Signs of
Dying
with Suggested Cares
Appreciating the preciousness of human life,
based on the understanding of one's body constantly changing, ageing,
moving toward death since birth and the uncertainty of life helps us
appreciate life and prepare for death. It is natural for one's body to
decay especially when accelerated by disease processes. In the final stage
when life-sustaining systems begin to shut down, physical, mental,
emotional and spiritual changes may occur over weeks, days or hours. Each
person's experience is unique but there are some general similarities.
The following is a very simple account of the
normal changes that may occur in the final stage of living, commonly
called "dying" and some suggested ways of caring:
Physical Weakness / Lack of Energy / Loss of Interest in Everyday Things
As the body's systems weaken less oxygen is
available to the muscles, the life force weakens, more effort is needed to
complete everyday tasks and one may become embarrassed, discouraged,
ambivalent, depressed, irritable and/or just naturally become more
interested in matters that seem more important: matters of the mind, heart
and spirit. This is often a time of self-examination, of questioning, of
looking for the meaning of life.
Caregivers can best help by assisting the person with physical tasks,
while being sensitive to their feelings, maintaining their dignity and
attending to their comfort as much as possible especially with regard to
symptom control and protection from injury. Love and humour can take the
tension away from a stressful situation. Laughter opens the heart and can
free one to see past appearances and circumstances, leaving the burden of
self and entering into a instant oneness with another, that is blissfully
rewarding. Physiological and spiritual support means being along side as a
good friend, patient, non-judgemental, compassionate, allowing the
person's own wisdom to evolve. When regrets appear - seeing them as
lessons, encouraging memories of meaningful events, rejoicing / seeing the
benefits of the kind actions of one's life, allowing whatever faith, hope
and love the person has, to exist and develop freely.
Withdrawal from Family and Friends / Increased Sleepiness / Coma
Neither family, friends nor wealth can be taken
with us when we leave this world. Much of the packing it all up and
leaving it behind is a solo job and one needs time and privacy to do it.
Visitors can be very exhausting and the person may feel they have to
entertain their guests even if they can't get up out of bed. Too many
visitors one day will often result in the person being more tired and/or
more withdrawn the next day. Sometimes the person may sleep more, be
difficult to arouse or uncommunicative. This may be due to disease
processes, medication, or the person's desire to withdraw from social
contact. Simply being a loving presence near the person, holding their
hand, sending loving thoughts, silently praying, meditating, just being
there for them provides a comforting, safe and peaceful atmosphere that
facilitates the person's inner work. The caregiver should try to respect
their wishes and be aware of what personal desires come up in their own
mind and how these can be addressed without disturbing the mind of the
dying. Be careful of what you say over their body while the person is
asleep or unconscious, they may hear you and it could upset them. Many
people who have recovered from a coma (a state where there is no response
to voice or touch stimuli, though eyes may still be open) have reported
being aware of what others said and even thought in their presence.
Random jerks or twitches can be due to dreams or
nightmares, you can reassure them with your kind tone of voice and/or a
gentle touch on their hand or arm. The dying are very sensitive to what is
communicated by the caregiver's body, speech and mind and the caregiver
can become more aware of reactions and messages from the person by
watching and listening. The eyes, facial expressions, and breathing
changes often indicate what the person is feeling or thinking. The reason
why communication is possible on this level and why you can trust your
deepest intuition is because the basic nature of every being is pure and
knowing, as Christians may say God-like or as Buddhists say having all
pervasive, indestructible wisdom nature. Awake or asleep this is always
present and available if one is relaxed, open and receptive, but it is
much more familiar and easy for those who are habituated to this awareness
through meditation practice. The depth of one's spiritual practice is
communicated by its own power and has remarkable benefits for others.
Stripped of dogma and doctrine, reputation and position, sex, age, and
relationship, leaving one's 'self' to enter nakedly with no agenda, into
unity with the person, even for a brief moment liberates both parties from
the bondage of duality temporally and is profoundly comforting.
Loss of Appetite
Food is a fuel that helps sustain life. As the
digestive system gets weaker, food may become more of a discomfort than an
enjoyment, some medications may change the tastes of food, and finally the
energy required to process the food becomes greater than the energy
derived it. Any of these may produce a loss of appetite. Eating habits
change. The person may become overwhelmed by a "normal size" meal. He/she
may take a few mouthfuls of their "favourite" meal and feel full. Small
attractively presented meals may tempt them. But who is getting the
satisfaction - family and friends who want to nourish them so that can get
better and live longer? Its often the hardest thing for the family to
face, but the refusal to feed the body is not a refusal for nourishment,
it is a sign that priorities have changed to nourishing the
soul/spirit/mind. Forcing the person to eat or making them feel guilty if
they don't, only isolates and distances them even further. The person
needs to know that it is OK not to eat. Respect and acceptance brings
people closer together which comforts the person and the caregiver too.
Difficulty Swallowing
As the swallowing reflex weakens, swallowing
becomes difficult. It may become frightening for the person to attempt to
eat or drink or the person may be slipping into unconsciousness. It is
best to offer very small amounts (half a teaspoon) and observe the throat
to see if swallowing has taken place. Tolerance of food generally
progresses from solid to soft to liquids (soups and dietary supplements),
to ice chips and spooned or sucked water. It is safer to feed a person who
is upright, but if the person is used to eating in an incumbent position,
it is generally easier to swallow if their head is kept straight, not
turned to the side. The sucking reflex seems to last a long time as the
caregiver will see when attempting to clean the person's mouth or teeth.
Mouth care is important for comfort and dignity. Medications can be
crushed and mixed with jam, jelly, yoghurt or like foods. Do not crush
time-release or long acting medications. Alternative medications or modes
of delivery are available. Do not give food or liquids to a person who is
unconscious. It may cause the person to choke or to inhale the foreign
matter.
Confusion
The level of awareness and cognition can change
frequently and unexpectedly, due to many causes (i.e. disease processes,
tiredness, medication). When a person becomes confused, there may be a
decrease of oxygen to the brain, they may not recognise familiar people,
places, the time of day, year etc. or they may hear voices or see visions.
Do not negate what they say or argue with them. This is their personal
reality and if it is a comforting experience for the person then be happy,
it is a sign that the person is at peace. If their experience disturbs
them, gently touch or stroke their arm, speak calmly with a soft
reassuring voice by reminding them of who you are, where they are, what
day it is etc. Aromatherapy and their favourite music or chanting of their
faith, is also helpful.
Restlessness
A person may become restlessness and make
repetitive motions like picking at the bed linen, their clothing or the
air. This can be a sign of less oxygen available in the brain or of being
distressed due to having pain, nausea, constipation or a full bladder or
could be due to being confused or anxious about something. Or if the
person is throwing or kicking bed covers off even in a cool room, it can
be the first stage of death when one feels like being buried under a great
weight. Before rushing in to do something about it, be calm and still.
Observe and listen with your mind and heart to what the person could need.
Do not try to interfere with their restless motions but protect for injury
and check out the physical side first. Pain doesn't conform to schedules.
When the physical is taken care, using a soothing voice, reminding them of
their goodness and virtues, music, aroma therapy or reciting the persons
favourite spiritual practice may help calm and reassure them. Like-wise
distracting the mind away from the disturbing thought or nightmare (if the
person is unconscious), by describing a favourite place or special
experience or simply giving the person assurance that it is OK 'to let go'
may address the real problem that the person is unable to articulate.
Restlessness can also be a sign of spiritual
crisis which needs urgent attention, not waiting for the minister or
religious person although they could of course be called to attend, but
there is no time to loose, one needs to know what the dying person
believes or what prayers or meditations practices that they do and also to
remind them of the positive things that they have done in their life,
remind them of their faith, their heaven or Amitabha pure land, recite
these prayers etc for them and whether the person has religious belief or
no faith, he or she can be encouraged to generate universal love and to be
that love (forgiving oneself and all others and to generate love for all
without exception). Universal Love replaces fear with calm and confidence.
Elimination
As the person gets weaker and is no longer able
to get out of bed, the muscles that control the bowel and bladder may
relax and "incontinence" or involuntary loss of urine or faeces may occur.
Often the person will feel embarrassed and/or may awaken if asleep. Attend
to them with dignity and respect and avoid exposing their private parts to
others. Its important to keep the skin clean and dry or the skin could
develop a rash or open sores and cause more discomfort. Use plastic gloves
and soap and water or a disposable skin wipe. Often when a person needs a
bowel movement they will get grumpy, irritable or restless. It's a good
idea to keep a record of the bowel movements to tell the nurse or doctor.
One can't expect a normal daily bowel motion but too many days between
eliminations can signal a problem. However, with little food intake there
is little reason for a bowel motion.
As the kidneys shut down and the skin takes on
more elimination work; the person may experience itching over different
parts of their body and also combined with increased sweating from failing
thermal regulators it is difficult to provide comfort. Different things
work for different people: some like warm bed baths, others cool tepid
sponging, or even a cool compress to the forehead and pulse areas can cool
down and soothe. Tea tree oil, calendula or lavender oils or other
commercial products can give relief. Change the bed linen if soiled with
sweat. This is a good opportunity to give a back rub and reposition the
person into a more comfortable position.
Body Temperature and Colour
Mechanisms that control the body's ability to
control its temperature will start failing. The skin may sweat and still
be very cool or may be hot. The person may kick off the bed linen but be
cold to touch. As the heart becomes weaker, circulation fails to
adequately reach the hands and feet and they will become cool to touch and
the nails maybe bluish, while the arms and legs maybe pale, grey, mottled
or purplish. At this time its best to follow the wishes of the dying to
keep them comfortable even if it's against reason (like trying to keep a
person covered when they keep kicking the blankets off). However it's
important to avoid drafts that may cause the body's temperature to fall
too fast and cause shivering. Normally Repositioning is advised every 3-5
hrs, but closely monitor whether it becomes too painful to turn or if one
position is not tolerated. If possible give extra pain relief before a
necessary turn (like when cleaning incontinence). If close to death it is
not necessary to turn for circulation. It is only necessary to turn the
patient if it helps breathing or provides more comfort. Always observe how
well a person settles into a new position and if they don't settle, try
another position, or gently return them to the previous position, and/or
give pain relief. This is a difficult judgement that can be a great
challenge for the caregiver because things are always changing. One
position favoured one day will not necessarily be tolerated the next day.
A loose sheet from the shoulders to the knees (called a "draw sheet"),
under the person's body will help turn or lift the person up the bed (One
person on each side of the bed, holding their side of the sheet, rolled up
close to the body).
Breathing
If breathing is difficult with or without oxygen
being given, sometimes a fan blown over the body to give the sensation of
being in fresh air, combined with the mental suggestion of visualising
sitting on a beach in the wind or the top of a high hill can give relief.
Keeping the head elevated will help breathing, be careful to still support
the lower back. A lubricant on the lips will help prevent cracking. And
mouth care with mouth swabs can help keep the tongue and mouth moist and
less dirty. Although this will not be necessary or may not be tolerated by
someone close to death.
A change in breathing pattern is significant
during the dying process. When the exhalation (out-breath) is longer than
the inhalation (in-breath) this is a sign that the dying process has begun
(even weeks before actual death). Next the breathing becomes irregular,
although irregular breathing can occur at anytime when someone has a lung
condition that causes shortness of breath. Closer to death, the breathing
involves the whole rib cage and fast (up to 30-50 breaths per minute)
mostly through the mouth and then may pause for even 10-15 seconds before
the next in-breath. This period of no breathing is called "apnoea". This
pattern of shallow quick breaths followed by no breathing (called Cheyne-Stokes
breathing) can continue for a few days, hours or minutes before the person
actually stops breathing, but rarely does a person improve from this
stage.
There maybe a rattling noise (often called the
death rattle) at the back of the throat, caused by the accumulation of
saliva because the person can no longer swallow. This is often distressing
for the helpers but it doesn't seem to bother the dying person. The pool
of secretions is too far down the throat to be suctioned. Sometimes
turning the person with their head to the side can help drain the
secretions from their mouth. Dying people breath better when they are not
completely lying on their side, as a health person would sleep. Lying
towards the right side is favoured because the heart is not obstructed and
according to Buddhist medicine it supports a happy mind, by blocking the
right channel. The Buddha passed away lying on his right side. Buddhist
scriptures say to block the right nostril with the ring finger, face
resting on the right hand. But if there is a medical reason or the person
just can't tolerate the right side, comfort is the priority, to keep the
person's mind happy.
Unexpected Alertness and Increased Energy
Often a day or two or even a few hours before
death, the person has a surge of energy, wakes up, becomes alert, can
sometimes eat or talk and can spend some quality time with loved ones.
This is a very special time for final spiritual practices and mental
preparations, which can be shared with loved ones if it is the dying
person's wish. This is a very precious time because it normally doesn't
last long, as most people become unconscious (unresponsive) hours or days
before they stop breathing.
Signs of Imminent Death
Eyes have glassy fixed stare with large pupils
Pasty grey, or blue greyish colour present especially on lips, hands and
feet
Hands and feet can be cold
Jaw open, breathing through mouth very rapid or very slow (often with
rattle) with pauses of 20-50 seconds between breaths
Unresponsive to voice or pain
It is most important not to do or say anything
that might disturb or anger the person, like speaking abruptly, arguing,
crying, rough handling; maintain a peaceful atmosphere with the people
praying, meditating or chanting according to the dying person's wishes or
as instructed by their spiritual guide/teacher. Any supporters can
generate limitless universal or devotion in their hearts and the wish for
the dying person to be released from suffering with this love or
devotion/faith, becoming unified with love, with god or with their source
of inspiration and virtue.
Clinical Death
No breathing (chest does not move)
No heart beat (no pulse)
Pupils large, do not change
Sometimes release of bowel or bladder
Because of the continuity of mind moments, the state of mind at the time
of death is vitally important, it's most important to die with a calm and
peaceful mind; with strong spiritual/ positive thoughts prevailing.
Therefore maintain a peaceful atmosphere and allow the death process to
proceed undisturbed, by not touching the body until all the heat has left
(indicating that the most subtle consciousness has left the body). If the
body needs to be cleaned or moved it is recommended to touch the top of
the head first so that the consciousness becomes aware of this and leaves
the body through the crown.
According to Buddhist texts: Death is the separation of body (physical
form) and "mind" formless, clear, luminous and knowing. (Only the most
subtle level of mind transmigrates.)
Death is a process with stages:
After conception, formation proceeds from subtler to grosser, but at death
there is dissolution from grosser to subtler. The four elements earth
(hard substances of the body), water (fluids), fire (heat), wind/air
(energy, movement) degenerate and dissolve in sequence and there are
external signs and internal visions at each stage. In the final stage of
death all the gross consciousnesses dissolve into the emptiness of clear
light, where with previous training one can discover the fundamental
innate reality. (see Buddhist Death and further suggested reading)
Further reading:
How We Die by Sherwin B. Nuland, MD
Advice on Dying by His Holiness the Dalai Lama
Good Life, Good Death by Gehlek Rimpoche
Sleeping, Dreaming and Dying edited by Francisco J. Varela, Ph.D
Advice and Practices for Death and Dying for the Benefit of Self and
Others by Lama Zopa Rinpoche
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Source: http://www.buddhanet.net
