As a person approaches the final hours of life, three types of changes occur. There are physical changes that take place as the body begins to shut down and there are emotional and spiritual changes. This article focuses on the physical changes that occur. I will defer to experts in other disciplines to address the emotional and metaphysical changes that take place as we prepare for death.

In some ways the process of dying is likened to the process of being born. Over nine months, a person goes through many stages of development that end in labor and eventually birth. In a similar way, a person with a terminal disease goes through many changes over a period of time. Here are some of the expected physical changes.

Cooling and Discoloration of the Skin

Hands, arms, feet and legs begin to cool as the circulation of blood slows. The heart and vessels do not have the capacity and strength to continue to pump blood to the extremities and reserves its flow to vital organs. The reduced blood flow to the arms and legs can cause the skin to discolor giving a red to purple marbling effect on the skin that is sometimes referred to as mottling

Most times the dying person is not even aware or bothered by the cooling. Caregivers can ease any discomfort by providing a simple cover, applying socks or holding the hands of the patient for comfort.

Sleepiness and Eventual Loss of Consciousness

As death nears, people usually become very lethargic, sleep more and harder and harder to wake. The effort to keep eyes open and speak is too exhausting. Eventually, they reach a point where they can no longer be awakened.

We do not know what their level of awareness might be. Even when your loved one seems unresponsive, studies have shown that he or she might very well sense your presence, whether you are sitting quietly nearby, holding hands, or speaking. Continue to speak as if
they can hear and defer all useless conversation away from their presence.

Confusion and Delirium

A person near death may become disoriented, agitated or even combative. This may be a result of less blood flows to the brain, metabolic changes, decreased oxygenation or simply the natural progression of the disease. This phase will pass but it is often the most distressing for those engaged directly with the person’s care.

When the dying person becomes restless and wants to get out of bed, do not argue. Rather reassure them with a calm voice, and decrease any unnecessary stimulation that could increase their restlessness. Keeping noise and external stimulation at minimum along with holding their hand. Gently stroking them may also help lessen the agitation. If the situation does not improve, notify your healthcare team for additional interventions which may include medications. Do not wait until the situation escalates and gets out of control.

Reduced Intake of Food and Fluid

The person who is dying usually wants little or no food and drink. This change usually occurs days or weeks before death. The body’s metabolism and need to consume energy and hydration is withdrawing. The physical ability to ingest, digest and excrete these useless calories is actually more distressing to the body. We can liken it to when we are sick with the flu. The body has other needs to attend to than processing food and liquids.

We are used to expressing our love with food. We need to transcend that demonstration of love to other means such as holding hands, reading or simply being a presence.

Loss of Ability to Swallow

Swallowing becomes more difficult as weakness increases. As the swallow reflex decreases saliva and other secretions increase. The sounds of gurgling or a rattling sound with each breath becomes noticeable. This death rattle may sound like choking, but it is not.

Repositioning the person’s body frequently facilitates the drainage and reduces the sound. Do not give any oral fluid at this point as the person is unable to handle their own saliva. You can keep the mouth moist with a small sponge dipped in water. You can also moisten the lips with a lip balm. The healthcare team may be able to use medications to deal with this development.

Changes in Breathing Pattern

The rhythm of breathing changes near death. There are periods of shallow and rapid breaths mixed in with episodes of deep breathing. Then the breathing progresses to where a person may not breathe at all for as long as ten to twenty seconds before breathing again. Twenty seconds may not sound like a very long time, but it is excruciatingly long for those maintaining vigil. There is no discomfort noted while this cessation of breathing occurs.

Simply close your eyes and hold the dying person’s hand as these irregular breathing patterns occur. It will be less stressful. In many cultures caretakers sit with the dying, eyes closed and matching the breathing pattern. This method is called merging of breaths and has been reported to be very comforting.

Loss of Bowel and Bladder Control

As all the muscles continue to weaken, the bowel and bladder function weakens as well. This can cause embarrassment for the person who is dying as well as the caregiver. In addition, depending on the disease process, the volume of urine and bowel contents will diminish. The urine will be darker and have a strong odor.

Speak with your healthcare team so they can suggest ways to maintain cleanliness and comfort as you care for your loved one.