Please remember The timeline for the following signs and symptoms is a flexible one with changes generally beginning anywhere from one to three months before death occurs.
Decreased socialization often occurs at this time, so patients may become more quiet and withdrawn. Your patient may be trying to detach himself from his surroundings
and those around him in order to “let go.”
Periods of rest and sleep increase for the patient at this time.
Increased restlessness and /or repetitive actions may be exhibited as death approaches. You may also observe increased confusion as time passes. Hearing the Maha Mantra, pastimes of Lord Krsna, or a solf bhajan may help to decrease anxiety at this time.
Decreased eating and drinking as digestion and swallowing become more difficult. During the last few days of life even small sips can cause choking. Never force foods or fluids, as this will not make your patient comfortable at this time.
Incontinence of bowel and bladder, even if your patient was previously continent, may occur as the disease progresses. Keeping the skin clean and dry and applying a thick, protective moisture barrier cream will prevent rashes and other skin breakdown that can result from incontinence.
Vital signs and skin color change as the body systems begin to shut down. Blood pressure may decrease. Pulse rate may increase or decrease above or below the normal range of 60 to 100 beats per minute. Body temperature may fluctuate to above or below normal rage of 96 degrees Fahrenheit to 100 degrees Fahrenheit (35.6 C to 37.8 C), often running a hight temperature a few days to hours before death.
The patient's skin may become moist and clammy. As death nears you may notice a mottling in the skin color beginning at the heels, knees, hands and feet. The lips and nail beds may become darker and bluish in color.
Change in Breathing Pattern. Your patient's lungs my begin to fill with fluid and her breathing may sound moist. Normal respirations are aound 16-20 breaths per minute. At the end stage respirations may become shallow and can increase up to 40 or more breaths per minute. You may also notice apnea, periods without breathing, which can last from as little as 10 seconds up to a minute or more.
A few things you can do to assist with more comfortable breathing are: keeping the head and chest elevated, having a fan blowing gently on the patients face, the use of oxygen, and adequate circulation of air in the room.
A Few Days to Hours Before Death.
Eventually your patient may become nonverbal and may not respond to external stimuli. The patinet may appear to be in a coma-like state. Even though he may not respond he can still hear you and others. For a devotee, continuous chanting of the hare Krishna mantra should be performed at this crucial time. Pain medication should be continued as the patient may still be experiencing pain even though she may not be able to let this be known.
The following signs of impending death may or may not occur, but if present,are indications that the patient will probably pass away within a day or two or even withing hours:
- Breathing may slow. Periods of apnea may be noticed.
- The lungs may fill with fluid, making breath sounds moist and rattly. This is often referred to as the "death rattle."
- Cheyne-Stokes respiration pattern may appear. This is a chaotic pattern of breathing with periods of apnea followed by periods of deep and rapid respirations.
- Skin may feel cooler to the touch, and may appear bluish in the hands and feet.
- Mottling may increase especially in the knees, ankles, or elbows.
- Discoloration may travel down the legs, or other part of the body as circulation slows.
- The eyes may remain partially open and have a fied stare without blink reflex.
- Pulses will become weaker and more difficult to locate.
- Body temperature can fluxuate between abnormally high or low.
Even when in this "actively dying" stage, some may linger for days and others for only hours. Continue to give physical and spiritual comfort to your patient at this tme.
As described in The Final Journey in much more vivid detail, often a patient will seem to hang on until he or she has closure for something important to them. Sensitivity to these matters of closure for a dying person is essential in hospice care. For a devotee, this principle also applies.