The Dying Process

When a person enters the final steps of the dying process, two different dynamics are at work which closely inter-related and inter-dependent. Therefore, as you seek to prepare yourself as this event approaches, the members of your Hospice care team want you to know what to expect and how to respond in ways that will help your loved one accomplish this transition with support, understanding and ease. This is the great gift of love you have to offer your loved one as this moment approaches.

The Two Dynamics
 
On the physical plane the body begins the final process of shutting down, which will end when all the physical systems cease function. Usually this is an orderly and undramatic progressive series of physical cues which are not medical emergencies requiring invasive interventions. These physical changes are a normal, natural way in which the body prepares itself to stop and the most appropriate kinds of responses are comfort enhancing measures.
 
The other dynamic of the dying process is at work on the emotional-spiritual-mental plane and is a different kind of process. The "spirit" of the dying person begins the final process of release from the body, its immediate environment, and all attachments. This release also tends to follow its own priorities, which include the resolution of whatever is unfinished of a practical nature - reconciliation of close relationships and reception of permission to "Let go" from family members. These "events" are the normal, natural way in which the spirit prepares to move from this materialistically-oriented realm of existence into the next dimension of life. The most appropriate kinds of responses to the emotional-spiritual-mental changes are those which support and encourage this release and transition.
 
When a person's body is ready and wanting to stop, but the person is still unresolved or unreconciled over some important issue or with some significant relationship, he or she will tend to linger even though very uncomfortable or debilitated in order to finish whatever needs finishing. On the other hand, when a person is emotionally - spiritually - mentally resolved and ready for this release, but his or her body has not completed its final physical process, the person will continue to live until the physical shut down is complete.
 
The experience we call death occurs when the body completes its natural process of shutting down and when the "spirit" completes its natural process of reconciling and finishing. These two processes need to happen in a way appropriate for the values, beliefs, and life-style of the dying person so that the death can occur as a peaceful release.
 
The physical, as well as the emotional-spiritual-mental signs and symptoms of impending death which follow are offered to help you  to you to help you understand the natural kinds of things which may happen and how you can respond appropriately. Not all these signs and symptoms will occur with every person, nor will they occur in this particular sequence. Each person is unique, and what has been most characteristic of the way your loved one has lived consistently will affect the way this final shut down and release occurs.
 
This is not the time to try to change your loved one, but the time to give full acceptance, support, and comfort.
 
Normal Physical Signs and
Symptoms with Appropriate Responses
 
Coolness - The person's hands and then arms, and feet and legs may become increasingly cool to the touch, and at the same time the color of the skin may change. This is a normal indication that the circulation of blood is decreasing to the body's extremities and being reserved for the most vital organs Keep the person warm with a blanket, but do not use an electric blanket.
 
Sleeping - The person may spend an increasing amount of time sleeping and appear to be uncommunicative and unresponsive. This normal change is due in part top changes in the metabolism of the body. Sit with your loved one, hold his or her hand, do not shake or speak loudly, but speak softly and naturally. Do not talk about the person in the person's presence. Speak to him or her directly as you normally would, even though there may be no response.
 
Disorientation - The person may seem to be confused about the time, place, and identity of people surrounding him or her. This is also due in part to the metabolism changes. Identify yourself by name BEFORE you speak rather than to ask the person to guess who you are. Speak softly, clearly and truthfully when you need to communicate something important for the patient's comfort, such as, "It is time to take your medication," and explain the reason for the communication, such as, "so you won't begin to hurt." Do not use this method to try to manipulate the patient to meet your needs.
 
Incontinence - The person may lose control of urine and / or bowel matters as the muscles in that area begin to relax. Discuss with your Hospice nurse what can be done to protect the bed and keep your loved one clean and comfortable.
 
Restlessness - The person may make restless and repetitive motions. This often happens and is due in part to the decrease in oxygen circulation to the brain and to metabolic changes. These changes may also temporarily alter personalities. Do not interfere with or try to restrain such motions. To have calming effect, speak in a quiet natural way, lightly massage the forehead, read to the person, or play some soothing music.
 
Fluid and Food Decreases - The person may begin to want little or no food or fluid. This means the body is conserving for other functions the energy which would be expended in processing these items. Do not try to force food or drink into the person, or try to use guilt to manipulate them into eating or drinking some thing. To do thins only makes the person much more uncomfortable. Small chips of ice, frozen Gatorade or juice may be refreshing in the mouth. Glycerin swabs may help keep the mouth and lips moist and comfortable. A cool moist washcloth on the forehead may also increase physical comfort.
 
Urine Decrease - The person's urine output normally decreases due to the reduced fluid intake, as well as a decrease in circulation through the kidney's. Consult with your Hospice nurse to determine whether there may be a need to insert or irrigate a catheter.
 
Breathing Pattern Change - The person's regular characteristic breathing patter may change with the onset of a different breathing pace which alternates with periods of no breathing. This is called the "Cheyne-Stokes" symptom and is very common. It indicates a decrease in circulation in the internal organs. Elevating the head may help bring comfort. Hold his or her hand. Speak gently.

Withdrawal - The person may seem unresponsive, withdrawn, or in a comatose-like state. This indicates preparation for release, a detaching from surroundings and relationships, and a beginning of "letting go." Since hearing remains all the end, speak to your loved one in your normal tone of voice, identify yourself by your name when you speak, hold his or her hand, and say whatever you need to say that will help the person "let go."
 
Vision-like Experiences - The person may speak or claim to have spoken to individuals who may have already died. They may say they see or have seen places not presently accessible or visible to you. This does not indicate an hallucination or a drug reaction. The person is beginning to detach from this life and is being prepared for the transition so it will not be frightening.. Do not contradict, explain away, belittle or argue about what the person claims to have seen or heard. Just because you cannot see or hear it does not mean it is real to your loved one. Affirm his or her experiences. They are normal and common. If the frightened your loved one, explain to him or her that they are normal
 
Restlessness - The person may perform repetitive and restless tasks. This may in part indicate that something is still unresolved or unfinished that is disturbing him or her, and preventing him or her from letting go. Your Hospice team members will assist you in identifying what may be happening, and help you find ways to help the person find release from the tension or fear. Other things which may be helpful in calming the person are to recall a favorite place your loved one enjoyed, a favorite experience, read something comforting, play music and give assurance it is ok to let go.
 
Fluids and Food Decrease - When the person any want little or no fluid or food, this may indicate that the person is ready for the final shut down. You may help your loved one by giving him or her permission to let go whenever he or she is ready. At the same time, affirm your loved one's ongoing value to you and the good you will carry forward into your life that you received from him or her.
 
Decreased Socialization - The person may only want to be with a very few or even just one person. This is a sign for preparation for release and an affirming of who the support is most needed from in order to make the approaching transition. If you are not part of this "inner circle" at the end, it does not mean you are not loved or are unimportant. It means you have already fulfilled you task with him or her and it is time for you to say "Goodbye." If you part of the final "inner circle," the loved one needs your affirmation, support and permission.
 
Unusual Communication - The person may make a seemingly "out of character" or non sequitur statement, gesture or request. This indicates that he or she is ready to say "good-bye" and is "testing" to see if you are ready to let him or her go. Accept the moment as a beautiful gift when it is offered. Kiss, hug, hold, cry and say whatever you most need to say.
 
Giving Permission - Giving permission to your loved one to let go without making him or her feel guilty for leaving or trying to keep him or her with you to meet your own needs can be difficult. A dying person will normally try to hold on, even though it brings prolonged discomfort, in order to be sure that those who are going to be left behind will be all right. Therefore, your ability to release the dying person from this concern and give him or her assurance that it's all right to let go whenever he or she is ready is one of the greatest gifts you have to give your loved one at this time.
 
Saying Good-Bye - When the person is ready to die and you are able to let go, then is the time to say "Good-bye." Saying "good-bye" is your final gift of love to the loved one, for it achieves closure and makes the final release possible. It may be helpful to lie in bed with the person and hold him or her, or to take the hand and say everything you need to say so afterward you need never to say to yourself, "Why didn't I say this or that" to him or her.
 
It may be as simple as saying, "I love you." It may include recounting your favorite memories, places and activities you shared. It may include saying, "I'm sorry for whatever contributed to any tensions or difficulties in our relationship." It may also include saying, "Thanks you for...." Tears are a normal and natural part of saying good-bye. Tears do not need to be hidden for your loved one or apologized for. Tears express your love and help you to let go.