Refusal of Food and/or Fluids

This means the body is reserving energy for other essential functions. The person will not experience pain or other discomfort, such as feeling thirsty, as this is a natural process. Often, as people become dehydrated, their discomfort lessens. It is important not to try to force a person to eat or drink. Doing this generally makes a patient more uncomfortable and will not improve their condition.

Changes in Skin Temperature or Color

You may notice a coolness, paleness or mottling of skin on the arms, legs and back. This occurs as circulation is conserved for vital organs. Blankets can increase the patient’s comfort. We avoid using electric blankets or heating pads as they can cause burns without the patient feeling it due to the lack of circulation.

Loss of Urine or Bowel Control

As muscles relax, the patient may lose control of these functions. There is often a decrease in urine output. Patients should be kept clean and dry. Turning the patient frequently is important to assure good skin care and to prevent bed sores. A catheter may be considered for urinary incontinence.

Altered Breathing or Congestion

Gurgling or gasping may occur as the muscles in the throat tend to relax. At times, the patient may appear to stop breathing for a moment and then gasp. This is called Cheyne Stokes breathing. Elevating the head may decrease the sounds. To help with secretions, gently turn the patient’s head to the side and wipe out the mouth with a damp cloth or mouth sponge. Suctioning is not helpful and can make secretions worse.

Mental, Emotional and Spiritual States

While death remains one of the universe’s mysteries, many believe the spirit of the dying person actually begins a process of release from the body, its environment and all emotional attachments. This release tends to follow its own priorities, including the resolution of unfinished business, and it will always relate to a person’s lifestyle, values and beliefs. It is often said that, “people die consistent with the way they lived.”

Restlessness

Sometimes a person may become restless, try to get up or make repetitive motions. Try to avoid restraining these motions. Speak in a quiet, natural way. Try reading to the person, playing soothing music and keeping lighting slightly dimmed.

Disorientation

The person may become confused about time, place and/or the identity of people. Many people at this time speak of going home. It is important to speak softly and clearly remind the person of where they are and any care that is being given (ie: “I am going to give you this medicine to keep you from hurting.”) Try to keep as many things the same and in routine as possible.

Unusual Communication

A surprising number of people make out of character statements. They may speak in metaphors, speak to other loved ones who have previously died or talk about being somewhere they’ve never seen before. Research suggests these may not be hallucinations, but rather a form of communication.

Withdrawal and Increased Sleeping

As death approaches, people may begin to withdraw. They may close their eyes often or seem to have a decreased desire to communicate. This is often hard for loved ones. Try not to take it personally. It is a normal process of letting go that has to happen. The person may actually become unresponsive at some point. Know that hearing remains even when a patient appears to be in a coma. Be cautious in what you say during this time. Speak to the person in a normal tone of voice, identifying yourself by name. Hold their hand. You may want to touch their neck as this is a place where sensation seems to stay. This can be a good time to let the person know what they have meant to you.

Other Physical Signs

• Decrease in blood pressure
• Increase in pulse rate and difficulty finding it
• Increase in perspiration
• Elevation in body temperature