As death approaches, the body slowly and naturally shuts down. There are physical signs indicating that death is near, which usually occur days or hours before death.
Usually the process includes:
- Decreased responsiveness
- Semi-coma like state
- Cannot be aroused to sound of name or light touch
- Eyes may be closed, or half open, glassy or tearing. If open, the eyes may appear to “look past you".
- Skin color changes as the heart slows down
- Usually the hands and feet become cool and bluish purple, which may progress to the knees, elbows, and back.
- Also, skin color on other parts of the body may become very pale, sallow yellow, or white.
- Breathing changes
- Initially, breathing may be fast and labored, then slow and stop [apnea] from seconds to over a minute in an ongoing pattern. This can appear days before death occurs.
- Then, breathing becomes rapid and regular. At times, the breathing may sound congested, like a rattle or gurgle, but is usually caused by mouth secretions collecting in the back of the throat.
- Lastly, the breathing becomes shallow, quiet, and slows.
- The breathing rhythm looks mechanical.
- At any time there may be an audible sigh or moan. These sounds are caused by air passing over the relaxed vocal cords causing them to vibrate and sound. This is not a sign of pain or distress.
- The lower jaw may move as if your loved one is trying to speak.
Skin discoloration occurs as the blood pools inside the body due to a weakening heart. Decreasing mental responsiveness occurs as the blood flow decreases to vital organs, including the brain. As the vital organs naturally shut down, less oxygen is required by the organs and breathing patterns change to meet these new, lesser requirements.
Usually it is hard for the family and caregivers to hear “noisy” breathing. The family may worry that their loved one is experiencing some distress. Always look to your loved one’s face to determine if they are comfortable or uncomfortable.
There is nothing you can do at this time for your loved one that would be wrong or inappropriate. Trust your inner feelings and act as you think best based on what you see. However, if you are unsure about anything, it is always okay to call the hospice nurse to discuss your questions or concerns.
- Medicate your loved one for signs of pain, congested or labored breathing, or restlessness, as directed by your hospice nurse and physician.
- For temperature changes, adjust the covers, apply a cool compress to the forehead for a fever, and socks to cold feet.
- Offer small sips of water, if your loved one is awake and able to swallow. Near death the body cannot process food or fluid comfortably or to any benefit.
- Mouth care - frequently moisten the lips, gum line, and tongue with swabs or toothettes dampened with warm water. Avoid using alcohol based mouth washes, as they only further dry the mouth.
- It is important to keep the mouth clean, if you are using medications that absorb under the tongue. Swab the mouth with toothettes prior to giving medications under the tongue.
- Apply Vaseline to dry lips, except when oxygen is in use. Discuss alternatives with your hospice nurse.
- Keep the skin clean and bed linens dry.
- Position your loved one in bed for comfort by using the electronic bed controls to elevate the foot and head of the bed slightly and frequently. Or use extra pillows and towel rolls to support good body alignment and ease the discomfort of constant bed rest.
- Always assume that your loved one can hear what is spoken, even if they cannot respond verbally. Look for subtle, non-verbal signs of response, like a moan, an attempt to raise an eyebrow, the lifting of a finger, or the slight squeeze of a hand.
- Your gentle touch and quiet presence is safe and comforting.
- “Being with” your loved one is now more important than “doing for” them.
- If you have not already done so and it feels appropriate for you at this time, tell your loved one that you will miss them, but that you will be okay without them and they do not need to worry about you.
- Reminisce - read a favorite poem or inspirational piece of literature.
- When your loved one awakens from periods of sleep, remind them of where they are and who is present.
As your loved one draws their last breath, you may hear and see some of the following signs:
- Quiet shallow breathing that slows to a final stop.
- Audible exhalation as the final breath is released.
- After your loved one has died, you may notice what appears to be a few additional “breaths,” as the lungs empty of air.
- Facial changes
- The eyes may open wide and then close, or remain partially open.
- The lower jaw muscles may relax and the jaw falls open.
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