Learn the Signs and How to Deal With An Approaching Death
When a person enters the final stages of the dying process, two different dynamics are at work. These are closely interrelated yet happen at different rates. On the physical plane, the body begins the final process of shutting down. This ends when all the physical systems cease to function. Usually, this is an orderly and non-dramatic, progressive series of physical changes. They are not medical emergencies requiring aggressive treatment. These physical changes are a normal way the body prepares itself to stop. The most appropriate kinds of responses are comfort measures
The other dynamic of the dying process is emotional-spiritual-mental. This is a different kind of process. The spirit of the dying person begins the final process of releasing from the body, its immediate environment, and all of its attachments. This release tends to follow its own priorities, which may include a resolution of unfinished or unresolved issues of relationships, and reception of permission to “let go” from family members. These events are the normal, natural way in which the spirit prepares to move from this existence into the next dimension of life.. The most appropriate kinds of responses to the emotional-spiritual-mental changes are those supporting and encouraging these resolutions and release.
When a person’s body is ready and waiting to stop, but the person still has unresolved issues or unreconciled relationships, he or she may tend to linger, seeking to finish whatever needs finishing. This occurs even though he or she may be uncomfortable or debilitated. On the other hand, when a person is emotionally-spiritually-mentally resolved and ready for this release, the person will continue to live until that shut down process is complete.
The experience that we call a “natural death” occurs when the body completes its natural process of shutting down, and 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 lifestyle of the dying person.
In preparation for these events, we want you to know what to expect and how to respond with support and understanding. You can help your loved one to accomplish this transition with comfort and ease. This is a great gift of love that you have to offer to your loved one as this transition approaches.
The signs and symptoms of impending death that follow are offered to help you understand the natural kinds of things that may happen and how you can respond appropriately. Not all of these signs and symptoms will occur with every person, nor will they occur in a particular sequence. Each person is unique and needs to do things in his or her own way. This is not the time to try to change your loved one. It is the time to give full acceptance, support and comfort.
The following signs and symptoms are indicative of the body preparing itself for the final stage of life.
COOLNESS
The person’s hands and arms, feet and legs may be increasingly cool to the touch, and the color of the skin may change. This is a normal indication that the circulation of blood is decreasing to the body’s extremities and is being reserved for the most vital organs. Keep the person warm with a blanket, but do not use one that is electric.
SLEEPINESS
The person may spend an increasing amount of time sleeping, and appear to be uncommunicative or unresponsive. At times, they may be difficult to arouse. This normal change is due in part to changes in the metabolism of the body. Sit with your loved one. Hold his or her hand, but do not shake them or speak loudly. Speak softly and naturally. Plan to spend time with your loved one during those times when he or she seems most alert or awake. Do not talk about the person in the person’s presence. Speak to him or her directly, as you normally would, even though there may be no response. Never assume the person can’t hear. Hearing is the last sense to be lost.
DISORIENTATION
The person may seem to be confused about time, place and the identity of the people surrounding him or her, including close and familiar people. This is also due in part to the metabolism changes. Identify yourself by name before you speak, rather than to ask the person to guess your identity. Speak softly, clearly and truthfully when you need to communicate something important for the patient’s comfort, such as, “It is time to take your medication”, and explain the reason for the medication, such as, “…so you won’t begin to hurt.” Do not try to manipulate the patient to meet your needs.
INCONTINENCE
The person may lose control of urine and/or bowel movements as the muscles in that area begin to relax. Discuss with your nurse what can be done to protect the bed and keep your loved one clean and comfortable.
CONGESTION
The person may have a gurgling sound coming from his or her chest as though marbles were rolling around inside. These sounds may become very loud. This normal change is due to the decrease of fluid intake and an inability to cough up normal secretions. Suctioning usually only increases the secretions and causes sharp discomfort. Gently turn the person’s head to the side and allow gravity to drain the secretions. You may also gently wipe the mouth with a moist cloth. The sound of the congestion does not indicate the onset of new or severe pain.
RESTLESSNESS
The person may make restless and repetitive motions such as pulling at bed linen or clothing. This may happen often and is due in part to the decrease in oxygen circulation to the brain and to metabolic changes. Do not interfere with or try to restrain such motions. To have a calming effect, speak in a quiet and natural way, lightly massage the forehead, read to the person or play some soothing music.
URINE DECREASE
The person’s urine output normally decreases and may become tea colored, which is referred to as “concentrated urine.” This is due to the decreased fluid intake, as well as decreased circulation through the kidneys. Consult with your nurse to determine whether there may be a need to insert or irrigate with a catheter.
FLUID AND FOOD DECREASE
The person may have a decrease in appetite and thirst, wanting to eat or drink very little. The body will naturally begin to conserve energy which is 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 something. To do this only makes the person much more uncomfortable. Small chips of ice, frozen Gatorade or juice may be given in small amounts. Glycerine swabs may help to keep the mouth and lips moist and comfortable. A cool, moist washcloth on the forehead may also increase physical comfort.
BREATHING PATTERN CHANGES
The person’s regular breathing pattern may change. A particular pattern consists of breathing irregularly, taking shallow breaths followed with a period of not breathing for a few seconds and up to a full minute. This is called Cheyne-Stokes breathing. The person may also experience periods of rapid, shallow panting. Both of these patterns are very common and indicate decrease of circulation in the internal organs. Elevating the head, and/or turning the person onto his/her side may bring comfort. Hold your loved one’s hand. Speak gently.
Normal Emotional, Spiritual and Mental Signs and Symptoms with Appropriate Responses
WITHDRAWAL
The person may seem unresponsive, withdrawn or in a comatose-like state. This indicates preparation for release, a detaching from surroundings and relationships, and a beginning of letting go. Since hearing remains all the way to the end, speak to your loved one in a normal tone of voice, identifying yourself by name when you speak. Hold his or her hand and say whatever you need to say that will help the person let go.
VISION-LIKE EXPERIENCES
The person may speak or claim to have spoken to persons who have already died. He/She may see or speak of places not presently visible to you. This does not indicate a hallucination or a drug reaction. The person is beginning to detach from this life and is being prepared for the transition so it will not be frightening. Do not contradict, explain away, belittle or argue about what the person claims to have seen or heard. Just because you cannot see or hear it does not mean it is not real to your loved one. Know that these are normal occurrences. Ask your loved one to say more about the encounter.
RESTLESSNESS
The person may perform repetitive and restless talks. This may in part indicate that something unresolved or unfinished is disturbing him or her, and prevents him or her from letting go. Your care team will assist you to identify what may be happening, and help the person find release from the tension or fear. Other things which may be helpful in calming the person are to recall a favorite place the person enjoyed, a favorite experience, read something comforting, play music or give assurance that it is OK to let go.
DECREASED SOCIALIZATION
The person may only want to be with a very few or even just one person. This is a sign of preparation for release and affirms from whom the support is most needed in order to make the appropriate transition. If you are not part of this inner circle at the end, it does not mean that you are not loved or are unimportant. It means that you have already fulfilled your talk with your loved one, and it is time to say good-bye. If you are part of the final, inner circle of support, the person needs your affirmation, support and permission.
UNUSUAL COMMUNICATION
The person may make a seemingly out of character statement, gesture or request. This indicates that he or she is ready to say good-bye and is testing you to see if you are ready to let him or her go. Accept the moment as a beautiful gift when it is offered. Kiss, hug, hold, cry, and say what ever you most need to say.
GIVING PERMISSION
Giving permission to your loved one to let go can be difficult. You may face a temptation to impose a sense of guilt for leaving you or to keep him or her with you to meet your own needs.. A dying person will normally try to hold on, even though it brings a prolonged discomfort, in order to be sure those who are being left behind will be all right. Your ability to release the dying person from this concern will give him or her assurance that it is all right to let go whenever he or she is ready. This is one on the greatest gifts you can give to your loved one at this time.
SAYING GOOD-BYE
When the person is ready to die, and you are able to let go, then it is time to say good-bye. Saying goodbye is your final gift of love to your loved one, for it achieves closure and makes the final release possible. It may be helpful to lie in bed and hold the person, or to hold his or her hand, and then say everything you need to say.
It may be as simple as saying, “I love you.” It may include recounting favorite memories, places and activities you shared. It may include saying, “I’m sorry for whatever I contributed to any tension to our relationship.” It may also include saying, “Thank you for…”
Tears are a normal and natural part of saying goodbye. Tears do not need to be hidden from your loved one, nor is apology needed for your tears. Tears express your love and help you to let go.
HOW WILL YOU KNOW WHEN DEATH HAS OCCURRED?
Although you may be prepared for the dying process, you may not be prepared for the actual moment of death. It may be helpful for you and your family to think about and discuss what you would do if you were the only one present at the moment of death. The natural death of a person at the end of this process is not an emergency. Nothing must be done immediately.
The signs of death include such things as no breathing, no heartbeat, release of bowel and bladder, no response, eyelids slightly open, pupils enlarged, eyes fixed on a certain spot, no blinking, jaw relaxed and mouth open slightly.
A nurse will come to assist you. Please notify the desk as soon as possible so we can send the nurse.
The body does not have to be moved until you are ready. The family may assist in preparing the body by bathing or dressing. Your nurse will call the funeral home when you are ready for your loved one to be picked up. The nurse will also notify the physician.
THANK YOU
We at the Baptist Health System thank you for the privilege of caring for your loved one. We salute you for all you have done to surround your loved one with understanding care, to provide your loved one with comfort and calm, and to enable your loved one to leave this world with a special sense of peace and love.
You will have given your beloved one of the most wonderful, beautiful, and sensitive gifts that we humans have to offer, and in giving that gift, have given yourself a wonderful gift as well.