On Death and Dying

This is another web classic. It describes the process of "normal" death in detail. I have personally known several people who have died and each of them followed this process exactly. Knowing this process made it all much easier for those of us remaining.


We have no choice in the matter of death, but we do have a choice as to what to learn about death. The dying process is one that must be experienced individually. Usually the act of dying, like that of giving birth, is a process requiring some assistance. Every death is a touching love story, a unique and special drama, just as each birth is. We know that the process of dying begins at birth, yet talk about death in our society is taboo. My process of dying begins when I learn I am dying. For you, my dying process begins when you learn I am dying. These two times may not be the same.

Dying refers to the process of coming to an end of life, while death refers to the event ending physical life on earth. Attitudes and concepts about death and dying vary greatly. Most of the fear experienced is of the unknown. Observing the process of a person dying is extremely difficult for loved ones. Most people do not usually just stop breathing. It is often a slow, lingering, unwinding process. With education and open discussion about the events that will occur, most fear can be alleviated. Sometimes "active dying" occurs over a period of hours or days. Even when the person displays many of the signs, it is difficult to predict the amount of time before death will occur. Some people will experience some of the symptoms we will discuss and then for some unexplained reason their condition may begin to improve a little. These rollercoaster changes can be emotionally and physically exhausting for the caregivers Your Hospice team hopes to support you and make this time less distressing.

When a person enters the final stage of the dying process, several factors are at work that are closely related. A peaceful death can be achieved when there is cohesion within and among the personal and social spheres of being, even though there is a progressive deterioration of the physical sphere. In the physical sphere, the body begins the final process of shutting down, which will end when all the physical systems cease to function. Usually, this is an orderly and undramatic sequence of events that are not medical emergencies. These physical changes are a normal, natural way in which the body prepares itself to stop.

There is not only a physical side of the dying process but also a personal and social side, which is a different kind of process. The "spirit" of the dying person begins the final process of releases from the body, its immediate environment and all attachments and connections. This release from the body has its own priorities, which include the resolution of whatever is unfinished, reconciliation of close 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.

When the body is ready and wanting to stop, but the person is still unresolved over some important issue or reconciled with some significant relationship, the person will tend to linger even though every uncomfortable or debilitated in order to finish whatever needs finishing. On the other hand, when a person is emotionally, spiritually and mentally resolved and ready for this release, but the body has not completed its final physical process, the person may continue to live until the physical shut down is complete.

Death occurs when the body completes its natural process of shutting down, and when the spirit completes its natural process of reconciling and finishing. Just as each person's life is unique, so is his or her death. Because of this, it is difficult to stage exactly what will happen in each situation but we can give you some common signs and symptoms of impending death which will help you to understand the things that may happen and how to respond. This is not the time to change the dying person, but the time to give full acceptance, support and comfort.

Normal Physical Signs And Symptoms With Appropriate Responses
* Your loved one may sleep more often and for longer periods of time and may become difficult to arouse. This normal change is due in part to changes in the metabolism of the body. Sit down with your loved one, hold his or her hand, do not shake or speak loudly but speak softly and naturally.

* Sensation, mobility and reflexes are first lost in the lower extremities, progressing to the upper extremities. As the dying process continues, the sense of touch is diminished yet the dying person can sense pressure. Touch the dying person gently but firmly, since extremely light stroking can be an irritant. Adapt routine care to decrease unnecessary manipulation of the person at this time.

* The sense of vision begins to fail. The person sees only what is nearby and always turns their head toward the light. Although bright, direct light is irritating, do not draw the shades and dim the lights. Instead the use of indirect light will increase the ability of the person to see. Family should sit near the head of the bed.

* The sense of hearing remains. Everyone who comes in contact with the person should talk in a clear, distinct voice, do not whisper. All should be informed that the person may be able to hear voices even when no longer capable of perceiving any other sensory stimuli. Sit near the head of the bed, touch your loved one, hold their hand and encourage everyone to continue talking to the person, even if they are not responsive, until death occurs. Save conversation about the person for other areas other than their room.

* The person may be confused about time, place and identity of the people present. Some of this is due to the decline in vision and hearing and may be in part due to increased sleeping as well as to the metabolism changes occurring. Have visitors identify themselves not "do you know who I am?" Speak softly, clearly and truthfully when you need to communicate something important to the person such as "it is time to take your medication," and explain the reason such as "so you won't begin to hurt. Do not use this method to manipulate the person to meet your needs.

* The person may begin to want little or no food or fluid. This means the body is conserving for other functions the energy that would be used to digest the food. Do not try to force food or drink into the person or try to use guilt to manipulate them into eating or drinking something. This will only make the person feel more uncomfortable. Small chips of ice, frozen Gatorade or juice may be refreshing to the mouth. Cover lips with chapstick, Vaseline or other protective coating. Avoid the drying effects of lemon and glycerin swabs. Remove any debris in the person's mouth by offering frequent peroxide and water rinses. (Dilute peroxide the patient's tolerance.) A cool moist wash cloth on the forehead may also increase physical comfort.

* urine output normally decreases due to the decreased fluid intake as well as a decrease in circulation through the kidneys. As weakness increases the person may lose control of urine and/or bowels as the muscles in that area begin to relax or atrophy. When this occurs, discuss with your Hospice nurse ways to protect the bed and to keep your loved one clean, dry and comfortable.

* Periods (seconds, minutes) of apnea (no breathing) of increasing duration may occur. These periods vary from 15-45 seconds but seem much longer to family members. Breathing may become noisy due to mucous collecting in the throat. Respiratory abnormalities may worsen. There may be periods of rapid respiration alternating with periods of no breathing (apnea). This is called "Cheyne-Strokes" respiration. It is very common and indicates a decrease in circulation to the internal organs. Elevating of the head of the bed 30-45 degrees may help bring comfort.

* You may hear sounds coming from the chest as though marbles were rolling around inside. This is a normal change and is due to the decrease in fluid intake and 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 congestion does not indicate the onset of severe or new pain.

* Peripheral circulation diminishes and extremities may become cold to the touch and the pulse will be harder to feel. There may be an increase in edema of the extremities at this time. The color of the skin may change also. A cool skin surface belies a rising internal body temperature. Sweating occurs as peripheral circulation falls with the most profuse perspiration on the upper parts of the body. Regardless of how cold the skin feels, most dying persons are not aware of feeling cold. Use light clothing and make sure there is fresh circulating air. Heavy blankets should be removed and the person should be covered with light sheets. It is not unusual for a person with cancer to have an elevated temperature even as high as 104 degrees F. as they draw closer to death. Do not become alarmed. Give Tylenol suppositories, use light clothing and cover and for comfort, you may use ice packs wrapped in clothes to the back of the neck, under the arms and at the groin.

* The person may make restless and repetitive motions. This often happens and is due partly to the decrease in oxygen circulation to the brain and to metabolism changes. Do not interfere with or try to restrain such motions. To have a claming effects, speak in a quiet natural way lightly massage the forehead, read to the person, or play some soothing music. In conscious persons, an interval of peace followed by restlessness that is not controlled by medication often signals soon-impending death.

Normal Emotional, Spiritual & Mental Signs

* Withdrawal. The person may seem unresponsive, withdraw or in a comatose-like stage. This may indicate preparation for release, a detaching from surroundings and relationships, and a beginning of "letting go." Just as you are losing someone you love, the person dying is in a process of losing everything and everyone they love, so it is only natural for them to be withdrawn. If the person is allowed to express sorrow, the stage of final acceptance will be easier. If the person is unresponsive, remember that hearing remains all the way to the end. Speak to your loved on in your normal tone of voice, identify yourself by name when you speak, hold their hand and say whatever you need to say that will help the person "let go."

* The person may speak or claim to have spoken to persons who have already died or to see or have seen places that are visible to you or accessible to them. This doesn't indicate a hallucination or drug reaction. Instead the person is beginning to detach from this life. Familiar people and place will make the transition less frightening. Do not contradict, explain away, belittle or argue about what the person claims to have seen or heard. Even though you cannot see or hear the things your loved one does, does not mean it is not real to them. Affirm their experience. They are normal and common. If they frighten your loved one, tell them that the experience is normal.

* Your loved one may perform repetitive, useless, restless tasks. They may indicate that something is still unresolved or unfinished and they are disturbed and can't let go. The hospice team may be able to help you identify what is happening and help discover a way for your loved one to find release from the tension or fear. Other things that may be helpful in calming the person include: recall a favorite place, favorite experience, read something comforting, play music and give assurance that is OK to let go.

* When they begin to want little or no food or fluids this may indicate that the person is ready for the final shutdown. You may help by giving them permission to let go whenever they are ready. At the same time, affirm their ongoing value to you and the good you have received from them.

* They may begin to want only a few certain people or just one person around. This is also a sign of preparation for release and an affirming from whom support is most needed in order to make the approaching transition. If you are not part of this "inner circle," at the end, it does not mean that you're not loved or are unimportant. Do not take it personally. It means you have already fulfilled your task with them and it is time for you to say goodbye. If you are part of the final "inner circle of support," the person needs your affirmation, support and permission.

* The person may make "out of character" statements, gestures or requests. This may indicate they are ready to say goodbye and are testing to see if you are ready to let go. Accept the moment. Kiss, hug, cry and say whatever you need to say.

* Giving permission to let go without making your loved on feel guilty for leaving or trying to keep them with you to meet your needs can be difficult. A dying person will try to hold one even though this brings prolonged discomfort, in order to make sure those who are left behind will be all right. Therefore, your ability to release your loved one from this concern and give them assurance that is all right to let go whenever they are ready is one of the greatest gifts you can give your loved one.

* It is time to say goodbye when the person is ready to die and you are able to let go. Saying goodbye is your final gift of love, it achieves closure and makes the final releases possible. It may be helpful to lay in bed with the person and hold them or to take their hand and say everything you need to say so that afterwards you never have to say to yourself, "Why didn't I say this or that to them?"

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 tensions or difficulties in our relationship." It may also include saying, "Thank you for..."

Tears are normal and natural part of saying goodbye. Tears do not need to be hidden from your loved one or apologized for. Tears express your love and help you to let go.