The question of whether to continue repositioning a patient during the active dying phase presents a difficult dilemma for caregivers and family members. Standard care protocols emphasize movement to prevent complications, but the goals of care shift entirely as a person approaches the end of life. The decision ultimately navigates the conflict between preventing future physical breakdown and prioritizing immediate comfort and dignity. Understanding the changing medical priorities is essential for making the most compassionate choice in the final days and hours.
Standard Rationale for Repositioning
Routine repositioning, or turning a bedridden patient every two to three hours, is a foundational practice in chronic and acute care. This practice is primarily aimed at preventing pressure injuries, commonly known as bedsores or pressure ulcers. Prolonged pressure on bony prominences, such as the heels, hips, and lower back, decreases blood flow and oxygen levels in the tissue, leading to skin breakdown.
Changing a patient’s position regularly helps to redistribute the weight, ensuring that no single area sustains constant pressure. Beyond skin integrity, movement also helps prevent other complications associated with immobility. These include joint stiffness, muscle contractures, and even pulmonary issues like certain types of pneumonia. For patients not in the active dying phase, this consistent repositioning is a preventative measure to maintain overall physical health and comfort.
Changing Priorities in Palliative Care
When a patient enters the active dying phase, the philosophy of care undergoes a fundamental transition from preventative measures to maximizing comfort. The focus moves away from preventing complications like pressure ulcers, which are a long-term concern, toward ensuring a peaceful experience in the present moment. This shift is driven by the understanding that the body’s systems are slowing down, and the physiological process of dying often supersedes the ability to prevent skin changes regardless of movement.
In palliative care, the primary directive becomes the alleviation of pain, anxiety, and distress. Attempting to reposition a person who is actively dying may cause more suffering than the potential benefit of preventing a pressure ulcer that may not fully develop. The goals of care are tailored to the individual’s wishes and needs, emphasizing dignity and symptom control over extending life or preventing further disease progression. This means that any intervention, including repositioning, that causes discomfort must be carefully re-evaluated against the new goal of immediate relief.
Assessing Patient Comfort During Movement
The decision to continue or cease repositioning must be guided by a continuous and careful assessment of the patient’s comfort level. For patients who are unable to speak or are minimally responsive, caregivers must look for non-verbal signs of distress during movement. These observable signs can include grimacing, moaning or groaning, tensing of the body, or a stiffening resistance to the movement.
A change in vital signs, such as a sudden increase in heart rate or breathing rate, can also signal that the patient is experiencing pain. If repositioning elicits any clear sign of discomfort, the consensus in palliative care is to stop the intervention, as the pain outweighs the marginal benefit.
Caregivers should consult with the hospice or palliative care team to discuss these observations and adjust the care plan, which may include administering pain medication before any necessary gentle movement. Respecting the patient’s immediate physical peace is paramount in the final hours.
Non-Movement Comfort Interventions
Once the decision is made to minimize or stop repositioning, several interventions can be implemented to maintain comfort and manage pressure relief without painful movement.
Pressure Relief Alternatives
- Specialized support surfaces are highly effective alternatives, such as low-air-loss mattresses or alternating pressure surfaces, which constantly redistribute pressure across the patient’s body. These systems reduce the need for frequent manual turning, thereby increasing the patient’s peace.
- Caregivers can use small pillows or foam wedges to provide gentle propping, which slightly shifts weight without requiring a full turn.
- This micro-movement can alleviate concentrated pressure on vulnerable areas.
- Ensuring the bed linens are kept clean, dry, and smooth is also a simple yet important step to prevent skin irritation and friction.
- Furthermore, the palliative care team can manage pain and agitation through prescribed medications, ensuring the patient remains physically relaxed regardless of their position.