When death looms - the signs and symptoms of final moments on earth
Death in a senior citizen, or anyone, for that matter...
Death is a natural progression of life. The truth hurts but there it is.
My mom is 95 and I've been her caregiver for 4.5 years now. During a week long hospitalization in November, 2010 for pneumonia, I had a lot of time to do some reading and writing as I watched her struggling for breath that first night in her hospital bed. The doctor in the ER had pretty much given us the word that death was looming - he gave her a 40% chance of making it through the night. So, as I wiped her brow and watched her restlessly move about the bed and try to get up, I wondered what was causing these new actions as she's generally a restful sleeper. When the nurse came in at 4 am to check vital signs (I waved her off), I asked her about the movement - she looked at me for a moment and then told me about what to expect when death looms. This article is a result of that very first conversation and my further delving into the subject.
Although I write from the perspective of death in a senior citizen, the signs and symptoms of death are the same in people of all ages.
And, while they're with us, cherish every single moment you can. Shower them with gifts - a gift can be something small like a surprise visit or something bigger like one of these items I've found on my article: Great Gifts For Senior Citizens - I'll bet there's stuff there that you've never thought about like large button TV remotes or talking alarm clocks. I also 'gifted' my Mom's sweet tooth with a lot of homemade dessert shooters - mini desserts served in small glasses. They were just the right size for her liking. Mix up a few Mini dessert shooters for your favorite elder. Why not sit a spell and enjoy a dessert with them?
BTW: My mom is fine. She's home after 5 days in the hospital and better than she's been for a while. Her pneumonia must have been around a while (asymptomatic) as her mental status decline was probably a result of the bacterial infection. Read more about sign and symptoms of pneumonia in the elderly by clicking Signs and symptoms of pneumonia in the elderly.
And, finally, here's another great article about the emotions you might deal with when someone close to you dies: Death of a loved one.
Update October, 2011: Mom turned 95 on October 28, 2011 so what did we do? Head off on a cruise! Cruising with a 95 year old can be a bit of a challenge, and I've written about it in this additional article: Taking a cruise with the elderly; things you MUST know prior to embarkation. We had a blast and, in retrospect, I'm so glad we went. It was another good week together (well, minus the hellacious storm and my seasickness..).
Another update November, 2011: 1 short week after the cruise, Mom fell and broke a hip. She's a trooper though - a full recovery is expected. Here's an article I wrote about caringbridge.org - a website where I update friends and family about her health status: CaringBridge.org - when health matters most.
Update July 19, 2012: Mom died Feb 15, 2012. Far from being tragic, her death was an easy end to a wonderful life. Mom certainly deserved the sleep, having worked very hard at living the last two weeks. Her death followed the typical pattern outlined in this article, and, in fact, I've updated it from a (now) even more personal standpoint. I miss my Mom greatly but am comforted by the best friends (both near and far) anyone can ever have. I am also so very glad that I had the resources to keep her at my home and to be with her when she died. Neither of us could have asked for more.
Update: August 10, 2012: I just had a friend die just the day before her 49th birthday. She fought a valiant fight against cancer and went way beyond her life expectancy. Still, it was quite sad that she didn't see 49. Here's a very interesting article that discusses a new study that shows people have an increased chance of dying on their birthday: People are more likely to die on their birthday, study finds.
Here's one more article that you might find helpful: Death and dying - dealing with the restless patient.
While They're With You, Come Get Some Good Gifts For Senior Citizens
I started my first website, GoodGiftsForSeniorCitizens.com when I was home caring for Mom. I was an expert at finding good gifts for senior citizens as I just had to be.
Some of the best gifts I bought Mom were things I'd never heard of like:
The signs and symptoms of death
There have been times in the recent past where my Mom's personality has shifted. Normally a cheerful, very funny woman, she would suddenly become agitated for little reason, become restless before bed, and become withdrawn from my friends who visit and family who come by. I thought she was being difficult and told her so. Sure wish I hadn't done that.
What my Mom was doing was signaling us (without knowing it) that she was preparing to, one day, say goodbye. The fact that her personality was slowly changing was, I think, preparing me for missing her as, in a strange way, I sort of missed her even when she was physically with me because, sometimes, emotionally, she wasn't.
The below are some of the signs and symptoms of impending death. Please note: death is a very personal experience so these signs and symptoms of death are generalized - not everyone will experience all of these symptoms and some may experience different symptoms of dying.
Please read through this carefully and share this article - everyone should be aware of these death signs so that they're compassionate to those going through the stages of death. It helps me immensely to remember that there are things that Mom cannot help - she's not being difficult, she's just helping me prepare to be alone one day. I felt sorry for those family members who took Mom's personality changes personally - they weren't at all meant to be that way. But, those who don't understand can frequently get their feelings hurt.
- Withdrawal. A person facing the last portion of life on earth may withdraw from daily life. The withdrawal may be physical, such as sleeping most of the day or appearing almost to be in a comatose-like state or, the withdrawal may be emotional. The elderly loved one may not want to spend a lot of time talking with family and friends.
This excellent white paper on death and dying is a worthwhile read: Understanding the psychological and social experience of a dying person
- Restlessness. Those in the last stages of life may appear restless for no reason. They may pull at the bed covers, try to get up from bed for no reason, or thrash around the bed. This restlessness may occur as blood flow to the brain slows. Restlessness, though, may also be a sign that your dying loved one has unfinished business to tend to.
To prevent the bedsheets from becoming tussled, you might consider buying a set of bedsheet suspenders which attach under the sheet to keep the sheet pulled down and straight. This can help shield against bedsores also.
- Changes in appetite. This is probably the toughest symptom of dying that a caregiver has to endure as, well, what we do is provide nourishment for our loved ones. And, in my Jewish upbringing, what do we do? We feed - they eat! So, my offers of my Mom's favorite foods of past such as blintzes or matzo ball soup are frequently turned down. I used to take this as an affront to my cooking until I started to research death and saw that refusing food is a typical way for the body to prepare for death. Not sure if I was pleased to find this little tidbit out but the cook in me did let go a sigh of relief.
Hospice workers also put this symptom in perspective for me. I was so concerned about Mom growing weaker but the excellent Hospice nurse told me that the body naturally slows down and forcing food is a bit cruel as the body can't digest the food as it used to. Bloating and uncomfortable feelings, such as constipation, can occur. Therefore, let the dying person dictate what they would like to eat. It's tough but must be done.
Here's a great article about feeding a dying person: Food, nutrition, artificial feeding methods, constipation, and quality of life issues in the dying person.
- Incontinence. Toward the end of life, the dying person may not recognize the body's signals to urinate or defecate. In addition to not recognize the symptoms of needing to "go", the body's muscles relax and there might not be any control of these activities any longer.
For more about how to deal with incontinence in the elderly, read my articleIncontinence in the elderly.
It was amazing to me how quickly I adapted to helping Mom stay clean and dry. The first few times were very difficult but, when I realized that it's just a part of life and dying, I quickly got over the queasiness of the situation.
- Changes in breathing. As someone nears the end of life on earth, breathing patterns usually change. Instead of the slow, deep breaths of a sleeping person, the dying breaths may become shallow and rapid followed by pauses in breathing all together. These pauses may last from 5 seconds to a full minute. This is very difficult to watch so be prepared. But, changes in breathing in the dying person is very normal and not at all painful for them.
Note to caregivers: As you sit by the bed and watch your loved one strive for breath, you might find yourself meeting their pattern. Remember to breathe!
- Gurgling sounds in the back of the throat. Although these gurgling sounds may sound painful, the dying person is not in any kind of pain. The gurgling sounds occur because the dying cannot swallow so saliva gathers in the back of the throat. And, in addition, depending on the medications the dying person is on, the gurgling may worsen as the kidneys stop producing urine so there is more water present in the body.
- Changes in body temperature. The dying body naturally will try to keep the internal organs warm so the extremities of a dying person may feel abnormally cool to the touch. But, a fever may also exist as the body's natural regulation of temperature weakens. Sweaty or clammy skin may occur with or without a fever.
With changes in body temperature come changes in the look of your loved one. The lips may take on a bluish cast, the skin may pale or become blotchy or purplish as circulation slows. These changes are normal signs of dying and are not painful to the your elderly loved one.
- Delusions or Dementia. As blood supply to the brain slows, the dying may become delusional. They may start talking out loud to others we can't see (and, who is to say those others aren't surrounding our loved one?). Frequently, those close to dying will utter words about "Going home." Some see this as a symbolic meaning and others see this as a way for the dying to signal to us that they're about to travel to somewhere else.
When we were in the hospital, my Mom mumbled in her sleep one night. All I could really catch was "I can get up and walk out of here if I want to." After I started looking into the signs and symptoms of death, I now realize that she was signaling me that her death was near. Thankfully, it wasn't that near as she's drinking coffee and eating a freshly made biscuit right now....
Come read my Kindle eBook - Senior Citizen Caregiving 101: Things I wish I'd known
I wrote my latest eBook to help other caregivers who tread in my sometimes astonishingly difficult path. I was lucky to have had the easiest elderly loved one, my Mom, to care for the last 5 years of her life, but, when I started caregiving, I had no idea of some of the challenges I would face. I learned by the seat of my pants - and, well, with Mom's gentle guiding hand. This book is 15 chapters of things I wish I'd known.
For those caregivers out there, here's my article The long goodbye - when your job as a caregiver is ending.
Books on death and dying that might help you understand the end of life process
All three of these books got the highest reviews possible (5 out of 5 stars) on Amazon.com. I haven't read any of these personally, having found them a year after my Mom died, but I read the reviews and they're awe inspiring. If you or a loved one is facing dealing with the end of life as we know it, these books might help you understand the process.
"These things happen"
A few of my other articles you might like.
Here's an article I wrote about Things I wish I had known when I first became a caregiver.
I didn't write this article the next article, and, thankfully, I couldn't have as it is eloquently penned by a physician who is dying. He puts things into words from both the side of the patient and the physician within him. It is beautifully written and well worth the read: A guide to dying.
Books on death
As my Mom's primary caregiver, I believe in being prepared. These books about death are on my wish list.
The Complete Eldercare Planner, Revised and Updated Edition: - Where to Start, Which Questions to Ask, and How to Find Help
This is one of the best books on the market for those of us who are responsible for the care of our elders.
Helpful links about death and dying
As I perused the internet during my days of caregiving for Mom, I was always glad to find resources like those below that helped validate both my feelings and my experiences taking care of the dying patient. There's also some good links to organizations which might help you cope with death, dying, and grief.
- BBC article about dying on one's birthday
This article reviews a study done in Switzerland between 1969 and 2008. The study looked at the birth and death dates and statistics of over 2.5 million people. The findings might surprise you.
- The Birthdate: Lifeline or Deadline
Another interesting article about the propensity of people dying on their own birthdate.
This is an excellent article documenting the 10 most frequent symptoms of approaching death. It's a must read companion to my own article.
- DNR - Do not resuscitate order
Here's an article explaining what a DNR order means. Note: this might be tough reading for some.
I found this frequently asked questions page fascinating. I liked reading through the questions of others and seeing how often the same issue was in my own head.
- Hospice foundation of America
I don't know how Mom and I could have gotten through those last months without the help from hospice nurses, clergy, and social workers. They were blessings for both of us. Here's information about hospice in general.
- Choosing Hospice - is it the right choice?
This is an article I wrote as we decided whether or not to enroll Mom in hospice. I am SO glad we did!
- Grief Share
Sometimes, leaning on others who share a similar pain can be helpful. Here's an organization that will help you find a grief group. And, grieving can actually start before the death of your loved one - you might be grieving for month earlier but don'
- Caregiver self-assessment questionnaire. How are you?
The American Medical Association's questionnaire is geared toward the wellbeing of the caregiver. You can download the questionnaire here in either English or Spanish.
- Signs of dementia
Another American Medical Association article which covers dementia. Most dying patients will probably show some signs of dementia as their organs slow down or stop functioning.
- More signs of death and dying
This excellent article goes over signs of death and dying also.
- Respite care
If you're a caregiver, no matter how much you might love your patient, you'll need a vacation once in a while too. I was lucky enough to have friends and other paid caregivers give me time off but, if you're not as lucky, here's a great article on re
One of my favorite pics of all time - Mom and Rita having a conversation.
Additional information on Hospice
Montgomery Hospice was truly a blessing to me and my friends as we eased Mom towards her last moments. I'm sure those last moments would have happened with or without Hospice but, for my sake, Hospice saved my sanity. The Hospice personnel were not only very knowledgeable (which I was not back then) but they always took the extra step of educating me. Death can be scary but, with Hospices' guidance, it wasn't at all.
Here's some good links to Hospice information. Please peruse these articles, especially if you don't understand what hospice is or what it can do for you and your loved one:
Hospice Myths and Facts - Some people believe Hospice is where you go when nothing else can be done. That's simply not true!
And, finally here's a good link to Locate a hospice in your area
Please read my accompanying article: Things I wish I had known before I became a caregiver.
Another sign of impending death is...
...Interestingly an energy surge
Your loved one may be lying in their deathbed and suddenly sit up and ask you something mundane - like, "Did you feed the dogs?" Now, this can be a bit unsettling but, if you're there, consider this time a blessed memory. Take a moment to talk with your loved one and ask them if there's anything they'd like or need you to do. It could be that your loved one arose after a cerebral need to finish something or make amends. Speak softly to them and remember to cherish the moment.
Important note!: If your loved one is in a hospital bed, make sure to lower the bed towards the floor to its lowest setting if no one is in the room with them. My hospice nurse mentioned to me that people who have been bed bound for months may suddenly "make a break for it" and fall to the floor.
The things that matter most in our lives are not fantastic or grand. They are the moments when we touch one another, when we are there in the most attentive or caring way.
Keep the dying comfortable with Comfort Washcloths
The hospital totally turned me onto these Comfort Washcloths. They're thick and pre-moistened. I'd take one and do my Mom's face, chest, arms and legs. She was always quite appreciative. I bought more of these when I came home for travel - I think they'd be great to have in a tote bag for a refreshing wipe during a busy day.
Mom still enjoys visits from the dogs periodically
How to help those who are dying
Along with the signs and symptoms of death, you should be aware of how your actions may comfort those dying. The below are just a few ideas to give you an idea of how to help the dying.
- For emotional withdrawal: Understand that the emotional or physical withdrawal is not a personal affront to anyone; it's simply a sign of dying. And, dying is about those who are actually dying - it's not about anyone else.
Try to schedule visits around the time when you most expect your elderly loved one to be alert - around meal times or after naps. Do not try to arouse the elderly loved one or force them into a conversation.
Talk to visitors and apprise them of the situation. Some people are more sensitive and may take the withdrawal personally. It's best to limit visitation by these folks as they're likely to be upset by the withdrawal which can, in turn, upset your dying loved one. Again, emotional withdrawal is simply a sign of dying and is not to be taken personally. But, some people simply don't get it...
- Changes in appetite. Accept that you're still a great cook (!) and offer light meals of clear broth or a few crackers. Liquids are more important than solids so try to make drinks interesting. Ensure plus is 350 calories and is a great thing to give the elderly once a day. Try to get your elderly loved one to sip water or offer small ice chips. Every bit of moisture counts. Even coffee is something.
Also, check with your senior citizen loved one's doctor and ask about an appetite enhancer. My mom is on Megace and I can't keep her full!
UPDATE: As my mom starts in on the last phase of life, we've withheld the Megace. This was the hardest thing for me to do as I knew she's stop eating. I talked this over with Hospice and found a new perspective. As we age, our digestion also slows. By giving Mom Megace, she'd eat more than her body could handle and would bloat. Megace was no longer a good medication for her. I now give her anything she wants which is usually coffee (!) and a bit of cereal in the morning, a very light lunch of broth, and a dinner of coffee (!) and cereal again. I also found a chocolate milk that she loves - Cocoa Metro Belgian Chocolate Milk. The stuff is really really delicious. Check out their website to see if this chocolate milk is carried in a grocery near you: Cocoa Metro website.
- Changes in urination or defecation. Protect the surfaces your dying loved on uses by covering with plastic sheets, and bed chucks (disposable bed pads). I actually bought washable bed chucks which are much more comfortable.
Depends are also a great item to protect the environment from urine or feces. Just make sure to never call depends "adult diapers" or to degrade the elderly for soiling themselves or their surroundings. At some point, it may be necessary to change to a different undergarment than traditional pull up Depends as it's too difficult to change them. Instead, find undergarments with tabs on the side so they'll fit snugly yet are still comfortable. I've placed a few choices below.
if your elderly loved one is able to walk, you might schedule bathroom visits. Sometimes, the elderly won't even know they're going so it's best to try to stay ahead of the issue with scheduled visits.
Make sure to change the elderly into new clothing shortly after an accident.
- Changes in breathing. Turning the dying person on their side may help clear the airway and provide easier breathing. Ask the doctor or nurse about any troublesome breathing - morphine is frequently used to ease laborious breathing patterns.
As you sit beside your dying loved one, you might find yourself unconsciously matching their breathing (and gasping) patterns. Try and be aware of this phenomenon and breath as normally as you can.
Ask your loved one's doctor or Hospice nurse if morphine would be a help for breathing. Morphine relaxes the muscles and allows air to be more fully processed. It's helped my Mom a lot.
- Changes in body temperature. Cover chilled extremities with warm blankets but do not use electric blankets! Electric blankets are a no-no around the elderly as they simply cannot tell when they're too hot and they can actually overheat under an electric blanket. Same goes for heating pads. I used a heating pad a few years ago on my Mom's aching back and didn't realize it was burning her. A trip to the doctor and some silvadene cream and she was back in action but I'd learned a painful (for her and me!) lesson.
To easily check a senior citizen's temperature, consider purchasing one of the new forehead thermometers - makes it much easier to take a temperature.
If a fever is evident. consider applying small amounts of rubbing alcohol to the body. Follow with a light dusting of baby powder which will provide additional cooling to the skin. Place a cool cloth on the head and wrists and, perhaps, reduce the room temperature.
- Confusion or disorientation. Identify yourself when you first speak to the elderly and tell them what tasks you're going to do before you do them. When visitors approach, say hello as a clue for your elderly loved one of who is coming.
Here's an important tip: Hearing is the last sense to die. Make sure you don't discuss the condition of even a comatose loved one while they're there. They very well may hear and understand you. Speak in a normal voice and speak slowly.
For the times when my Mom has been disoriented, I've just sat by her bed, held her hand, and told her that she didn't have to worry about anything - I was going to be there to handle everything. She seemed to calm down after hearing these words. I also tell my Mom every single day that I'm glad she's here living with me and I am. I honestly would not have her be anywhere else than in her bed and in my arms when her time comes.
- Restlessness or agitation. Make sure that the dying person has any medications needed to alleviate restlessness or agitation. Contact a nurse or doctor as needed. If possible, if your dying loved one is cognizant, ask them if there is anything they'd like you to do after their gone (this is a difficult conversation). Ask if there is anything they need or try and distract them from their condition by mentally painting a pleasant picture of something you've done in the past.
For the times at night when Mom was restless, I have sat and spoken to her about how Dad would have liked the garden I'd planted, or how he would have loved the first tomato we had the other day. Frequently, she will calm down as I go deeper into thoughts of past times with my dad and her.
Sometimes, simply holding her hand will calm her down. I will speak to her in a light voice until she settles down. The other thing I've done that I've found works for Mom is to put one of my lap dogs on her bed. Having a dog to place her hand upon usually stops any agitation.
Here's another of my articles which might help: Death and dying - dealing with the restless patient.
I am pleased to introduce my Mom, Gertie - Click on any small picture to enlarge it.Click thumbnail to view full-size
Some additional books which may help you deal with a loved one's death
The sweet smell of death
After Peggy Hazelwood (an amazing online writer friend) left me a comment regarding the smell of death, in true Lori fashion, I took to the internet to explore.
It seems that some people report smelling a sweet odor just prior to death - one person noted it to be like old pancakes with a bit of syrup. Hmmmm...interest analogy. Anyway, the scientific reason for this odor seems to be many fold:
1. The shut down of the organs, particularly the liver and kidneys, produces chemical that are exuded in sweat of the dying.
2. Some think it could be changes in hormones.
3. Some think that the sweet smell comes from the breath of dying people and is attributed to acidosis.
Whatever causes the sweet smell of death, there's no disputing that it does, indeed occur with some people and other people seem to be able to smell it, but not all people. There's a thought that this is why the animals (usually cats) who live in nursing homes go and sit on the bed of those about to die. Whatever the reason, I'm glad God made cats...
Life is not about weathering the storm - it's about learning to dance in the rain.
A beautiful story about dying
One of my online friends sent me a PM through Facebook to tell me this beautiful story. It really touched me. I immediately asked if I could post it on my lens - she asked to remain anonymous which I will certainly respect. Read on, dear readers...it's a beautiful story...
Lori - I've been reading your articles. They are very good and spot-on advice (from my nurse prospective).
After reading the article on death and dying, I wanted to share an experience that I was so fortunate to witness. I had a resident (in her late 90's) who was really in good health for her age. She was deeply religious and quiet natured. She told one of my staff nurses one day that she would like for us to call her daughters to come as this was her last day. She told me that she had a dream the night before and in it, she and her late husband had reviewed their life together. Then, this morning, God had spoken to her to tell her that it was her last day.
We assessed her carefully - everything looked fine. As I helped her into her bed to rest until her daughters arrived, she pulled me down to her face and whispered in my ear "if I could only tell you how beautiful it is." She had such a look of peace and happiness. Her daughters came and then she wanted them to call the sons from Atlanta to come up right away - she wanted to say goodbye to them. She told her boys that.
I checked on her and her daughters frequently that afternoon. Much of the time was spent reading scripture and talking family topics. One of the daughters came to my office at one point and said that her mom wanted to go out for ice cream - would that be OK? I went with her back to her mom's apartment and told her "sure you can go! " She replied that she wanted to go in her daughters red convertible!
Before I left that day, I asked her "will I see you tomorrow?" Her response was "sure you will." Her daughters all kind of rolled their eyes and laughed like - so what is today all about?
Her sons and all the families did get there that evening and they had a nice visit. At bedtime they left. The aid helped her into bed right at 10pm. Her grandfather clock chimed the hour. This beautiful woman closed her eyes and left this world. This experience was such --- I can't describe the feeling I had except that I felt blessed. That God would let me witness this. And you know - I did see her that day, but in my heart. Some of my nurses didn't "get it". All of her family did. I am so grateful that I did.
The timeline for signs and symptoms of death
The below information was gleaned from the Montgomery Hospice booklet we were given when Mom was enrolled in hospice. For more information about hospice, click and read my article Hospice: is it the right choice?.
- One to three months pre-death:
Withdrawal from people and activities
Appetite changes - generally reduced appetite
Resting more - you might see your loved one sleep all day.
- One to two weeks pre-death:
Increase or decrease in pulse - decrease in blood pressure
Changes in skin color - paling, blotchiness or a blue or purple tinge to the skin
Changes in breathing patterns
Changes in body temperature - either clammy/cool or a fever
More changes in appetite - usually refusing food and having a problem even drinking water (use those ice chips)
- Days to hours pre-death:
Possible surge of energy - remember to enjoy these times!
Restlessness or agitation
Further changes in breathing - gasping with periods of no breathing between
Rattling breath sounds
Decreased urine or feces output as the kidneys shut down
Eyelids may be slightly opened
- Minutes to death:
Shallow breathes with longer pauses
Eyes may remain open or half closed
Remember though: even during this last period of life, the dying loved one may be able to hear you. Now is the time to tell them how much you have loved having them as your mother, father, brother, sister, etc... Tell them how much you have admired them, how you will always keep them in your heart and how you hope to one day see them again. Now, some might find this calloused but, during what I thought might be my Mom's last moments, I leaned in and said all of the above and ended with "Tell Dad to send money...." Mom laughed...
Update 3/29/12: I wanted to update this section by saying that the very last moments of the dying may be difficult to watch. Some liken the breathing to "a fish out of water" and that's what I thought when Mom took her last breaths. Please be assured that your loved one is not suffering while exhibiting this type of breathing - it's simply what happens. Mom went quite peacefully, surrounded by friends and family in my own home. She won the game.
This book got excellent reviews on Amazon.com and is a must read for those of us going through difficult times in our lives. I've always believed that things happen for a reason, and this book goes along with that theory.
Death also brings out the very best in some people and the, sadly, the very worst in others. I read a lot of books to help me deal with my own fractured family. I came to the conclusion that I just had to let some people go. I can honestly say that I've never looked back.
I also would really appreciate it if you would forward this article to any caregivers who are in the same boat as I am. I think this information needs to be shared. Thanks in advance.