Most individuals are not comfortable in discussing death even when it comes as a surprise. The situation can become worse as the patient of a loved one rapidly changes his or her state and the symptoms are not known.
When the body systems start to fail, actively dying, is an end stage that hospice and palliative clinicians describe. This will be different in each individual, however, some trends will be recurrent. The acknowledgment of them can assist the families to look at comfort and connection instead of fear.
1. Gurgling (the so-called death rattle) breathing
When one can swallow or cough appropriately to clear normal saliva and mucus, a wet, gurgling sound can be detected. The noise is caused by air passing through pooled secretions and it is very distressing to the families rather than the individual undergoing it.
Basic comfort measures can be used: the head can be moved slightly or the person can be turned a bit to the side so that the secretions can run out. Paying attention to the mouth can help here since wetting the lips and maintaining the mouth hygienic can help to make the mouth more comfortable, particularly when the breathing sounds are noisy.
2. Slowing, accelerated or halting breathing
Close to the end of life, breathing becomes erratic in most cases. Others develop Cheyne-Stokes breathing, during which a few successive breaths are repeated after a moment (apnea). Others take more time and have a greater delay between breaths which may appear out of the ordinary in the bedside.
Such patterns may be disturbing to observe but they do not necessarily indicate pain. Raising the head and shoulders and maintaining a quiet room and talking in a calm voice could be beneficial to the individual as well as the other people around them.
3. Blindness with eyes open (unfocused or glasses look)
With the body shutting down, one is likely to fall in and out of consciousness and become a deep unresponsive person. Eyes might be glazed or out of focus and the mouth might be open. This situation is referred to, by some caregivers, as a stare although what is being done in a room is not being followed by the person.
Numerous hospice groups urge family members to continue speaking softly and assume that hearing might persist. One can break the atmosphere of the room and address the person directly, not about them, to make the room rather down to earth.
4. Severe activity and communication impairment
Talking is usually reduced, and the sleep is made longer and deeper. Exercise can be reduced to virtually zero, and the individual will not want to be moved just because it will take more effort.
Comfort care tends to change to small, practical activities: turning in bed without causing any pressure injuries, flattening the linen and aligning motion with discomfort treatment once grimacing or guarding are witnessed. In case of uncertainty, the hospice nurse can provide guidance on how to customize the safest and most comfortable.
5. Minimal or no appetite of food and liquids
Reduced intake of food and beverages is typical because the digestion process slows down and energy requirements are altered. The process of swallowing may get complicated, and it may prove to be harder to take food, fluids, or pills.
As an alternative to compelled intake, families can pay attention to relief: mouth swabs, sips only when the person chooses and is able to swallow safely, and frequent mouth lip hydration. It is a shift that is usually significant, calories versus comfort.
6. Cold hands and feet, reddish-broken skin
Lower legs, feet, knees, and hands can get cool as the circulation slows down. Skin can appear pale, purplish, gray or blotchy (mottling) particularly on extremities and pressure points.
Soft blankets may aid in comfort, but heating pads are generally shunned since delicate skin is easily burned. This symptom is more likely to indicate decreased circulation and not an issue that has to be repaired.
7. Unquiet, impatience, or delusions
Others are agitated or restless during the last days or hours, which is also known as terminal restlessness. Others have hallucinations or misperceptions, but these can be reassuring or disturbing to the individual based on what they feel.
Reassurance can be given calmly, with soft hands and using less noise in the room. Since agitation can also indicate the presence of pain, the urinary retention or the effects of medication or anxiety, the hospice team should be notified of the changes as soon as possible.
These symptoms usually cross each other and death does not appear in the same way to everybody. There are those who exhibit more than one change in the course of days; others suffer a rapid decline. The most reliable objective when a loved one is approaching death is comfort, which implies physical comfort, serene atmosphere, and the presence of support.
Even minor decisions can be important to families; maintaining low tones, recognizing who is present, providing handholding, and uttering what must be uttered. The care team also has the opportunity in the hospice settings to inform the caregivers through what is normal, what can be treated, and what is just part of the normal close up process of the body.
