Hospice journey: Practical information about natural death

Physical signs through the dying journey, a natural part of life. Just as we are all unique in how we live, we are also unique in how we die.

woman pushing person in wheelchair under trees

Many people avoid discussing death, but some of the pain of natural death can be eased when people know the signs and symptoms, and when loved ones know what they can do to help.

The following information is designed to help individuals and families go through the journey of dying — a natural part of life.

A body goes through a variety of changes as it prepares for death. These changes usually begin in the final one to three months before death. None, one or all of the following signs may be present during the journey. You may see a slow or rapid progression of these signs as the body prepares for death.

Just as we are all unique in how we live, we are also unique in how we die.

Pain control

When people say they are having pain, it generally means they are hurting somewhere in their body. Pain can usually be controlled well by medications. The person may have side effects such as drowsiness or nausea during the first few days of a new pain medication or an increased dose. But most side effects usually pass in a few days.

Nonverbal signs of pain:

  1. Moaning
  2. Grimacing
  3. Crying
  4. Restlessness
  5. Withdrawal
  6. Weakness
  7. Skin pale in color
  8. Low or high blood pressure
  9. Slow or fast heart rate
  10. Problems breathing
  11. Excessive sweating
  12. Guarding, lack of mobility

Verbal signs of pain: Rank the pain on a scale of 0–10, with 0 being no pain and 10 being the worst pain that can be imagined.

What you can do

  • If there is pain most of the day, medication scheduled around the clock is more helpful than if it were taken only as needed.
  • Try to stay on top of the pain. Rather than wait until the pain gets really bad, the person should take pain medicine when pain starts.
  • Take pain medication a half-hour before activities if activity makes pain worse.
  • The person should try to relax and take deep breaths. Muscles will be less tense, and pain medication will work better. A change in position, listening to relaxing music or dimming the lights can help.
  • Heat or cold may help. Only apply heat or cold for 20 minutes at a time. Allow at least 20 minutes between applications. Never apply ice or heat directly on the skin. Never allow someone to sleep with a heating pad on.
  • At times, the pain medication dose and/or frequency may need to be increased. If the pain medicine doesn’t work as well as it used to, talk to a nurse about what can be done for comfort.
  • Use assistive devices as needed such as a walker, wheelchair, etc.

Nutrition and dehydration

Nutrition is a big part of our lives. Our culture places a lot of importance on meals and the role of nutrition in healing and becoming stronger. Often, feeding and preparing meals for a loved one are ways of showing love, concern and caring.

One of the hardest things for the caregiver to accept is when the dying person no longer eats or drinks enough to stay alive. But as the body changes, not wanting to eat or drink is a natural response. Food may not taste as good. Liquids may be preferred. It is common for hard-to-digest foods such as meats to be the first foods the person rejects. Next, the person may not want to eat vegetables.

People who are terminally ill often are not hungry. Those who do become hungry usually only need small amounts of food or fluid to satisfy their hunger. Changes that happen with dehydration may produce a natural analgesic (pain relief) effect in the final days of life.

Dehydration also causes:

  • Less urine output or less need to use a bed pan, urinal or commode, or fewer episodes of incontinence
  • Fewer secretions in the lungs, which may relieve coughing and congestion
  • Less swelling, which may decrease pressure symptoms
  • The mouth to be dry — this can be controlled with frequent oral care

What you can do

  • Allow your loved one to direct their intake of food.
  • Don’t force food or fluid intake. It is a natural response to not want to eat or drink as the body prepares to die, and weight loss can be expected.
  • You may wish to try nutritional supplements.
  • Offer four to six small meals or snacks throughout the day. More frequent, small meals may be more appealing than three large meals. Cool, bland or soft foods may be best.
  • Change the times of meals to when the person is pain-free and has the most energy. This is often the morning or mid-afternoon. Offer pain or nausea medicine one hour before mealtime.
  • Cups with lids such as travel mugs or children’s sippy cups allow a weak person to drink without worry of spilling.
  • Provide frequent mouth care. As the body becomes dehydrated, the mouth will get dry. Offer ice chips and use artificial saliva and moisturizer for the lips.
  • Toothette swabs are also helpful in keeping the mouth moist.
  • IV fluids are not routinely used by hospice when a person begins to decline or is not drinking fluids. IV fluids can overload the body and cause more discomfort.
  • Fever can occur as the body becomes dehydrated. First try removing extra blankets and use a lighter covering such as a sheet. Fever can be checked by placing a thermometer in the mouth or under the arm. A cool washcloth to the forehead or a sponge bath can offer comfort. If the fever still remains, medications may be given.

Constipation

Constipation is common when a person is on pain medications. Usually the following interventions will be started at the same time as a pain medication. In addition to pain medications, less activity or movement and less food and drink can contribute to constipation. Nausea, vomiting and more pain may be felt when a person is constipated.

What you can do

  • Try to increase fiber intake, offering more fruits, vegetables and grains.
  • Drink fluids as tolerated.
  • Consider drinking a cup of a stimulant such as coffee or 1/2 to 1 cup of warm prune juice.
  • Try taking a stool softener and/or stimulant.
  • Be more active if able.

Skin care

Good skin care can help make the dying person more comfortable. This becomes more important when your loved one has to stay in bed, eats and drinks less or is no longer able to control bladder or bowel function.

What you can do

  • Daily personal care and hygiene.
  • Encourage daily movement and activities as tolerated, even simple motion exercises to the arms and legs.
  • Prevent rubbing and friction injuries.
  • Use skin barrier creams or ointments. Apply liberally. There is no need to remove all the skin barrier cream or ointment every time.
  • Use mineral oil to make removal of cream or ointment easier.
  • Protective barrier creams or ointments may prevent fungal or yeast infections.
  • Reposition the person every two hours for comfort.
  • Encourage high-protein, high-calorie foods (as tolerated and desired).
  • Pressure relief devices can be used for heels and elbows.
  • Keep skin moisturized with a lotion of choice.
  • Special padding or cushions can be used for the bed or chair.
  • Tell the hospice nurse if any skin irritation or breakdown occurs.

Seizure precautions

  • The person should take medication to prevent or treat seizures as instructed by their doctor and hospice nurse.
  • Seizures are rarely a severe threat but can be when a seizure is immediately followed by another and another.
  • A person may feel a warning sensation (aura) before a seizure. This will alert them that a seizure is about to happen. Confusion, disorientation and sleepiness often follow a seizure.
  • When a person begins to have feelings of an aura or starts to seize, have the person lie down. Stay away from areas that would result in injury until the seizure stops. If they are in bed, pad side rails with a blanket to prevent injury.
  • Do not try to restrain the person when a seizure happens.
  • Position the person on their side to allow drainage of secretions and to keep the airway open.
  • Do not put anything in the person’s mouth.
  • Call the hospice nurse for more instruction and help.

Physical changes the last one to two weeks of life

During this time you will see many physical changes. You may see some or all of these changes:

  • The heart rate may increase or decrease from the normal heart rate. This is the body’s way of conserving energy. As the heart gets weaker, it won’t pump as strongly as before. The blood pressure may drop.
  • Body temperature may go back and forth between hot and cold. The skin may be clammy. The person may sweat more.
  • The skin may turn a bluish or purple color (mottling). This may be seen first in the nailbeds, legs and arms.
  • Breathing patterns may change as the body tries to conserve energy. The dying person may breathe faster or slower than usual. The depth of breaths may decrease and become more shallow. An irregular breathing pattern may be seen. Pauses in breathing (apnea) may occur. These pauses may last from a few seconds up to a minute.
  • Congestion or a rattily sound may be heard when the dying person breaths. The cough is usually weak and does not always clear this congestion. Often congestion can be helped by turning the person on one side or the other.
  • Little to no intake of food and fluids can be expected. Because the dying person is taking in fewer liquids, there is less urine output. He or she may be incontinent of bladder or bowel.
  • Confusion or disorientation may occur or be increased. They may see things and/or people that others do not see and speak to people who are not there. The dying person may become unresponsive sometime before death. The person may have a glassy look in their eyes, or they may shed tears.

What you can do

  • Keep room quiet and peaceful.
  • Keep skin dry and clean. Accept help with bathing your loved one in bed.
  • Talk to your loved one. Sit and hold their hand. Touch and hearing are the final senses to go.
  • Consider getting a hospital bed so the head of the bed can be raised to ease breathing.
  • Position your loved one so there is less congestion or rattily breathing. Medications may help with congestion.
  • Continue to give medications as directed to help with pain, restlessness or shortness of breath.
  • Use disposable diapers or disposable pads for incontinence to protect linen.
  • Being there is one of the most comforting things you can do.

Withdrawal

As a person accepts that they are dying, they may start to withdraw. They may lose interest in favorite activities, friends and family. They may spend more time sleeping. While sleeping, a dying person is often reviewing their life. Caregivers and family may see a dying person “working” with their hands and arms in the air or picking at blankets while they are sleeping.

At times, the dying person may also talk about leaving or going home. They may talk about deceased family members or friends. A dying person may become agitated and restless.

What you can do

  • Talk to the dying person. They may not be able to respond, but they can hear you.
  • Hold their hand; give a massage. Touch can be comforting.
  • Keep the environment relaxed.
  • Consider medications to help with anxiety or treat the underlying cause such as pain or shortness of breath.
  • Encourage activities, or offer distractions.
  • Welcome visitors. But also be aware your loved one may not tolerate long visits or many visits in one day. Be honest with visitors. Ask them to limit visit time or tell them your loved one does not want visitors today.
  • Help your loved one resolve any issues.
  • Disorientation and confusion may occur before a person dies.

Signs of death may include

  • Breathing cannot be seen or heard
  • No heartbeat
  • Loss of bladder or bowel control
  • No response to your voice or touch
  • Eyelids slightly open
  • Eyes fixed on a certain spot
  • Jaw relaxed and mouth slightly open

Preparing for and responding to death

This checklist will help you keep track of what needs to be done when someone dies. Not all of the items will be needed by everyone. It will be helpful to check off items as they are done.

Before death

  • Write down bank account numbers, personal identification numbers and computer/website passwords.
  • Address organ, eye or tissue donation as needed.
  • Find and review deceased’s funeral and burial wishes.
  • Arrange care for children or other dependents.
  • Arrange care for pets.
  • Make arrangements with funeral home (cremation, burial, funeral and/or memorial services).
  • Prepare and arrange for obituary. Have post office hold or forward mail. Cancel or rearrange home deliveries.
  • Locate safe deposit box(es). Contact bank for safe deposit box procedures.
  • Locate important papers and documents. Some of the items you may need include:
      • Birth and marriage certificates
      • Social Security card for dependent children, spouse and deceased
      • Recent federal tax returns
      • Military records, discharge certificates
      • Wills, codicils and trusts
      • Bank accounts, stocks, bonds, and real estate records
      • Life insurance policies
      • Social Security benefits (800) 772-1213 or www.ssa.gov
      • Veterans burial allowance and benefits
      • Union or fraternal organization death benefits
      • Employee benefits including: vacation pay, death benefits, retirement plans, deferred compensation, final wages, and medical reimbursements
      • Refunds on insurance or canceled subscriptions
      • IRA accounts
      • Business, partnership and investment arrangements

After death

  • Notify hospice, not 911 or the ambulance. The hospice staff will help you confirm that the person has died. They will call the funeral home and the doctor. Although this may sound frightening, the hospice team’s goal is to prepare you for what will happen. Your physical and emotional well-being is important to us.
  • Notify immediate family and close friends.
  • Notify the power of attorney.
  • Arrange for care or disposal of perishable property (food, plants, etc.)

After the funeral

  • Get death certificate (at least six copies for bank accounts and insurance policies).
  • Keep records of all payments for funeral and other expenses.
  • Tell Social Security and other agencies as needed.

As needed

  • Meet with attorney about estate.
  • Meet with CPA for tax and accounting matters.
  • Meet with life insurance agent to collect benefits or consider options.
  • Deal with fire, theft, liability and auto insurance on deceased’s property.
  • Determine value of assets.
  • Review credit cards and charge accounts; cancel if needed.
  • Do not pay any of the deceased’s debts until the attorney discusses this with the family.
  • If there is a trust involved, arrange for any allocations and transfers.
  • Arrange for final income tax return and estate tax return as needed.

Posted In Family Medicine, Health Information, Hospice, Midlife, Senior Services, Symptom Management

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