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26 As Death NearsAS DEATH NEARSBIOLOGICAL (PHYSICAL) ORIENTATION (BEHAVIOR) SPIRITUAL (EXISTENTIAL)EnergyIncontinenceSleepyDisorientedRestlessnessAgitationCLINICAL SIGNS DESCRIPTION MANAGEMENT TECHNIQUES SYSTEM%u201cRally%u201d a surge of energy, suddenly alert, oriented, hungryIncontinent of bowel and bladder, decreased output, dark urine Sleeps most of the time, non-communicative, difficult to arouse Confused about time, place, and identity of people including those close or familiar Restless and repetitive motions such as pulling at bed linen or clothing. Abrupt onset of restless disorienting behaviors that do not respond to normal comforting interventions %u2022 Encourage family members to spend this precious time with the patient%u2022 Keep clean and comfortable%u2022 Treatment: urinary catheter if causing skin if irritation%u2022 Encourage family to sit with loved one, speak softly, naturally%u2022 Assume they can hear, hearing is the last sensation lost%u2022 Identify yourself before you speak, speak clearly%u2022 Avoid joking and sarcasm%u2022 Reduce stimuli that seem to make it worse%u2022 Implement sensory interventions that seem to make it better (music, gentle massage, soothing smells, reading aloud)%u2022 Assess the cause of the agitation and treat as indicated (such as full bladder, pain, impaction (constipation), or an effect of hypoxia (decrease oxygen)%u2022 Medication: opioids, haloperidol, benzodiazepinesVisionsWithdrawalVision-like experiences, speaking or seeing persons who have already died, or speaking of going to places not presently accessible or visibleA person may become less communicative, use symbolic language relating to travel, such as %u201cgoing home or on a trip%u201d or %u201cstanding in a line%u201d%u2022 Affirm the experience instead of contradicting what they see and hear%u2022 This is typically not distressing to the patient and can be comforting to them %u2022 Family and friends may need reassurance that these comments are natural and not causing the patient distress.