Alexander Peralta, Jr., M.D.

Director of Palliative Care Services

American Hospice

THE PROCESS OF DYING

Introduction:
As a person enters the final stage of the dying process, two different
dynamics stages are closely at work. The First Stage is Physical; the body
begins the final process of shutting down. Death occurs when all physical
systems cease to function - homostenosis. Usually, this is an orderly and normal
series of physical changes that may be stressful to observe, but are not
considered medical emergencies. The changes are a natural way in which the
body prepares itself to shut down and the most appropriate responses to this
process is to provide palliative or comfort measures to the patient.
The Second Stage of the dying process is emotional, spiritual and
psychosocial. It is a different kind of process. The dying person may express a
need to complete unfinished business, to reconcile relationships, and to begin to
let go, and even seem to withdraw (decathexis) from family members. These
events are normal and natural. The most appropriate responses to the
emotional, spiritual, social and psychological changes are those of acceptance,
understanding and support in carrying out the existential and spiritual wishes of
the dying person.
When a persons body is ready to shut down but the person still is has
unresolved issues or unreconciled relationships, it may seem to some people
that the person may be resisting death in order to attend to this unfinished
issue(s). This may happen inspite of the patients weakening condition and
overt symptoms. On the other hand, when a person is emotionally, spiritually
and mentally ready for its transcendence but the body has not completed its final
physical process, the person may continue to live until the process of shutting
down is completed.
The experience we all call death occurs when the body completes its
natural process of shutting down and the mental, emotional and spiritual
processes come together in a way that is appropriate for the values, beliefs and
lifelong relationships of the dying person which gives him/her the buoyancy to
transcend peacefully to the unknown. Therefore, as you prepare for this loss, 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
your support and understanding. This is the great gift of love you can offer them
as you accompany them in this final journey.
The physical, emotional, spiritual, social and psychological signs and
symptoms of impending death that follow are to help you understand the natural
process of dying that may happen and how you can respond appropriately.
These signs and symptoms will not occur with each person, nor will they occur in
a particular sequence. Each person is unique and whatever has been most
characteristic of the way your loved one has lived will affect his or her final

Alexander Peralta, Jr., M.D.

Director of Palliative Care Services

American Hospice

moments as death occurs. This is not the time to try to change them, but the
time to give full acceptance, support and comfort.
Physical Signs & Symptoms and Appropriate Responses:
1. Coolness -- The persons face, hands, arms, feet and legs may
become increasingly cool to the touch and at the same time the color of the skin
may change to a pale hue (mottling). This is a normal sign indicating that
circulation of blood to the bodys extremities is decreasing and is being reserved
for vital organs; that is the brain, heart, lungs and kidneys. Keep the person
warm. Avoid using an electric blanket. Socks may help keep the feet warm. Do
not adjust the air conditioning by making the environment warmer as this may
cause infections or odors.
2. Sleeping -- Your loved one may spend an increasing amount of time
sleeping and appear to be uncommunicative, withdrawn or unresponsive. This
normal change is due in part to changes in the bodys metabolism. Spend time
with your loved one; hold hands. Speak to him or her as you normally would
although there may be no response. Dont say anything that you would not want
your loved one to hear. They can hear you even in a comatose state.
3. Disorientation-- Your loved one may seem to be confused about the
time, place and identity of people. This also is due, in part, to metabolic
changes. Identify yourself by name before you speak. Speak softly, clearly and
truthfully when you need to communicate. For example: It is time to take you
medication, so you wont have pain. Be honest. Dont try to force or trick your
loved one into taking medications, even though you may believe you are only
acting in the patients best interest. The trust between the patient and caregiver
is too important to be jeopardized.
4. Incontinence-- The patient may lose control of urine and/or bowel
matter as the muscles in that area relax. Discuss this with your Hospice nurse to
determine what can be done to protect the bed and keep the patient clean and
comfortable.
5. Congestion-- Your loved one may have gurgling, bubbling or rattling
sounds coming from the chest or throat. This is normal and is sometimes due to
inability to clear secretions, i.e. cough up secretions or due to thickness of
secretions. Elevate the patients head and gently turn it to the side, allowing
gravity to drain the secretions. You also may give mouth care as instructed by
your nurse. Congestion is often distressing to listen to but may not indicate
discomfort to the patient.
6. Restlessness-- The patient may make restless or repetitive motions.
This occurs frequently and is due partially to the decrease in oxygen to the brain
plus metabolic changes. Do not interfere with or try to restrain such motions. Try
to establish a calm atmosphere; speak in a quiet, natural way; eliminate bright
lights. Look for calming things to do --a gentle back rub, stroking the arms or
forehead, reading aloud or playing soothing music may help.
7. Fluid and Food Decreases-- Your loved one may want little or no food
or fluids. This means that the body is conserving energy for other functions. Do
not try to force them to take food or fluids or try to manipulate them into eating or
drinking. This only causes more discomfort. Instead, offer small chips of ice, soft

Alexander Peralta, Jr., M.D.

Director of Palliative Care Services

American Hospice

drinks, juice, or popsicles. Cater to the likes of your loved one. Vaseline can be
applied to dry lips. Lemon and glycerin swabs also can keep the mouth and lips
moist and comfortable. Lips and mouth may need to be moistened ever hour or
two, especially when the patient is mouth breathing. A cool, moist washcloth on
the forehead will sometimes be very soothing.
8. Urine Decrease-- Urine output normally declines because of
decreased fluid intake as well as a decrease in circulation throughout the body
and decrease clearance in the kidneys. Ask you Hospice nurse whether there
may be a need to insert an indwelling Foley catheter. The color of the urine will
change from yellow to amber to tea-color to coca-cola color.
9. Breathing Pattern Change - The regular breathing pattern of the
patient may change. There may be periods where breathing stops for several
seconds (apnea spells or Cheyne-Stokes respiration). Open mouth with jaw
movements or breathing (Mandibular respiration's) and use of chest accessory
muscles may also be noticed. This is common. Elevating the head with a pillow
or blanket may help. Hold hands, speak gently and be reassuring. Slow down
your own breathing!
10,
MedicationsOur hospice professional staff will offer medications
to ameliorate symptoms of discomfort such as pain, nausea, agitation and severe
dyspnea. The focus of our treatments is grounded on the ethical Principle of
Double Effect. It is our intent to provide comfort measures to your loved one and
not hasten or prolong the natural dying process.
Psychosocial and Spiritual Signs & Symptoms and Appropriate
Responses:
1. Withdrawal -- Your loved one may seem withdrawn or in a coma-like
state; this may indicate preparation for release --a disengagement from
surroundings and relationships and the beginning of letting go. Since hearing
remains to the end, speak to your loved one in a normal tone of voice, identify
yourself by name when you speak, hold hands, and say whatever you need to
say he/she will hear you.
2, Vision-like ExperiencesNearing Death Awareness -- Your loved
one may speak to or claim to have spoken to persons who already have died or
claim to see places not visible to you. If you are unable to gently re-orient them,
validate their experiences. This may mean that they are beginning to detach from
this life and are preparing for the transition. Do not contradict, explain, or argue
about what they claim to have seen or heard. Just because you cannot see or
hear what they are experiencing does not mean it is not real to your loved one.
This is a common experience called nearing death awareness. If these
experiences are frightening to your loved one, probe for their meaning and try to
reassure them they are in a safe place.
3. Restlessness-- Your loved one may perform repetitive and restless
tasks. Your Hospice team members will assist you in identifying what may be
happening and will assist you in finding ways to help them find relief from tension
or fear. Other things that may be helpful in calming them are to recall a favorite

Alexander Peralta, Jr., M.D.

Director of Palliative Care Services

American Hospice

place or experience (guided imagery), read something comforting, play soft

music, or provide assurance. Give them permission to let go.
4. Decreased Socialization-- Your loved one may want to be with a
limited number of friends, family or just you. The dying person has limited
strength and energy to deal with socialization. This withdrawal and detachment
occurs, as they become more involved in making the transition, a journey that
must be made alone. Do not interpret this as a rejection or lack of love, but as a
natural part of the process of death through which everyone must pass. In
Transpersonal psychology these stages of human development are know as the
Subtle, Causal and Ultimate Realms. Your loved one needs your support and
love. You may feel the need for your Hospice nurse, Social Worker and/or
Chaplain at this time.
5. Unusual Communication-- Your loved one may make a seemingly
out of character statement, gesture or request. This may indicate that your
loved one is ready to say good-bye and is testing to see if you are ready to say
goodbye. Accept the moment as a beautiful gift when it is offered. Kiss, hug,
hold, cry and say whatever you need to say. It is an opportunity to share love
and forgiveness.
6. Giving Permission-- Giving permission to your loved one to let go can
be difficult. A dying person may try to hold on, even if it brings prolonged
discomfort. This is there way of showing concern and love for those who are
going to be left behind. Therefore, your ability to release the dying person from
this concern and give him or her the assurance that it is all right to let go
whenever your loved one is ready. This is one of the greatest gifts you have to
give at this time.
7. Saying Good-bye-- When the person is ready to die and you are able
to let them go--this is a milestone event. This may happen at the time of death
but perhaps you and your loved one have already said your good-byes. This
process seems to achieve closure and makes the final release possible. You
may want to touch or hold your loved one, or do whatever is and has been a
comfort to the both of you. The moment may include recounting favorite
memories, places and activities you shared. It is a time when forgiveness can be
extended or received, love that may have never been expressed may be shared
The dying person may wish to know if they have made a difference in our lives
and that they will be remembered. Tears are a normal and natural part of saying
good-bye. These emotions are normal and need not be hidden nor do you have
to apologize for them. The hardest task we do as humans is saying our final
good-bye.
Finally
The impending death of a patient is not a medical emergency and does
not require emergency room treatment. You and your Hospice team have
worked together to allow your loved one to die at home in familiar surroundings
and without painful and/or extraordinary treatments. Nothing must be done
immediately, unless the patient is having severe symptoms.

Alexander Peralta, Jr., M.D.

Director of Palliative Care Services

American Hospice

The signs of death include such things as no breathing, no heartbeat,

release of bowel and bladder, no neurological response, eyelids slightly open,
eyes fixed on a certain spot, no blinking, jaw relaxed and mouth slightly open.
We at Hospice admire you for caring for your loved one at home. Our
hope is that this information will decrease some of the anxiety you may feel
during this very stressful time and milestone event. The miracle of life is having
family and/or friends support you at this time in your life. Remember that a nurse
from Hospice will be available to help you. Please know, that every question or
concern you have is important and our hospice team will try to provide an answer
to the best of our knowledge.