Dying Process

Alexander Peralta, Jr., M.D. Director of Palliative Care Services American Hospice

THE PROCESS OF DYING

Introduction: As a person enters the final stage of the dying process, two different dynamics stages are closely at work. The First Stage is Physical; the body begins the final process of shutting down. Death occurs when all physical systems cease to function - homostenosis. Usually, this is an orderly and normal series of physical changes that may be stressful to observe, but are not considered medical emergencies. The changes are a natural way in which the body prepares itself to shut down and the most appropriate responses to this process is to provide palliative or comfort measures to the patient. The Second Stage of the dying process is emotional, spiritual and psychosocial. It is a different kind of process. The dying person may express a need to complete unfinished business, to reconcile relationships, and to begin to let go, and even seem to withdraw (decathexis) from family members. These events are normal and natural. The most appropriate responses to the emotional, spiritual, social and psychological changes are those of acceptance, understanding and support in carrying out the existential and spiritual wishes of the dying person. When a persons body is ready to shut down but the person still is has unresolved issues or unreconciled relationships, it may seem to some people that the person may be resisting death in order to attend to this unfinished issue(s). This may happen inspite of the patients weakening condition and overt symptoms. On the other hand, when a person is emotionally, spiritually and mentally ready for its transcendence but the body has not completed its final physical process, the person may continue to live until the process of shutting down is completed. The experience we all call death occurs when the body completes its natural process of shutting down and the mental, emotional and spiritual processes come together in a way that is appropriate for the values, beliefs and lifelong relationships of the dying person which gives him/her the buoyancy to transcend peacefully to the unknown. Therefore, as you prepare for this loss, the members of your Hospice care team want you to know what to expect and how to respond in ways that will help your loved one accomplish this transition with your support and understanding. This is the great gift of love you can offer them as you accompany them in this final journey.

The physical, emotional, spiritual, social and psychological signs and symptoms of impending death that follow are to help you understand the natural process of dying that may happen and how you can respond appropriately. These signs and symptoms will not occur with each person, nor will they occur in a particular sequence. Each person is unique and whatever has been most characteristic of the way your loved one has lived will affect his or her final


moments as death occurs. This is not the time to try to change them, but the time to give full acceptance, support and comfort. Physical Signs & Symptoms and Appropriate Responses:

1. Coolness -- The persons face, hands, arms, feet and legs may become increasingly cool to the touch and at the same time the color of the skin may change to a pale hue (mottling). This is a normal sign indicating that circulation of blood to the bodys extremities is decreasing and is being reserved for vital organs; that is the brain, heart, lungs and kidneys. Keep the person warm. Avoid using an electric blanket. Socks may help keep the feet warm. Do not adjust the air conditioning by making the environment warmer as this may cause infections or odors. 2. Sleeping -- Your loved one may spend an increasing amount of time sleeping and appear to be uncommunicative, withdrawn or unresponsive. This normal change is due in part to changes in the bodys metabolism. Spend time with your loved one; hold hands. Speak to him or her as you normally would although there may be no response. Dont say anything that you would not want your loved one to hear. They can hear you even in a comatose state.

3. Disorientation-- Your loved one may seem to be confused about the time, place and identity of people. This also is due, in part, to metabolic changes. Identify yourself by name before you speak. Speak softly, clearly and truthfully when you need to communicate. For example: It is time to take you medication, so you wont have pain. Be honest. Dont try to force or trick your loved one into taking medications, even though you may believe you are only acting in the patients best interest. The trust between the patient and caregiver is too important to be jeopardized.

4. Incontinence-- The patient may lose control of urine and/or bowel matter as the muscles in that area relax. Discuss this with your Hospice nurse to determine what can be done to protect the bed and keep the patient clean and comfortable.

5. Congestion-- Your loved one may have gurgling, bubbling or rattling sounds coming from the chest or throat. This is normal and is sometimes due to inability to clear secretions, i.e. cough up secretions or due to thickness of secretions. Elevate the patients head and gently turn it to the side, allowing gravity to drain the secretions. You also may give mouth care as instructed by your nurse. Congestion is often distressing to listen to but may not indicate discomfort to the patient.

6. Restlessness-- The patient may make restless or repetitive motions. This occurs frequently and is due partially to the decrease in oxygen to the brain plus metabolic changes. Do not interfere with or try to restrain such motions. Try to establish a calm atmosphere; speak in a quiet, natural way; eliminate bright lights. Look for calming things to do --a gentle back rub, stroking the arms or forehead, reading aloud or playing soothing music may help.

7. Fluid and Food Decreases-- Your loved one may want little or no food or fluids. This means that the body is conserving energy for other functions. Do not try to force them to take food or fluids or try to manipulate them into eating or drinking. This only causes more discomfort. Instead, offer small chips of ice, soft


drinks, juice, or popsicles. Cater to the likes of your loved one. Vaseline can be applied to dry lips. Lemon and glycerin swabs also can keep the mouth and lips moist and comfortable. Lips and mouth may need to be moistened ever hour or two, especially when the patient is mouth breathing. A cool, moist washcloth on the forehead will sometimes be very soothing.

8. Urine Decrease-- Urine output normally declines because of decreased fluid intake as well as a decrease in circulation throughout the body and decrease clearance in the kidneys. Ask you Hospice nurse whether there may be a need to insert an indwelling Foley catheter. The color of the urine will change from yellow to amber to tea-color to coca-cola color.

9. Breathing Pattern Change - The regular breathing pattern of the patient may change. There may be periods where breathing stops for several seconds (apnea spells or Cheyne-Stokes respiration). Open mouth with jaw movements or breathing (Mandibular respiration's) and use of chest accessory muscles may also be noticed. This is common. Elevating the head with a pillow or blanket may help. Hold hands, speak gently and be reassuring. Slow down your own breathing!

10, MedicationsOur hospice professional staff will offer medications to ameliorate symptoms of discomfort such as pain, nausea, agitation and severe dyspnea. The focus of our treatments is grounded on the ethical Principle of Double Effect. It is our intent to provide comfort measures to your loved one and not hasten or prolong the natural dying process. Psychosocial and Spiritual Signs & Symptoms and Appropriate Responses:

1. Withdrawal -- Your loved one may seem withdrawn or in a coma-like state; this may indicate preparation for release --a disengagement from surroundings and relationships and the beginning of letting go. Since hearing remains to the end, speak to your loved one in a normal tone of voice, identify yourself by name when you speak, hold hands, and say whatever you need to say he/she will hear you.

2, Vision-like ExperiencesNearing Death Awareness -- Your loved one may speak to or claim to have spoken to persons who already have died or claim to see places not visible to you. If you are unable to gently re-orient them, validate their experiences. This may mean that they are beginning to detach from this life and are preparing for the transition. Do not contradict, explain, or argue about what they claim to have seen or heard. Just because you cannot see or hear what they are experiencing does not mean it is not real to your loved one. This is a common experience called nearing death awareness. If these experiences are frightening to your loved one, probe for their meaning and try to reassure them they are in a safe place.

3. Restlessness-- Your loved one may perform repetitive and restless tasks. Your Hospice team members will assist you in identifying what may be happening and will assist you in finding ways to help them find relief from tension or fear. Other things that may be helpful in calming them are to recall a favorite


place or experience (guided imagery), read something comforting, play soft music, or provide assurance. Give them permission to let go.

4. Decreased Socialization-- Your loved one may want to be with a limited number of friends, family or just you. The dying person has limited strength and energy to deal with socialization. This withdrawal and detachment occurs, as they become more involved in making the transition, a journey that must be made alone. Do not interpret this as a rejection or lack of love, but as a natural part of the process of death through which everyone must pass. In Transpersonal psychology these stages of human development are know as the Subtle, Causal and Ultimate Realms. Your loved one needs your support and love. You may feel the need for your Hospice nurse, Social Worker and/or Chaplain at this time.

5. Unusual Communication-- Your loved one may make a seemingly out of character statement, gesture or request. This may indicate that your loved one is ready to say good-bye and is testing to see if you are ready to say goodbye. Accept the moment as a beautiful gift when it is offered. Kiss, hug, hold, cry and say whatever you need to say. It is an opportunity to share love and forgiveness.

6. Giving Permission-- Giving permission to your loved one to let go can be difficult. A dying person may try to hold on, even if it brings prolonged discomfort. This is there way of showing concern and love for those who are going to be left behind. Therefore, your ability to release the dying person from this concern and give him or her the assurance that it is all right to let go whenever your loved one is ready. This is one of the greatest gifts you have to give at this time.

7. Saying Good-bye-- When the person is ready to die and you are able to let them go--this is a milestone event. This may happen at the time of death but perhaps you and your loved one have already said your good-byes. This process seems to achieve closure and makes the final release possible. You may want to touch or hold your loved one, or do whatever is and has been a comfort to the both of you. The moment may include recounting favorite memories, places and activities you shared. It is a time when forgiveness can be extended or received, love that may have never been expressed may be shared The dying person may wish to know if they have made a difference in our lives and that they will be remembered. Tears are a normal and natural part of saying good-bye. These emotions are normal and need not be hidden nor do you have to apologize for them. The hardest task we do as humans is saying our final good-bye.

Finally The impending death of a patient is not a medical emergency and does not require emergency room treatment. You and your Hospice team have worked together to allow your loved one to die at home in familiar surroundings and without painful and/or extraordinary treatments. Nothing must be done immediately, unless the patient is having severe symptoms.


The signs of death include such things as no breathing, no heartbeat, release of bowel and bladder, no neurological response, eyelids slightly open, eyes fixed on a certain spot, no blinking, jaw relaxed and mouth slightly open. We at Hospice admire you for caring for your loved one at home. Our hope is that this information will decrease some of the anxiety you may feel during this very stressful time and milestone event. The miracle of life is having family and/or friends support you at this time in your life. Remember that a nurse from Hospice will be available to help you. Please know, that every question or concern you have is important and our hospice team will try to provide an answer to the best of our knowledge.

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Dying Process