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Preparing for Death

Preparing for Approaching Death: Signs and Symptoms

Death occurs when the body completes its natural process of shutting down, and when the spirit completes its natural process of reconciling and finishing. These two processes need to happen in a way appropriate and unique to the values, beliefs, and lifestyles of the dying person.

In the final stage of terminal illness, caregiver anxiety reaches its peak and anticipation of the unknown brings many questions to mind.

When a person enters the final stages of the dying process, two different dynamics are at work that are closely inter-related and inter-dependent. On the physical plane, the body begins the final process of shutting down, which will end when all physical systems cease to function. Usually this is an orderly and undynamic series of physical changes which are not medical emergencies and do not require invasive interventions. These physical changes are a normal, natural way in which the body prepares itself to stop, and the most appropriate kinds of responses are comfort-enhancing measures.

The following signs and symptoms describe how the body prepares itself for the final stage of life.

Fluid and Food Decreases
The person may have a decrease in appetite and thirst, wanting little or no food or fluid. The body will naturally begin to conserve the energy expended on these tasks. Do not try to force food or drink into the person, or try to use guilt to manipulate them into eating or drinking. Since normal hydration is often not feasible, it is more peaceful to decline in a state of dehydration than fluid overload. Small chips of ice, frozen juice or popsicles may be refreshing in the mouth. Be careful of decreased swallowing ability, and do not force fluids if the person coughs soon after. Reflexes needed to swallow may be sluggish. The loss of desire for food or liquids is a signal that the body is shutting down and dehydration no longer makes the person uncomfortable. Glycerin swabs to apply water-soluble lubricant will keep the mouth and lips moist, comfortable and hydrated.

Decreased Socialization
The person may want to be alone or with just one person. This is natural when one is weak and fatigued. As well, the path seems a solitary one of progressive detachment.

Sleeping
The person may spend an increasing amount of time sleeping, and appear to be uncommunicative, unresponsive, and at times difficult to arouse. This is normal and due in part to changes in the metabolism of the body. At this point being with the patient is more important than doing for them. Speak directly and normally even though there may be no response. Never assume that the person cannot hear; hearing is the last of the senses to be lost.

Restlessness
The person may make restless and repetitive motions such as pulling at bed linen or clothing. This is called terminal restlessness and is due to the decrease in circulation to the brain and metabolic changes. Do not be alarmed, interfere, or try to restrain such motions. Speak in a quiet, natural way, lightly massage the hand/forehead, read aloud or play soothing music.
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Disorientation
The person may be confused about time, place and the identity of the people surrounding them including close and familiar people. Identify yourself by name before you speak rather than asking the person to guess who you are. Speak softly, clearly, and truthfully when communicating something important for the patient’s comfort, such as, “It’s time to take your medication,” explaining “so you won’t begin to hurt.”

Urine Decrease
Urine output normally decreases and may become tea-colored, referred to as concentrated urine. This is due to the decreased fluid intake, as well as decreased circulation through the kidneys, and fluid loss through breathing and respiration.

Incontinence
The person may lose control of urine and/or bowels as the muscles in that area begin to relax. Protective measures should be taken to keep the patient clean and comfortable.

Breathing Pattern Changes
The person’s regular breathing may change with the onset of a different breathing pace. A particular pattern consists of breathing irregularly with shallow respirations, or periods of no breaths for 5 – 30 seconds, followed by a deep breath. The person may also have period of rapid swallow panting type breathing. Sometimes there is a moaning-like sound on exhale that is not distress, but rather the sound of air passing over relaxed vocal chords. These patterns are common and indicate a decreased circulation in the internal organs. Speak gently and reassuringly.

Congestion
The person may develop gurgling sounds coming from the chest like a percolator. Sometimes these sounds become very loud and can be distressing to hear. The person may have sounds like marbles rolling around coming from the chest. The person is usually unaware of this process, and it is probably harder to watch than it is on the patient. Suctioning is usually ineffective and can be hard on the patient. Raise the head of the bed so the secretions pool low and therefore they don’t stimulate the gag reflex. Speak gently and reassuringly.

Color Changes
The person’s arms and legs may become cold, hot or discolored. The underside of the body may become discolored as circulation decreases. This is a normal indication that the circulation is conserving to the core to support the most vital organs. Irregular temperatures can be the result of the brain sending unclear messages. Keep the patient warm if they appear cold but do not use an electric blanket. If the patient continues to remove the covers allow them a light sheet.

Permission to Go
Families should give permission to let go without feelings of guilt for leaving. A dying person will commonly try to hold on, even though it brings prolonged discomfort, in order to be assured that those left behind will be all right. A family’s ability to reassure and release the dying person from this concern is the greatest gift of love they can give at this time.

Saying Good-Bye
When the person is ready to die, and the family is able to let go, this is the time to say good-bye in personal ways. This closure allows for the final release. It may be helpful just to lay in bed with the person, hold a hand, and say everything you need to say. Tears are a natural part of making peace and saying goodbye. They do not need to be hidden or apologized for; they are an expression of love.

Although this is a stressful time, by being free of anxiety and fear you can help the terminally ill to experience the final stage of life in an atmosphere of calmness and peacefulness.

Knowing When Death Has Occurred

Although you may be prepared for the death process, you may not be prepared for the actual death moment. The death of a hospice patient is not an emergency. Nothing must be done immediately.

At the time of death:

• Breathing ceases
• Heartbeat ceases.
• The person cannot be aroused.
• The eyelids may be partially open with eyes in a fixed state.
• The mouth may fall open as the jaw relaxes.
• There is sometimes a release of bowel and bladder contents as the body relaxes.