When death looms - the signs and symptoms of final moments on earth

The signs and symptoms of death

• 1Withdrawal. A person facing the last portion of life on earth may withdraw from daily life. The withdrawal may be physical, such as sleeping most of the day or appearing almost to be in a comatose-like state or, the withdrawal may be emotional. The elderly loved one may not want to spend a lot of time talking with family and friends.
  
  This excellent white paper on death and dying is a worthwhile read: Understanding the psychological and social experience of a dying person
• 2Restlessness. Those in the last stages of life may appear restless for no reason. They may pull at the bed covers, try to get up from bed for no reason, or thrash around the bed. This restlessness may occur as blood flow to the brain slows. Restlessness, though, may also be a sign that your dying loved one has unfinished business to tend to.
  
  To prevent the bedsheets from becoming tussled, you might consider buying a set of Bedsheet suspenders which attach under the sheet to keep the sheet pulled down and straight. This can help shield against bedsores also.
• 3Changes in appetite. This is probably the toughest symptom of dying that a caregiver has to endure as, well, what we do is provide nourishment for our loved ones. And, in my Jewish upbringing, what do we do? We feed - they eat! So, my offers of my Mom's favorite foods of past such as blintzes or matzo ball soup are frequently turned down. I used to take this as an affront to my cooking until I started to research death and saw that refusing food is a typical way for the body to prepare for death. Not sure if I was pleased to find this little tidbit out but the cook in me did let go a sigh of relief.
  
  Hospice workers also put this symptom in perspective for me. I was so concerned about Mom growing weaker but the excellent Hospice nurse told me that the body naturally slows down and forcing food is a bit cruel as the body can't digest the food as it used to. Bloating and uncomfortable feelings, such as constipation, can occur. Therefore, let the dying person dictate what they would like to eat. It's tough but must be done.
  
  Here's a great article about feeding a dying person: Food, nutrition, artificial feeding methods, constipation, and quality of life issues in the dying person.
• 4Incontinence. Toward the end of life, the dying person may not recognize the body's signals to urinate or defecate. In addition to not recognize the symptoms of needing to "go", the body's muscles relax and there might not be any control of these activities any longer.
  
  For more about how to deal with incontinence in the elderly, read my article Incontinence in the elderly.
  
  It was amazing to me how quickly I adapted to helping Mom stay clean and dry. The first few times were very difficult but, when I realized that it's just a part of life and dying, I quickly got over the queasiness of the situation.
• 5Changes in breathing. As someone nears the end of life on earth, breathing patterns usually change. Instead of the slow, deep breaths of a sleeping person, the dying breaths may become shallow and rapid followed by pauses in breathing all together. These pauses may last from 5 seconds to a full minute. This is very difficult to watch so be prepared. But, changes in breathing in the dying person is very normal and not at all painful for them.
  
  Note to caregivers: As you sit by the bed and watch your loved one strive for breath, you might find yourself meeting their pattern. Remember to breathe!
• 6Gurgling sounds in the back of the throat. Although these gurgling sounds may sound painful, the dying person is not in any kind of pain. The gurgling sounds occur because the dying cannot swallow so saliva gathers in the back of the throat. And, in addition, depending on the medications the dying person is on, the gurgling may worsen as the kidneys stop producing urine so there is more water present in the body.
• 7Changes in body temperature. The dying body naturally will try to keep the internal organs warm so the extremities of a dying person may feel abnormally cool to the touch. But, a fever may also exist as the body's natural regulation of temperature weakens. Sweaty or clammy skin may occur with or without a fever.
  
  With changes in body temperature come changes in the look of your loved one. The lips may take on a bluish cast, the skin may pale or become blotchy or purplish as circulation slows. These changes are normal signs of dying and are not painful to the your elderly loved one.
• 8Delusions or Dementia. As blood supply to the brain slows, the dying may become delusional. They may start talking out loud to others we can't see (and, who is to say those others aren't surrounding our loved one?). Frequently, those close to dying will utter words about "Going home." Some see this as a symbolic meaning and others see this as a way for the dying to signal to us that they're about to travel to somewhere else.
  
  When we were in the hospital, my Mom mumbled in her sleep one night. All I could really catch was "I can get up and walk out of here if I want to." After I started looking into the signs and symptoms of death, I now realize that she was signaling me that her death was near. Thankfully, it wasn't that near as she's drinking coffee and eating a freshly made biscuit right now....

How to help those who are dying

• 1For withdrawal: Understand that the emotional or physical withdrawal is not a personal affront to anyone; it's simply a sign of dying. Try to schedule visits around the time when you most expect your elderly loved one to be alert - around meal times or after naps. Do not try to arouse the elderly loved one or force them into a conversation.
  
  Talk to visitors and apprise them of the situation. Some people are more sensitive and may take the withdrawal personally. It's best to limit visitation by these folks as they're likely to be upset by the withdrawal. Again, this is simply a sign of dying and is not to be taken personally. But, some people simply don't get it...
• 2Changes in appetite. Accept that you're still a great cook (!) and offer light meals of clear broth or a few crackers. Liquids are more important than solids so try to make drinks interesting. Ensure plus is 350 calories and is a great thing to give the elderly once a day. Try to get your elderly loved one to sip water or offer small ice chips. Every bit of moisture counts. Even coffee is something.
  
  Also, check with your senior citizen loved one's doctor and ask about an appetite enhancer. My mom is on Megace and I can't keep her full!
  
  UPDATE: As my mom starts in on the last phase of life, we've withheld the Megace. This was the hardest thing for me to do as I knew she's stop eating. I talked this over with Hospice and found a new perspective. As we age, our digestion also slows. By giving Mom Megace, she'd eat more than her body could handle and would bloat. Megace was no longer a good medication for her. I now give her anything she wants which is usually coffee (!) and a bit of cereal in the morning, a very light lunch of broth, and a dinner of coffee (!) and cereal again. I also found a chocolate milk that she loves - Cocoa Metro Belgian Chocolate Milk. The stuff is really really delicious. Check out their website to see if this chocolate milk is carried in a grocery near you: Cocoa Metro website.
• 3Changes in urination or defecation. Protect the surfaces your dying loved on uses by covering with plastic sheets, and bed chucks (disposable bed pads). I actually bought washable bed chucks which are much more comfortable.
  
  Depends are also a great item to protect the environment from urine or feces. Just make sure to never call depends "adult diapers" or to degrade the elderly for soiling themselves or their surroundings. At some point, it may be necessary to change to a different undergarment than traditional pull up Depends as it's too difficult to change them. Instead, find undergarments with tabs on the side so they'll fit snugly yet are still comfortable. I've placed a few choices below.
  
  if your elderly loved one is able to walk, you might schedule bathroom visits. Sometimes, the elderly won't even know they're going so it's best to try and stay ahead of the issue with scheduled visits.
  
  Make sure to change the elderly into new clothing shortly after an accident.
• 4Changes in breathing. Turning the dying person on their side may help clear the airway and provide easier breathing. Ask the doctor or nurse about any troublesome breathing - morphine is frequently used to ease laborious breathing patterns.
  
  As you sit beside your dying loved one, you might find yourself unconsciously matching their breathing (and gasping) patterns. Try and be aware of this phenomenon and breath as normally as you can.
  
  Ask your loved one's doctor or Hospice nurse if morphine would be a help for breathing. Morphine relaxes the muscles and allows air to be more fully processed. It's helped my Mom a lot.
• 5Changes in body temperature. Cover chilled extremities with warm blankets but do not use electric blankets! Electric blankets are a no-no around the elderly as they simply cannot tell when they're too hot and they can actually overheat under an electric blanket. Same goes for heating pads. I used a heating pad a few years ago on my Mom's aching back and didn't realize it was burning her. A trip to the doctor and some silvadene cream and she was back in action but I'd learned a painful (for her and me!) lesson.
  
  To easily check a senior citizen's temperature, consider purchasing one of the new forehead thermometers - makes it much easier to take a temperature. Here's an nice one on Amazon.com: Vick's forehead thermometer.
  
  If a fever is evident. consider applying small amounts of rubbing alcohol to the body. Follow with a light dusting of baby powder which will provide additional cooling to the skin. Place a cool cloth on the head and wrists and, perhaps, reduce the room temperature.
• 6Confusion or disorientation. Identify yourself when you first speak to the elderly and tell them what tasks you're going to do before you do them. When visitors approach, say hello as a clue for your elderly loved one of who is coming.
  
  Here's an important tip: Hearing is the last sense to die. Make sure you don't discuss the condition of even a comatose loved one while they're there. They very well may hear and understand you. Speak in a normal voice and speak slowly.
  
  For the times when my Mom has been disoriented, I've just sat by her bed, held her hand, and told her that she didn't have to worry about anything - I was going to be there to handle everything. She seemed to calm down after hearing these words. I also tell my Mom every single day that I'm glad she's here living with me and I am. I honestly would not have her be anywhere else than in her bed and in my arms when her time comes.
• 7Restlessness or agitation. Make sure that the dying person has any medications needed to alleviate restlessness or agitation. Contact a nurse or doctor as needed. If possible, if your dying loved one is cognizant, ask them if there is anything they'd like you to do after their gone (this is a difficult conversation). Ask if there is anything they need or try and distract them from their condition by mentally painting a pleasant picture of something you've done in the past.
  
  For the times at night when Mom was restless, I have sat and spoken to her about how Dad would have liked the garden I'd planted, or how he would have loved the first tomato we had the other day. Frequently, she will calm down as I go deeper into thoughts of past times with my dad and her.
  
  Sometimes, simply holding her hand will calm her down. I will speak to her in a light voice until she settles down. The other thing I've done that I've found works for Mom is to put one of my lap dogs on her bed. Having a dog to place her hand upon usually stops any agitation.

The timeline for signs and symptoms of death

• 1One to three months pre-death:
  
  Withdrawal from people and activities
  Less communication
  Appetite changes - generally reduced appetite
  Resting more - you might see your loved one sleep all day.
• 2One to two weeks pre-death:
  
  Increase or decrease in pulse - decrease in blood pressure
  Changes in skin color - paling, blotchiness or a blue or purple tinge to the skin
  Changes in breathing patterns
  Changes in body temperature - either clammy/cool or a fever
  More changes in appetite - usually refusing food and having a problem even drinking water (use those ice chips)
• 3Days to hours pre-death:
  
  Increased sleepiness
  Possible surge of energy - remember to enjoy these times!
  Restlessness or agitation
  Difficulty swallowing
  Further changes in breathing - gasping with periods of no breathing between
  Rattling breath sounds
  Weak pulse
  Decreased urine or feces output as the kidneys shut down
  Eyelids may be slightly opened
• 4Minutes to death:
  
  Shallow breathes with longer pauses
  Mouth open
  Unresponsive
  Eyes may remain open or half closed
  
  Remember though: even during this last period of life, the dying loved one may be able to hear you. Now is the time to tell them how much you have loved having them as your mother, father, brother, sister, etc... Tell them how much you have admired them, how you will always keep them in your heart and how you hope to one day see them again. Now, some might find this calloused but, during what I thought might be my Mom's last moments, I leaned in and said all of the above and ended with "Tell Dad to send money...." Mom laughed...
  
  Update 3/29/12: I wanted to update this section by saying that the very last moments of the dying may be difficult to watch. Some liken the breathing to "a fish out of water" and that's what I thought when Mom took her last breaths. Please be assured that your loved one is not suffering while exhibiting this type of breathing - it's simply what happens. Mom went quite peacefully, surrounded by friends and family in my own home. She won the game.