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What happens when we are close to death? header photo of Weldmar nurse holding a patient's hand

What happens when we are close to death?

A guide for relatives

What happens when we are close to death? The experience leading up to death can be a very worrying and upsetting time for you. This information has been written to give you some advice and reassurance at this difficult time.

The dying process is unique to each individual, each person has lived their life in different ways and so they do in death. Therefore, not everyone experiences the same physical signs and symptoms we describe in this leaflet, however we hope it will give some understanding of what to expect.

The body’s physical methods of preparing itself for the final stages of life are:
(please click underneath each heading to view the information)

Coolness

  • Hands, arms, feet and legs may become increasingly cool to touch. The colour of the skin may change, particularly the underside of the body. Fingers and toes may become a bluish/purple colour and may seem mottled in appearance.
  • This is a normal process of the circulation of blood slowing to those parts of the body. There is no need to add further blankets as the cooling process will continue and does not cause the dying person distress.
  • Prior to death skin can become pale and moist.

Restlessness

  • You may observe your relative make restless and repetitive movements such as pulling at clothing or sheets. This again is due to changes in metabolism.
  • Calmness and things known to soothe them e.g. favourite music played quietly or your presence may provide a calming reassurance.

Pain and other symptoms

  • Sometimes there is a surge in pain or other physical symptoms. This is not unusual as death approaches. The healthcare team will assess these symptoms at least daily and medications may be prescribed for control or easing this. The healthcare team will also talk with you to explain these symptoms.
  • There are many other symptoms that may occur which can best be described as emotional, spiritual or psychological. Should you feel that your relative is experiencing these symptoms, for example; visual experiences (hallucinations), feeling fearful or anxious or behaving differently, please talk to a member of the healthcare team. These symptoms occur just as commonly as the physical symptoms, but again, not everyone experiences them all. By talking to a member of the healthcare team, they can direct you to the most appropriate professional in order to answer your questions and suggest ways of coping.

Incontinence

As our bodies slow down we may lose control of our bowels and bladder. This is caused by the relaxing of abdominal and bladder muscle control. The healthcare team will take every precaution to prevent any soiling of your relative’s clothes and bed linen. However, occasionally this may happen.

Congestion

  • When your loved one is close to death, you may hear gurgling sounds coming from their throat or chest. These sounds can be very loud.
  • The cause of this is the inability to swallow: normal saliva and fluids tend to collect, causing a sound as the breath reverberates.
  • District Nurses and other qualified clinicians may give medication to dry these fluids and secretion, but a gentle turn of the head to allow this to drain out of the mouth also helps, as does a wipe with some tissues. Please be assured the noise may be upsetting for you but it is not causing any distress to your relative.

Dry Mouth

  • A dry mouth can be a common problem and is different from feeling thirsty. Medicines such as special saliva sprays or gels may be helpful.
  • Good mouth care is the most important comfort measure.

Decreased Urine Output

A person’s urine will tend to change colour, becoming darker, and it reduces in quantity in the last hours of life. This is due to decreased circulation to the kidneys and it is a natural process which causes no pain or distress.

Changes to breathing

  • When death is very close the breathing pattern may change. Sometimes there are long pauses between breaths, or the tummy muscles will take over the work, with the abdomen rising and falling instead of the chest. A possible pattern is a shallow breath followed by a pause in breathing for several seconds, followed again by a breath, deep or shallow. Another pattern of breathing is rapid, shallow and panting.
  • These patterns are part of changes occurring in the brain and lungs during the last hours of life.
  • The healthcare team may turn your loved one’s head on their side to ease the pattern. However, the pattern often returns, but it is not distressing to them.
  • As your relative comes towards the end of their life the demand for oxygen is much less, and people who have experienced breathlessness often find breathing eases as they start to die. Sitting quietly holding your loved one’s hand can ease any feelings of anxiety (if they exist).
  • Occasionally there can be a noisy rattle to the breathing. This is due to a build up of mucus in the chest, which the person is no longer able to cough up. Medication may be used to reduce it and changes in position may help. The noisy breathing can be upsetting to you but does not distress the dying person.

Diminished need for food and drink

  • Your relative may not want to eat or drink, but this does not cause distress to them. When someone starts to die, their body no longer has the same need for food and drink as before. The body’s metabolism slows down and the body cannot digest the food so well or take up the goodness from it.
  • It is normal for people who are dying to stop drinking and feeling thirsty. As the body weakens and the systems start to work less well there is a decreasing need for fluid. It is important to remember at this time that it is the illness which is making the body systems fail, not a lack of fluid. If someone is very weak and is given fluid by mouth it may go down the ‘wrong way’ and make them cough and splutter, which may result in vomiting, lung congestion and abdominal bloating.

Decreased Muscle Strength

  • Your relative may have reduced muscle strength and may not be able to hold a hand firmly, or talk so well.
  • Muscle weakness is a symptom happening throughout the body. It causes loss of bowel and bladder control as well as a relaxed jaw and facial muscles, causing the mouth to drop open.
  • The healthcare team will attend to all your relatives’ bodily functions and may change their position to reduce the effect of someone’s open mouth.

Confusion

  • Your relative may experience confusion as to time, place and identity of people.
  • This, also, is a process of the body’s metabolism slowing down. Do speak calmly, clearly and honestly to your relative.
  • It may be necessary for medication to be given, to reduce possible mental distress. The medication may cause sleepiness.

Sleeping

  • As our bodies slow down we may spend more and more time sleeping and it will seem more difficult to wake up your relative. They may not be able to talk so well or may not be responding to you. For most, the process of ‘withdrawal from the world’ is a gradual one. This natural process can be accompanied by feelings of calmness and tranquillity.
  • This is a normal process of your relative’s body slowing down. Do sit with them, hold their hand and talk quietly or just sit quietly.
  • As professionals we are aware that a person’s hearing is the last sense to be lost. So when talking or discussing anything at the bedside do so openly and honestly.

Saying Goodbye

Saying goodbye is the final act for you and your relative. It can be an extremely difficult and painful time for you as you lose someone you love or have cared for. It can be hard to know what to say, how to help or what to do.

Tears should not be held back as they are a most natural process. Most people do not rouse from sleep, but die peacefully, comfortably and quietly.

Death has finally happened when there is no breathing or heartbeat. Most commonly the eyelids open a little, eyes fix and the pupils enlarge, the jaw relaxes and opens slightly. A nurse or doctor will confirm your relative’s death with you and later agree with you a time to talk through formalities. You will be given as much time as you feel is appropriate with the person who has died.

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