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As the Time of Death Nears...

As your loved one's time draws near, your anxiety level reaches its peak and your anticipation of the unknown prompts many questions. In an attempt to answer some of these questions, I have prepared the following information for you. It consists of signs which precede death in most people as their body systems slow down and finally cease functioning. For some people these signs appear a few hours before death; for others, a few days. There is no particular order in which these events occur, and some people do not experience all of them. I hope that by your knowing what to expect, you will be comfortable in continuing to provide your loved one the same loving support which has sustained him/her during the illness. Also included are some suggestions for promoting the comfort of your loved one as these signs occur. During this final stage of life, there are no "rights" and "wrongs." Whatever you feel like doing for your loved one is the "right" thing for you to do. This may be no more than sitting or lying with your friend or loved one and communicating assurance that you are there.

Your Loved One May Experience...

There will be less interest in eating and drinking. For many patients, refusal of food is an indication that they are ready to die. Fluid intake may be limited to that which will keep their mouth from feeling too dry.

WHAT YOU CAN DO: Offer, but do not force, food, liquids, and medications. Pain which has required medication to control in the past may no longer be a problem. Urinary output may decrease in amount and frequency.

WHAT YOU CAN DO: Nothing, unless the patient expresses a desire to urinate and cannot. Call the hospice nurse for advice. As the body weakens, the patient will sleep more and begin to detach himself from his environment. The caregiver's attempts to make him more comfortable may be refused.

WHAT YOU CAN DO: Let him/her sleep. At this point, "being with" is more important than "doing for." Mental confusion may become apparent as less oxygen is available to supply the brain. The patient may be disturbed by "strange" dreams.

WHAT YOU CAN DO: As he awakens from periods of sleep, remind him of the day and time, where he is, and who is present. This is best done in a casual, conversational way. Vision and hearing may be somewhat impaired, and speech may be difficult to understand.

WHAT YOU CAN DO: Speak clearly, but no more loudly than necessary. Keep the room as light as the patient wishes, even at night. Carry on all conversations as if they can be heard, since hearing is the last of the senses to cease functioning. Many patients are able to talk until minutes before death and are reassured by the exchange of a few words with a loved one. Secretions may collect in the back of the throat and rattle or gurgle as the patient breathes through his mouth. He may try to cough up mucous. His mouth may become dry and encrusted with secretions.

WHAT YOU CAN DO: If the patient is trying to cough up secretions and is experiencing choking or vomiting, humidification of the air with a cool mist vaporizer may help. Otherwise, call your Hospice nurse for advice. Secretions may drain from the mouth if the patient is placed on his side and supported with pillows. Cleansing the mouth with swabs dipped in glycerin or mineral oil or even cool water will help to relieve the dryness that occurs with mouth breathing. Offer water in small amounts to keep the mouth moist. A straw with one finger placed over the end can be used to transfer sips of water to the patient's mouth. Breathing may become irregular with no periods of breathing, or apnea, lasting around 20 to 30 seconds. The patient may seem to be working very hard to breathe and may make a moaning sound with each breath. As the time of death nears, breathing may again become regular but shallower and more mechanical in nature.

WHAT YOU CAN DO: Raise the head of the bed if the patient breathes more easily this way. The moaning is not necessarily indicative of pain or distress, but often is only the sound of air passing over very relaxed vocal cords. As the oxygen supply to the brain decreases, the patient may become restless. It is not unusual for patients to pull at bed linens, to have visual hallucinations, or even try to get out of bed at this point.

WHAT YOU CAN DO: Reassure the patient in a calm voice that you are there. Prevent him from falling if he tries to get out of bed. Soft music or a back rub may help quiet him. The patient may feel hot one minute and cold the next as the body loses its ability to control its temperature. As circulation slows down, the arms and legs will become cool and may be bluish in color. the underside of the body may darken. It may be impossible to feel a pulse at the wrist.

WHAT YOU CAN DO: Provide and remove blankets (not electric) as needed. Sponge patient with cool washcloth if this promotes comfort. Change perspiration-soaked garments and bed linens if the patient wishes. Loss of control of bladder and bowel function may occur around the time of death.

WHAT YOU CAN DO: Protect the mattress with a plastic sheet. Keep chux or waterproof padding under the patient, and change as needed to keep the patient comfortable.

At the Time of Death...

Breathing ceases.

Heartbeat ceases.

The patient cannot be aroused.

The eyelids may be partially open with the eyes in a fixed stare.

The mouth may fall open slightly as the jaw relaxes.

Any waste matter in the bladder or rectum will be released as the sphincter muscles relax.


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