dying process and death

8/4/2019 Dying Process and Death

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The dying process usually begins well before death actually occurs.

Death is a personal journey that each individual approaches in their own unique way. Nothing is

concrete, nothing is set in stone. There are many paths one can take on this journey but all lead to

the same destination.

As one comes close to death, a process begins; a journey from the known life of this world to the

unknown of what lies ahead. As that process begins, a person starts on a mental path of

discovery, comprehending that death will indeed occur and believing in their own mortality. The

journey ultimately leads to the physical departure from the body.

There are milestones along this journey. Because everyone experiences death in their own unique

way, not everyone will stop at each milestone. Some may hit only a few while another may stop

at each one, taking their time along the way. Some may take months to reach their destination,

others will take only days. We will discuss what has been found through research to be the

journey most take, always keeping in mind that the journey is subject to the individual traveler.

The Journey Begins: One to Three Months Prior to Death

As one begins to accept their mortality and realizes that death is approaching, they may begin to

withdraw from their surroundings. They are beginning the process of separating from the world

and those in it. They may decline visits from friends, neighbors, and even family members.

When they do accept visitors, they may bedifficult to interact withandcare for. They are

beginning to contemplate their life and revisit old memories. They may be evaluating how they

lived their life and sorting through any regrets. They may also undertakethe five tasks of dying.

The dying person may experiencereduced appetite and weight lossas the body begins to slow

down. The body doesn't need the energy from food that it once did. The dying person may besleeping more now and not engaging in activities they once enjoyed. They no longer need the

nourishment from food they once did. The body does a wonderful thing during this time as

altered body chemistry produces a mild sense of euphoria. They are neither hungry nor thirsty

and are not suffering in any way by not eating. It is an expected part of the journey they have

begun.

One to Two Weeks Prior to Death

Mental Changes

This is the time during the journey that one begins to sleep most of the time. Disorientation iscommon and altered senses of perception can be expected. One may experience delusions, such

as fearing hidden enemies or feeling invincible.

The dying person may also experience hallucinations, sometimes seeing or speaking to people

that aren't there. Often times these are people that have already died. Some may see this as the

veil being lifted between this life and the next. The person may pick at their sheets and clothing
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in a state of agitation. Movements and actions may seem aimless and make no sense to others.

They are moving further away from life on this earth.

Physical Changes

The body is having a more difficult time maintaining itself. There are signs that the body mayshow during this time:

The body temperature lowers by a degree or more. The blood pressure lowers. The pulse becomes irregular and may slow down or speed up. There is increased perspiration. Skin color changes as circulation becomes diminished. This is often more noticeable in

the lips and nail beds as they become pale and bluish.

Breathing changes occur, often becoming more rapid and labored. Congestion may alsooccur causing a rattling sound and cough.

Speaking decreases and eventually stops altogether.

Journey's End: A Couple of Days to Hours Prior to Death

The person is moving closer towards death. There may be a surge of energy as they get nearer.

They may want to get out of bed and talk to loved ones, or ask for food after days of no appetite.

This surge of energy may be quite a bit less noticeable but is usually used as a dying person's

final physical expression before moving on.

The surge of energy is usually short, and the previous signs become more pronounced as death

approaches. Breathing becomes more irregular and often slower."Cheyne-Stokes"breathing,

rapid breathes followed by periods of no breathing at all, may occur. Congestion in the airwaycan increase causing loud, rattled breathing.

Hands and feet may become blotchy and purplish (mottled). This mottling may slowly work its

way up the arms and legs. Lips and nail beds are bluish or purple. The person usually becomes

unresponsive and may have their eyes open or semi-open but not seeing their surroundings. It is

widely believed that hearing is the last sense to go so it is recommended that loved ones sit with

andtalk to the dyingduring this time.

Eventually, breathing will cease altogether and the heart stops. Death has occurred.

Sources:

The Hospice Foundation of America: The Dying Process: A Guide for Caregivers

Barbara Karnes: Gone From My Sight: The Dying Experience

Sherwin Nuland, M.D.:How We Die
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Lesson Thirteen--The Death and Dying ProcessOverviewDeath and DyingAdvance DirectivesRequired ReadingOnline Activities

Overview

As caregivers, one either becomes a better person through compassion, patience, and

humor, or they become embittered and angry. Wendy Lustbader is an author who haswritten a moving book entitled " Counting on Kindness: The Dilemmas ofDependency."1991. The Free Press, New York, New York. In the book she describes the

importance of receiving gratitude when we help others; because giving help withoutrecognition can embitter us as individuals. We need to be kind, in order to count onkindness as we age.

The person who has dementia cannot always provide gratitude for their caregiver. Gratitude

must be looked for in gentle ways and unassuming ways. Perhaps it is a smile, or agesture, or an expression of love such as placing the head on the caregiver's shoulder. Ifgratitude is not felt even on an occasional basis, it is difficult to cope with death and dying.Death and dying as Dr. Kubler-Ross indicates, is the "final stage of growth".

Death and Dying

During the final stages of dementia due to Alzheimer's disease, an individual may lose

his/her ability to ambulate, verbally communicate, swallow, or may become totallyincontinent and continue to lose weight despite nutritional supplements. Usually people

with Alzheimer's die of another problem---perhaps a stroke, or pneumonia due toaspiration. At this point, the caregiver must be aware that the only way a person can stay

alive is by inserting a stomach tube that provides artificial nutritional sustenance.Caregivers may have different feelings about this intervention for religious or personal

reasons. At the end stage of Alzheimer's the use of invasive procedures such as a stomach

tube, can keep the persons alive from months to years. This important decision must bemade by the family member and can create an "ethical dilemma". Families, should in noway feel pressured by a medical professional to insert life sustaining interventions.

When family members are prepared with regard to the physical process of death and dying

they are more able to accept death as an inevitable and peaceful process. The recent

expansion of Hospice Services has done much to promote discussions about death and

acceptance of withholding end-of-life medical interventions. Once a person is terminal, asdetermined by a physician who understands the disease process, a caregiver may decide to

engage Hospice Services. The physician must be willing to certify that a person will diewithin six months. If the person does not die within six months, they are not disqualifiedfrom the program.

Hospice Services are usually provided by a local Home Health Agency. Hospice services can

be provided in the home, assisted living facility as well as a skilled nursing facility. When afamily signs up for Hospice Benefits they agree to forgo extreme invasive procedures and
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agree to support procedures that alleviate pain for the person with dementia. This is known

as "palliative care" or comfort measures. At the final stage of death, water and food are

withheld as the individual no longer desires this. This is a part of the natural process ofdying.

Families can anticipate the final stages of death by the various physical stages a person

may be going through. Barbara Karne, a Hospice R.N. developed a very comprehensivebooklet entitled "Gone From My Sight: The Dying Experience" which delineates the

various physical stages of death and dying. To obtain a booklet, contact her at the followingaddress: Barbara Karnes, R.N., P.O. Box 335, Stillwell, Kansas, 60085, 1995.

In Karnes' booklet she describes what occurs , one-three months prior to death, one to twoweeks before death, days or hours before death, and then the final minutes. Thisinformation has been extremely helpful to families and can be summarized as follows:

One to three months prior to death

Withdrawal from world and people Decreased food intake Increased sleep Going inside self Less Communication

One to Two Weeks Prior to Death

Disorientation Agitation Talking with Unseen Confusion Picking at Clothes

Physical Changeso Decreased blood pressureo Pulse increase or decreaseo Color changes; pale, bluisho Increased perspirationo Respiration irregularitieso Congestiono Sleeping but respondingo Complaints of body tired and heavyo Not eating, taking little fluidso Body temperature hot/cold

Days or Hours

Intensification of 1-2 week signs Surge of energy Decrease in blood pressure Eyes glassy, tearing, half open Irregular breathing, stop/start Restlessness or no activity Purplish knees, feet, hands, blotchy Pulse weak and hard to fine


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Decreased urine output May wet or stool the bed

Minutes

Fish out of water breathing Cannot be awakened

Advance Directives:

It is important that individuals be aware of their wishes and that the wishes be formally

documented in a legal document that is known as an "Advance Directive". Each state has

different instruments for these directives and the caregiver should contact the local medicalfacility to determine the appropriate document to be be used. The Advance Directive

delineates one's wishes regarding medical treatment and appoints a surrogate decision-maker on a person's behalf. Of course, the important aspect of the Advance Directive is to

discuss end-of-life care before one becomes diagnosed with dementia or has an anotherdebilitating illness.
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Care at the End of Life - The Dying Process

If you are dying or are caring for a dying loved one, you may have questions and concerns about

what will happen physically and emotionally as death approaches. The following information

may help answer some of these questions.

Signs of approaching death

The dying process is as variable as the birthing process. The exact time of death cannot be

predicted, nor can the exact manner in which a person will die. But people in advanced stages of

a terminal illness experience many similar symptoms as they approach the end of life, regardless

of their illness.

Several physical and emotional changes occur as death approaches, including:

Excessive sleepiness and weaknessas periods of wakefulness become shorter and overall energydeclines.

Breathing changes, such as periods of rapid breathing alternating with short episodes whenbreathing stops.

Visual and hearing changes, such as seeing people or scenes that others do not (hallucinations). Decreased appetiteas yourmetabolismslows and you no longer have the same interest in food. Urinary and bowel changes, such as dark or red urine and hard stools that are difficult to pass

(constipation).

Temperature changes, such as running a high temperature or feeling very cold. Emotional changes, such as becoming less interested in the outside world and being less socially

involved with others.

Dying people may also experience symptoms specific to their illness. Talk to your doctor aboutwhat to expect. Also, if you have chosen to receivehospice care, the hospice team is available to

answer any questions you may have about the dying process. The more you and your loved ones

know, the better prepared you will be to cope with what is happening.

Pain

Palliative carecan help you to feel relief from physical symptoms related to your illness, such as

nauseaor difficulty breathing.Pain control and symptom controlare important parts of managing

your illness and improving the quality of your life.

Whether a person suffers from physical pain in the days before death often depends on theillness. Some terminal illnesses, such as bone orpancreatic cancer, are more likely to be

accompanied by physical pain than others.

Pain and other symptoms can be so feared that a person considersphysician-assisted death. But

pain associated with the dying process can be managed effectively. Any pain should be reported

to your family and your doctor. Many medicines and alternative methods (such asmassage) are
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available to treat the pain associated with dying. Do not hesitate to ask for help. Have a loved

one report your pain if your illness prevents you from communicating with your doctor.

You may want to protect your family from your suffering. But it is important to tell them if your

pain level is not tolerable so they can tell your doctor right away.

If you and your doctor are not able to control your pain, ask about seeing apain management

specialist. This is a doctor who finds ways to treat pain that won't go away.

Spirituality

Spirituality refers to a person's sense of meaning and purpose in life. It also refers to a person's

relationship to a higher power or an energy that gives life meaning.

Some people do not think of spiritual matters often. For others, spirituality is a part of daily life.

Facing the end of your life may cause you to confront your own spiritual questions and issues.

Organized religion provides comfort to many people as they face death. Others may find solacein exploring nature, through community involvement, by strengthening existingrelationships, or

by developing new relationships. Think about what provides comfort and support to you. What

questions and concerns do you have? Don't hesitate to ask for support from friends, family,

hospice, or spiritual advisors.

Caring for a dying loved one

The dying process can be a time for growth. It offers the dying person and his or her family and

friends a time to mend relationships, share memories, and say their good-byes. If you are a

caregiver, it is important to communicate openly with your dying loved one. Also, seek support

from others andtake care of yourselfso you don't become physically and mentally exhausted.
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