Hospice of San Luis Obispo County : 805.544.2266

Hospice of San Luis Obispo County

As Death Approaches

The following is excerpted from "The Dying Experience", by Barbara Karnes:

Each person approaches death in his own way, bringing to this last experience his own uniqueness. What is listed here is simply a guideline, a road map. Like any map there are many roads arriving at the same destination, many ways to enter the same city.
Use this guideline while remembering there is nothing concrete here, all is very, very flexible. Any one of the signs in this booklet may be present, all may be present, none may be present. For some it will take months to separate from their physical body, for others only minutes.
Death comes in its own time, in its own way.
Death is as unique as the individual who is experiencing it.
If the following signs were to be put on a time table, a very flexible time table, we could say these changes begin one to three months before death occurs. The actual dying process often begins within the two weeks prior to death. There is a shift that occurs within a person which takes them from a mental processing of death to a true comprehension and belief in their own mortality. Unfortunately this understanding is not always shared with others.

One to Three Months Prior to Death
Withdrawal:
As the knowledge that "yes I am dying" becomes real, a person begins to withdraw from the world around them. This is the beginning of separation, first from the world--no more interest in newspapers or television; then from people--no more neighbors visiting: "Tell Aunt Jessie I don't feel like company today," and finally from the children, grandchildren, and perhaps even those persons most loved.
This is a time of withdrawing from everything outside of one's self and going inside. Inside, there is sorting out, a processing of one's self and one's life. But inside there is only room for one.
This processing of one's life is usually done with the eyes closed, so sleep increases. A morning nap is added to the usual afternoon nap. Staying in bed all day and spending more time asleep than awake becomes the norm. This appears to be just sleep, but know that important work is going on inside at a level of which "outsiders" aren't aware.
With this withdrawing comes less of a need to communicate with others. Words are seen as being connected with the physical life that is being left. Words lose their importance; touch and wordlessness take on more meaning.

Food:
Food is the way we energize our body. It is the means by which our body is kept going, moving, alive. We eat to live. When a body is preparing to die, it is perfectly natural that eating should stop. This is one of the hardest concepts for a family to accept.
There is a gradual decrease in eating. Nothing tastes good. Cravings come and go. Liquids are preferred to solids. "I just don't feel like eating." Meats are the first to go, followed by vegetables and other hard-to-digest foods until even soft foods are no longer eaten.
It is okay not to eat. A different kind of energy is needed now. A spiritual energy, not a physical one, will sustain from here on.

One to Two Weeks Prior to Death
Disorientation:
Sleeping is most of the time now. A person can't seem to keep his eyes open. They can, however, be awakened from that sleep. There is literally one foot in each world. A person often becomes confused, talking to people, and about places and events, that are unknown to others. They may see and converse with loved ones who have died before them. There may be picking at the bedclothes and agitated arm movements. There is a seeming aimlessness to all physical activity. Focus is changing from this world to the next. They are losing their grounding to earth.

Physical Changes:
· There are beginning changes which show the physical body is losing its ability to
maintain itself.
· The blood pressure often lowers.
· There are changes in the pulse: either increasing from a normal of eighty to upwards of
one hundred fifty, or decreasing anywhere down to zero.
· The body temperature fluctuates between fever and cold.
· There is increased perspiration, often with clamminess.
· The skin color changes: flushing with the fever, bluish with the cold. A pale yellowish pallor (not to be confused with jaundice) often accompanies approaching death. The nails, hands, and feet are often pale and bluish because the heart can't circulate the blood through the body at a normal flow.
· Breathing changes also occur. Respiration may increase from a normal of sixteen to twenty to upwards of forty or fifty or decrease to nine or even six breaths every minute. There can be a puffing, a blowing of the lips on exhaling, or actual stopping of the rhythmic breathing only to resume again. This generally occurs during sleep. Congestion can also occur, a rattled sound in the lungs and upper throat. There might be coughing with this but generally nothing can be brought up. All of these breathing changes and congestion have a tendency to come and go. One minute any or all of these symptoms can be present, the next minute breathing may clear and even.

One or Two Days, to Hours Prior to Death
Sometimes there is a surge of energy, a person may talk clearly and alertly when before there had been disorientation. A favorite meal might be asked for and eaten when nothing had been eaten for days. A person might sit in the living room with relatives and visit when they hadn't wanted to be with anyone for quite awhile. The spiritual energy for transition from this world to the next has arrived and it is used for a time of physical expression before moving on. This surge of energy is not always as noticeable as the above examples, but in hindsight it can usually be recognized.
The one to two week signs that were present before become more intense as death approaches.
Restlessness can further increase due to lack of oxygen in the blood.
The breathing patterns become slower and more irregular. Breathing often stops for forty-five seconds before resuming again.
Congestion can be very loud. It can be affected by positioning on one side or the other. It still comes and goes.
The eyes may be open or semi-open but not seeing. There is a glassy look to them, often tearing.
The hands and feet now become purplish. The knees, ankles, and elbows are blotchy. The underside of the arms, legs, back, and buttocks can also be blotchy.
Generally, a person becomes non-responsive, unable to respond to their environment, sometime prior to death.
How we approach death is going to depend upon how much fear we have, how much we participated in life, and how willing we are to let go of this known expression to venture into a new one. Fear and unfinished business are two big factors in how much resistance we put into meeting death.
The separation becomes complete with breath stopping. What appears to be the last breath is often followed by one to two long spaced breaths and then the physical body is empty. The owner is no longer in need of a heavy, nonfunctional vehicle.
They have entered a new city, a new life.

Summary of Guidelines:
One to Three Months
Withdrawal from the world and people
Decreased food intake
Increase in sleep
Going inside of self
Less communication
One to Two Weeks
Disorientation
Agitation
Talking with the unseen
Confusion
Picking at clothes or bed sheets
Decreased blood pressure
Pulse increase or decrease
Color changes, pale, bluish
Increased perspiration
Respiration irregularities
Congestion
Sleeping but responding
Complaints of body, tired and heavy
Not eating, taking little fluids
Body temperature hot/cold
Days or Hours
Intensification of one to two week signs
Surge of energy
Decrease in blood pressure
Eyes glassy, tearing, half open
Irregular breathing, stop/start
Restlessness or no activity
Purplish knees, feet, hands, blotchy
Pulse weak and hard to get
Decreased urine output
May wet or stool the bed
Cannot be awakened

The Hospice staff realizes that this particular period of time is one of the most difficult times you and your family will have to live through. Our approach in all matters affecting you during this time is to be as honest and straightforward as possible. Our philosophy of care is that fear of the unknown is always greater than the fear of the known. In this vein, we offer you the following information to help you prepare and anticipate symptoms which are indicative of approaching death. Your Hospice staff member, nurse, Hospice nurse, volunteer, and physician are the best resources to help you clarify your concerns about this information.
Note: Not all symptoms will appear at the same time and some may never appear.
We want to relate each possible symptom to you in order to decrease your fear if one should appear suddenly. All of the symptoms described are indicative of how the body prepares itself for the final stage of life.

1. The arms and legs of the body may become cool to the touch and you may notice the underside of the body becoming much darker in color. These symptoms are a result of blood circulation slowing down.
2. The Hospice patient will gradually spend more and more time sleeping during the day and at times will be difficult to arouse. This is a result of a change in the body's metabolism.
3. Your family member may become increasingly confused about time, place, and identity of close and familiar people. Again, this is a result of body metabolism changes.
4. Incontinence (1oss of control) of urine and bowel movements is not often a problem until death becomes imminent. Your Hospice nurse can help you with this.
5. Oral secretions may become more profuse and collect in the back of the throat. You may have heard friends refer to a death rattle. This symptom is a result of a decrease in the body's intake of fluids and inability to cough up normal saliva productions.
6. Clarity of hearing and vision may decrease slightly, but they may also be enhanced, so you should be aware that your family member may hear and be comforted by what you are saying to him, even though your family member may seem to be unaware of his surroundings.
7. You may notice your loved one becoming restless, pulling at bed linen, and having visions of people or things which do not exist. These symptoms are a result of a decrease in the oxygen circulation to the brain and a change in the body's metabolism.
8. Your family member will have decreased need for food and drink because the body will naturally begin to conserve energy .
9. During sleep, at first, you will notice breathing patterns in your loved one change to an irregular pace where there may be 10 to 30 second periods of no breathing. Your doctor and nurse refer to this as periods of apnea. This symptom is very common and indicative of a decrease in circulation and build up in body waste products.
10. If your loved one has a bladder catheter in place, you will notice that the amount of urine will decrease as death comes closer.

What You Can Do About Symptoms
1. Keep light but warm blankets on the patient to prevent the feeling of being cold as circulation decreases.
2. Spend time with the patient when they appear to be more alert. Encourage family members to visit at these times.
3. Remind the patient what day it is, the time, who is in the room, and continue talking to them.
4. Check for incontinence when patient is repositioned every two hours.

5. A cool mist humidifier and elevating the head of the bed slightly may make breathing easier.

6. Providing mouth care, such as offering ice chips, will help relieve dehydration of the mouth.

7 . Never assume that the patient cannot hear you. Hearing is the last of the five senses to be lost.

8. Talk calmly and assure the confused patient that they are being cared for and are not alone.

9. Ask the nurse about offering food supplements when patient cannot eat.

10. Notify the nurse if foley catheter drainage stops. The catheter may be occluded

11. Encourage family to be involved in the care if they wish to be. Offer coffee and other fluids to family members. They may not take good care of themselves at this time.

12. Often, family members want to be present at the time of death. Provide privacy and time with their loved one, both before and after the death occurs.

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