Topic: 19

Signs of Approaching Death and What to Do

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What You Need to Know

Some deaths may take a long time, and this puts tremendous strain on everyone involved in the person’s care, especially you. Some deaths are sudden, some are painful and some do not progress as expected. However, most people do slip into a state of unawareness. For example, many people die after being in a coma for several days or hours. Some family members become troubled toward the end of a person’s life because they feel that they are not doing enough. Many exhausted family members, who have watched their loved ones struggle, will long to have the ordeal end. The expression of such a desire creates a lot of unnecessary guilt.

Note: Having had Advance Care Plan discussions at an earlier time can provide much comfort at this very emotional time. See Topic #7.

Physical Changes in the Last Hours of Life

Each person’s experience will be different. Some people will have all of these physical changes and other people will only have a few.

The person may:

  • Sleep longer and sometimes have difficulty waking up eventually slipping into a coma
  • Become confused or agitated
  • Eat and drink less if at all and have no appetite or thirst
  • Become unable to recognize familiar people or surroundings
  • Become profoundly weak
  • Have difficulty responding verbally
  • May have difficulty swallowing or forget how to swallow
  • Develop a fixed stare
  • Breathe shallowly and irregularly even stopping breathing for several seconds at a time
  • Make wet or moist breathing sounds or make a rattling gasp for air
  • Have a weak or irregular pulse
  • Have cool hands and feet and pale bluish or mottled skin (dark and light patches)
  • Have less urine output and/or lose bladder control
  • Have no bowel movement or have uncontrolled oozing of soft liquid or stool

Strategies to Support the Person in the Last Hours

  1. Conversation: Continue to speak to the person, say their name, often hearing is the last sense to diminish
  2. Personal care: Bathe as needed, use the usual bed coverings although the person’s skin may feel cold, reposition every 1-2 hours, moisten the eyes with eye drops especially if their eyes have been open for long periods of time
  3. Pain management: Continue giving pain medication, if the person can’t swallow use a suppository or injection under the skin that the doctor will prescribe; provide reassurance, speak soothingly, massage the person gently, be alert to any needs the person communicates
  4. Be present: Encourage reminiscing, prayers, tears, touching, hand holding, hugging
  5. Oral care: Only offer what the person wants, remind them to swallow, if they can’t swallow do not attempt to force fluids as it may cause choking or vomiting, moisten the mouth with swabs or a moist cloth, lubricate the lips
  6. Breathing management: Turn the person on their side, raise the head of the bed, and contact the doctor or nurse if breathing becomes moist as medications can decrease this moisture
  7. Incontinence management: Place protective pads or toweling under the person’s hips and change when necessary, use adult incontinence briefs if necessary and change as needed

The Stages of Death People wonder when exactly a person is going to die. Sometimes a doctor has made a prognosis about how much time a patient has but people may live longer or die earlier.

There are two phases which arise prior to death:

a. Pre-active phase of dying (The pre-active phase of dying takes about two weeks)

  • Increased restlessness, confusion, agitation, inability to stay content in one position and insisting on changing positions frequently (exhausting for caregivers)
  • Withdrawal from active participation in social activities
  • Beginning to show periods of pausing in the breathing (apnea) whether awake or sleeping
  • Decreased intake of food and liquids
  • Reports seeing persons who had already died
  • Increased swelling (edema) of either the extremities or the entire body
  • Inability to heal or recover from wounds or infections

b. Active phase of dying (The active phase of dying takes about three days.)

  • Inability to arouse the person at all (coma) or, able to only arouse the person with great effort but they quickly return to a severely unresponsive state (semi-coma)
  • Severe agitation, hallucinations, not in the person's normal manner or personality
  • Dramatic changes in the breathing pattern including very rapid breathing or slow progressing to fast breathing
  • Inability to swallow any fluids at all
  • Hands, arms, feet and legs feel very cold to touch
  • Body is held in rigid unchanging position
  • Jaw drop; jaw is no longer held straight and may drop to the side their head is lying towards
  • Cyanosis or a bluish or purple coloring to the arms and legs, especially the feet, knees, and hands)
  • Urinary or bowel incontinence in a person who was not incontinent before; this symptom may be present for longer than 3 days

When to Call for Help

Caregivers must know whom to call with questions about pain and if they need urgent help. If you are caring for someone at home, ask the person’s doctor(s) or the visiting nurse when and whom to call for help.

Some situations that require assistance from health care professionals include:

  • The person has pain or other symptoms that are difficult to manage or relieve.
  • The person is unable to take prescribed medications.
  • The person shows signs of distress, such as pain, breathing problems, or agitation.
  • You are overwhelmed by the person’s needs and condition.
  • You believe the person has died.

 

1. Read this scenario

Clarence and Lydia were suffering from shock and denial about the recent diagnosis of their son, Luke. With a rare form of cancer and a very poor prognosis they were having a great deal of difficulty coming to terms with the fact that their son was dying. Wishing to care for him at home, they made the decision to move forward with taking leaves of absence from their jobs and outfitting their home to ensure that Luke was still at the heart of the home.

2. Now that you understand more about the final weeks of life, do you think Lydia and Clarence should be told what to expect/what will happen? Why or why not? Write down your thoughts before checking the sample answer.

Sample response:

Yes they should be told. If they want to care for Luke at home then they need all the information possible ahead of time to prepare them to handle what lies ahead. Once they understand what is going to happen they will be more prepared and more able to put supports in place to help them if and when they feel that might be necessary.

 

 

Use these additional resources to learn more about the topic of the signs of approaching death.

Canadian Cancer Society: Signs that Death is Near
http://www.cancer.ca/en/cancer-information/cancer-journey/advanced-cancer/signs-that-death-is-near/?region=on

How to Say Good-bye When Someone You Love is Dying
https://www.caring.com/articles/how-to-say-goodbye

What Dying Looks Like During the Final Weeks of Life

What Dying Looks Like During Final Days of Life

Comforting Your Loved One When They Are Dying 

 

Funeral Planning