DTH

Five Physical Signs that Death is Nearing

There is no way to fully “prepare” for the death of a loved one. But, one of the ways caregivers can begin to prepare is to know what signs / symptoms to look for at the end of their loved one’s life.

1. Loss of Appetite

As the body shuts down, energy needs decline. Your loved one may start to refuse foods that are hard to chew or digest like meat. Declining meals or simply taking a few bites is common. This can be a very emotionally upsetting time for the family. Our natural response is to insist that our loved one eats, but towards end-of-life this can cause more harm than good. (for more information on this see the article titled "Terminal Dehydration" in the Caring for a Loved One section).

Near the very end

People experience difficulty swallowing and therefore will begin to refuse liquids and food

How you can help

• Offer modified (softer) foods that are easy to digest.
• Allow more time for eating and never rush your loved one.
• Offer high protein supplements such as protein shakes.
• Try offering popsicles if liquids are being refused.
• Keep your loved one’s mouth and lips moist to aid in comfort.
• As hard as it is, be patient and understanding that this is part of the natural death and dying process.

2. Increased Physical Weakness

Decreased food intake leads to less energy and simple activities like sitting on the edge of the bed, lifting one’s arms to change clothes and having a short conversation become difficult.

Near the very end

Sipping from a straw, lifting her head, or shifting in bed may take great effort for your loved one. Movement might slow to the point where you need to help your loved one make even the slightest shift in position.

How you can help

• Understand energy conservation. Your loved one will not be able to tolerate personal care for long periods of time so break these tasks up into smaller intervals. Arrange tasks into no longer than 15 minute increments.
• Focus on keeping the person comfortable above the task. If your loved one is comfortable in the same shirt she wore yesterday perhaps changing her would cause more harm than good.

3. Labored Breathing

Towards end of life most people begin to experience changes in breathing. Shortness of breath is often described as air hunger. Air hunger is a fearful desire to breathe better. The body is telling the heart and lungs that it needs more oxygen and this can produce fear and anxiety. Another change a patient can experience is Cheyne-Strokes breathing which is loud breathing with a distinctive patter. Deep rapid inhalations that slowly decrease, followed by a pause of not breathing. This is caused by unstable ventilatory control as the heart and/or brain fails.

Near the very end

Excessive secretions (moisture in the mouth and throat) can create a loud gurgling noise during breathing that some may call the “death rattle”

How you can help

• Understand that this is a natural part of the dying process and at this point your loved one is unaware of the changed breathing.
• Talk with your hospice nurse about options for medical patches to help dry up some secretions.
• Position your loved one in ways that reduce the work it takes to breathe. Such as, elevating the head or sitting up slightly with pillows and adequate support.
• Keep the lips and mouth moistened with a wet cloth, moisturizer or lip balm.
• Your hospice nurse may educate you that suctioning the secretions is not advised as this will trigger a physiological response for the body to produce more secretions.
• Morphine may be used to treat air hunger as it decreases the heart’s urge to have more oxygen. Introducing morphine can be scary to families. Talk openly and honestly with your hospice team about your feelings and and listen to their expert advice.

4. Changes in Urination

Dehydration from decreased oral intake will lower blood pressure, leading to decreased renal function (decreased urine output) and eventually renal failure. Urine will become concentrated, brownish, reddish or tea colored. It may have a very strong odor that may not necessarily be infection, so antibiotics will not be appropriate. With severely decreased renal function, antibiotic treatment may further contribute to loss of renal function. Also, patients who normally have bladder and/or bowel control may lose function during the dying process and eventually there will be no urine output.

Near the very end

Kidney failure causes urine and other waste products to accumulate in the body. This results in further decreased mental alertness. Eventually, your loved one will reach a peaceful twilight state or comatose state.

How you can help

• Talk with the hospice nurse to ensure that there is not a urinary obstruction and/or bladder distention when there is no urine for eight hours.
• If your loved one is still aware, new onset incontinence can be embarrassing. It can also be hard for family members so helping to normalize the situation and provide understanding and comfort is vital to the care of your loved one.

5. Swelling to Feet, Ankles and Hands

Various chronic illnesses contribute to edema and swelling of the feet and hands as the disease becomes unmanageable. Fluid is not effectively pumped through the kidneys to be filtered and regulated. As a person ages, the kidney function decreases naturally. A very common cause of edema in a dying person is protein malnutrition. Fluid is most evident in dependent areas that are below the heart like the ankles and feet. In bed ridden patients, the hands and hips may swell as well. The most common chronic diseases that will exhibit edema are chronic heart failure, renal failure and liver disease.

Near the very end

As your loved one nears death fluid is more evident in the lungs that increases shortness of breath. You may be able to hear a “rattle” when breathing.

How you can help

• Position your loved one in a way that is easier to breathe and this may be with the head of the bed raised.
• Talk with the hospice nurse about the beneficial use of a compression hose to the legs. Also, elevate your loved one’s legs slightly.
• Protein supplements help raise protein stores so the fluid can better be regulated. Offer small, frequent high-protein meals and snacks.