When a person is nearing the end of life, their skin can take on a yellowish hue. This is referred to as jaundice or icterus. Jaundice occurs when there is a buildup of bilirubin in the blood. Bilirubin is a yellow pigment that is formed by the breakdown of red blood cells. Normally, the liver filters bilirubin out of the blood and excretes it into the intestines as bile. However, when the liver is not functioning properly, bilirubin can build up and leak into the skin, causing a yellow discoloration.
What causes jaundice in dying patients?
There are several possible causes of jaundice in patients who are dying:
- Liver failure – As the liver shuts down, it is unable to properly filter bilirubin out of the bloodstream. Liver failure can occur due to cirrhosis, hepatitis, cancer that has spread to the liver, or other liver diseases.
- Bile duct obstruction – Tumors or gallstones can block the bile ducts leading from the liver to the intestines. This prevents bilirubin from being excreted, causing a buildup in the blood.
- Hemolysis – The rapid breakdown of red blood cells releases a flood of bilirubin into the blood, overwhelming the liver’s ability to clear it. This can occur in blood cancers or autoimmune diseases.
- Sepsis – Widespread infection can damage the liver and lead to cholestasis, where bile flow is impaired.
- Cancer – Cancers that have spread to the liver or pancreas can impair bile production and cause jaundice.
- Medications – Some medications are processed by the liver and can cause inflammation or toxicity that impairs liver function.
What happens to the liver as death approaches?
As death approaches, the dying process causes profound changes in the functioning of organs, including the liver. Here is what happens in the liver as the body shuts down:
- Reduced blood flow – Blood pressure drops and circulation slows, reducing blood flow to the liver. This impairs its ability to filter toxins and wastes.
- Impaired metabolism – Dying cells release toxins into the blood that the liver must metabolize. With reduced liver function, these build up.
- Fluid retention – The kidneys start to fail, leading to fluid retention and swelling. This fluid can back up into the liver, further impairing function.
- Reduced bile flow – Sphincters constrict bile ducts, blocking the flow of bile needed to excrete bilirubin.
- Cell death – Liver cells start dying off, further reducing the liver’s functional capacity.
All of these changes mean the liver is unable to keep up with clearing bilirubin from the bloodstream, allowing it to build to high levels that cause jaundice.
How quickly does jaundice develop in dying patients?
Jaundice can develop rapidly in the final days and hours of life. The speed of onset depends on the underlying cause:
- Acute liver failure – Jaundice can appear in hours to days if acute injury causes rapid total loss of liver function.
- Worsening chronic disease – In chronic liver disease, jaundice may build slowly over weeks as function declines.
- Obstructive jaundice – Blockage of bile ducts can cause bilirubin levels to rise sharply over a period of days.
- Terminal cancer – Jaundice often develops over 1-2 weeks as liver metastases or cachexia impair function.
- Sepsis – Jaundice can develop in 24-48 hours as infection overwhelms the liver’s defenses.
Rapidly rising bilirubin levels in the final stages of illness can quickly lead to visible jaundice. Patients near death often have bilirubin levels of 6-10 mg/dL or higher, compared to a normal range of 0.3-1.2 mg/dL.
How common is jaundice in dying patients?
Jaundice is very common as death approaches. Estimates suggest:
- 60-80% of patients with terminal cancer develop jaundice in the final weeks.
- Up to 65% of patients dying from chronic liver disease exhibit jaundice.
- Approximately 50% of patients dying from sepsis develop jaundice.
- Jaundice occurs in 30-60% of patients with end-stage heart, kidney, or lung disease.
Overall, research indicates that visible jaundice occurs in 50-70% of actively dying patients in the final days to hours of life across all diseases. The table below summarizes the frequency of jaundice by condition:
| Disease/Condition | Frequency of Jaundice |
|---|---|
| Cirrhosis/liver failure | 60-65% |
| Metastatic cancer | 60-80% |
| Sepsis | 40-50% |
| Congestive heart failure | 25-40% |
| Chronic lung disease | 30-60% |
| Chronic kidney disease | 30-55% |
Is jaundice painful for the patient?
Jaundice itself does not cause pain. However, some of the underlying conditions leading to jaundice can be painful, such as:
- Gallstones blocking bile ducts may cause right upper quadrant abdominal pain.
- Cancer metastases in the liver can cause hepatomegaly (enlarged liver) which can be painful.
- Massive liver cell death in acute failure causes swelling and an aching pain.
- Bile duct inflammation leads to itching which can be very uncomfortable.
Thankfully, dying patients are often not awake or conscious during the final stages when jaundice develops. The body releases endogenous opioids and sedatives that induce a coma-like state of reduced consciousness. So while jaundice may signal a painful underlying illness, patients are usually unaware and not experiencing pain as they pass away.
Can jaundice be treated in dying patients?
It is very difficult to treat or reverse jaundice in dying patients. Usually the focus is on comfort and reducing suffering. Possible medical interventions include:
- Treating underlying infections with antibiotics
- Using stents to open blocked bile ducts
- Medications to reduce fluid retention
- Pain management with opioids
- Reducing itching with antihistamines
However, since jaundice indicates organ failure, treatment options are very limited so close to death. Interventions may be too invasive or cause unnecessary discomfort. Therefore, the priority is minimizing distress and helping the patient pass peacefully once jaundice sets in.
What is the significance of jaundice before death?
For clinicians, the development of jaundice is an important prognostic indicator. It signals that death is nearing and the patient has days to hours left to live. Jaundice indicates that multiple organ systems are failing and the body’s physiology is shutting down. Specifically, jaundice shows that:
- The liver is no longer able to clear toxins and wastes.
- Bile flow is obstructed, preventing bilirubin excretion.
- Red blood cell turnover is increasing as the body deteriorates.
- The kidneys can no longer properly regulate fluid balance.
Seeing scleral icterus (yellowing of the eyes) is a clear sign that bilirubin levels are pathologically elevated. For family members, jaundice signals the need to gather at the bedside and prepare for farewells. So while not painful in itself, jaundice is an important indicator of the body’s declining functioning as death approaches.
Can jaundice occur after death?
It is possible for jaundice to develop in the hours after death as the body settles. This occurs due to a continuation of the processes leading to increased bilirubin shortly before death. For example:
- Remaining red blood cells break down, dumping bilirubin into tissues.
- With no blood flow, bilirubin cannot be cleared and spreads through the body.
- As blood pools due to gravity, bilirubin stains the lower skin surfaces yellow.
- Cold temperatures cause greenish skin discoloration that may look jaundiced.
So while most jaundice develops in the final living stages, additional yellowing can continue post-mortem. However, the bilirubin levels usually do not increase significantly after death compared to the hyperbilirubinemia seen terminally.
Can jaundice be prevented?
There is no reliable way to prevent jaundice as death approaches if the underlying diseases follow their natural courses. However, some measures can potentially slow its progression:
- Treating diseases like HIV or autoimmune conditions that cause liver injury.
- Catching liver and bile duct tumors early before they cause impairment.
- Preventing hepatitis infection through vaccination.
- Avoiding alcohol abuse and toxin exposure that damage the liver.
- Controlling chronic illnesses that can lead to fluid overload.
Palliative care specialists also focus on optimizing nutrition and hydration in terminal patients to support liver function as long as possible. But when multiple organs begin to fail as death nears, jaundice usually cannot be avoided entirely.
Conclusion
Jaundice in the last days of life signals multiorgan failure and the body’s release of toxins as tissues start to break down. While not inherently uncomfortable, it is an expected consequence of the dying process as the liver shuts down. Jaundice provides families and clinicians with a visual indicator that the end is approaching. Understanding its causes, timeline, and implications allows full preparation for the final farewells.