardia Hypotension Central and peripheral cyanosis and peripheral cooling. || Comfort measures. Space out activities.  

! colspan="3" style="text-align:left; background: lightblue;"| Food and Fluids

! colspan="3" style="text-align:left; background: lightblue;"| Food and Fluids

|-

|-

| Decreased interest in food and fluid. || Weight loss/dehydration || Do not force fluid or foods.Provide excellent mouth care.  

| Decreased interest in food and fluid. || Weight loss/dehydration || Do not force fluid or foods. Provide excellent mouth care.  

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| Swallowing difficulties || Food pocketed in cheeks or mouth/choking with eating/coughing after eating || Soft foods and thickened fluids (e.g. nectar) as tolerated. Stop feeding patient if choking or pocketing food.  

| Swallowing difficulties || Food pocketed in cheeks or mouth/choking with eating/coughing after eating || Soft foods and thickened fluids (e.g. nectar) as tolerated. Stop feeding patient if choking or pocketing food.  

| Skin may become mottled or discolored. || Patches of purplish or dark pinkish color can be noted on back and posterior arms/legs. || Keep sheets clean and dry-avoid paper directly to skin. Apply lotion as tolerated.  

| Skin may become mottled or discolored. || Patches of purplish or dark pinkish color can be noted on back and posterior arms/legs. || Keep sheets clean and dry-avoid paper directly to skin. Apply lotion as tolerated.  

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| Decubitusulcers may develop from pressure of being bedbound, decreased nutritional status. || Red spots to bony prominences are first signs of Stage I decubiti  and open sores may develop. || Relieve pressure to bony prominences or other areas of breakdown with turning and positioning Q2 hrs if tolerated. If patient has increased pain or discomfort with position changes, decrease the frequency.

| Decubitus ulcers may develop from pressure of being bedbound, decreased nutritional status. || Red spots to bony prominences are first signs of Stage I decubiti  and open sores may develop. || Relieve pressure to bony prominences or other areas of breakdown with turning and positioning Q2 hrs if tolerated. If patient has increased pain or discomfort with position changes, decrease the frequency.

Special mattress as needed.Duoderm or specialized skin patch to Stage I-II ulcers. Change Q5-7 days or as needed. Goals of wound care for Stage III and IV decubiti should be to promote comfort and prevent worsening rather than healing since healing most likely will not occur.Consider application of specialized products such as charcoal or metronidazole paste (compounded) if odor present.  

Special mattress as needed. Duoderm or specialized skin patch to Stage I-II ulcers. Change Q5-7 days or as needed. Goals of wound care for Stage III and IV decubiti should be to promote comfort and prevent worsening rather than healing since healing most likely will not occur. Consider application of specialized products such as charcoal or metronidazole paste (compounded) if odor present.  

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! colspan="3" style="text-align:left; background: lightblue;"| Respiratory   

! colspan="3" style="text-align:left; background: lightblue;"| Respiratory   

| Dyspnea || Shortness of breath || Oxygen at 2-3 liters  may help for some patients and often helps families to feel better. Link to Dyspnea module  

| Dyspnea || Shortness of breath || Oxygen at 2-3 liters  may help for some patients and often helps families to feel better. Link to Dyspnea module  

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| Cheyne-Stokes respirations || Notable changes in breathing. || A gentle fan blowing toward the patient may provide relief.Educate families that this is normal as the patient is dying.  

| Cheyne-Stokes respirations || Notable changes in breathing. || A gentle fan blowing toward the patient may provide relief. Educate families that this is normal as the patient is dying.  

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! colspan="3" style="text-align:left; background: lightblue;"| General changes  

! colspan="3" style="text-align:left; background: lightblue;"| General changes  

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|-

|}

|}

== References ==

== References ==