Closure.org Blog

By Jonathan Weinkle, MD

Every doctor and nurse knows what the vital signs are. There are four of them: pulse, respiratory rate, temperature and blood pressure. They are called vital, meaning crucial. Meaning alive. Meaning essential – both to the patient, who cannot live without them, and to the medical system, which cannot function without them.

More recently a fifth vital sign has been added: oxygen saturation. Surely to a creature that breathes air in order to live this is crucial, too. So there are five vital signs, five numbers that we must know about everyone in order to know anything about them at all.

That is, until they are dying.  When vitality is about to be extinguished, how vital are the vital signs? How necessary, how crucial, is it to awaken the old man from a peaceful sleep to discover these formerly all-important pieces of information?  When all have understood that death is approaching? After all, if we find the vital signs are abnormal, that there is a fever, or elevated blood pressure, or slow breathing, what will we do?  Will these bits of data tell us anything other than what we already know – that the end is near?

We are in love with data, with numbers that can tell us where we stand, with monitors that keep us abreast of what is going on second-by-second. So in love, in fact, that without numbers we may find it impossible to recognize the obvious facts of the drama playing out before us. So in love that even in hospice care, even when a person’s impending death has been explicitly acknowledged by everyone involved, the protocol dictates disturbing sleep to check the vital signs.

The obvious fact, in this case, is that there are now different vital signs, different indicators of how well a person is doing:

• Sleep

• Pain, which some consider a vital sign even in patients who are not dying

• Nausea

• Shortness of breath – not the kind that can be identified by a pulse oximeter or a respiratory rate, but the kind you recognize when you see it, the kind someone just feels. The kind for which oxygen can be a comfort even when saturations are normal, and useless even when saturations are low

• Constipation

• Itching

• Dry mouth – or its opposite, excess secretions with nowhere to go

• Loneliness, anger, despair, abandonment, depression, fear

If these vital signs are stable enough to let a dying man sleep peacefully, why should we wake him up because of our burning need to know his other five vital signs?