As with life, death also is a process. Life has been described as a journey, and that is often true of death. It can certainly be a journey and though the final end point is the same, each person’s experience with it is unique. Those who are terminally ill may go through the different stages of dying.
Even though the end of life looks somewhat different for each individual, it is also similar in the symptoms of each stage. Knowing what those stages are, and what to expect as death approaches is pivotal. Hospice services offer the support that families will need as a loved one begins their final journey. We will discuss both the stages of dying and how hospice can support a patient and their loved ones at each stage.
The Dying Process In Three Stages: Early, Middle, And Final
To help better understand what changes take place before death and how to be prepared to support a loved one near death, we will outline the three main stages of the dying process. These are categorized as the early stage, the middle stage, and final stage. In each stage, there are physical, emotional, and even spiritual changes. Hospice providers are specially trained to meet the transitional needs of patients at end of life.
As previously mentioned, although death is a unique experience, there are symptoms that are common to the dying process and examining those are beneficial to properly prepare for a death in the family. The time each stage may last is multifactorial and it can be dependent upon the specific disease process, age of the patient, comorbidities, and other factors.
The early stage of dying often begins within one to several months prior to death. This stage is characterized by a general slowing down of activity, and even a time of withdrawing into self. It can be a time of self reflection, reminiscing, and soul searching.
Physical Changes In The Early Stage
There are common physical changes that tend to occur in the early stages of the dying process. As life begins to wind down to a much slower pace than a patient has been used to, it is helpful to have the support of the hospice team to assist with the transition to preparing for death. It is important to note that a patient may not experience every single early symptom but the following list can be helpful as a guide.
- Decreased appetite, decreased interest in food, decreased eating/drinking
- Decreased energy, decreased interest in activities
- Increased need for sleep
- Increased weakness
- Increased need for assistance with activities of daily living
- Weight loss
- Increased pain, nausea, or other symptoms
- Increased risk of infection
Emotional and Spiritual Changes In The Early Stage
As the body is slowing down in the early stage of the dying process, the mind also experiences a kind of lag as well. Introspection and self evaluation may be happening, but an overall coming to terms with separating from this world is also taking place. Hospice chaplains and social workers are great resources for supporting a loved one who is dealing with complicated emotions and at the end of life.
There may be things that are difficult to speak about to family members, and having someone to lean on for emotional and spiritual support is key in finding peace. It is also a time when patients make amends with estranged family and friends and say final goodbyes while they are still cognitively aware.
The middle stage of the dying process usually occurs within a few weeks of death. Marked changes happen in the 7-14 days just prior and may feel overwhelming for caregivers. Hospice team members are dedicated to ensuring patients remain comfortable and that the family receives the physical, emotional, and spiritual support they need.
Physical Changes in the Middle Stage
In contrast to the early stage of dying, the middle stage is marked with a more rapid onset of decline. Some of the physical changes that indicate that death is near:
- Sleeping the majority of every day
- Loss of verbal communication skills
- Total dependence for all needs/bedbound
- Total incontinence/Little to no oral intake/decreased urine and stool output
- Increased pain/increased shortness of breath
In the middle stage of the dying process, the hospice nurse carefully evaluates the patient to look for nonverbal signs of pain, agitation, and other signs of approaching death. End of life care education is provided on an ongoing basis, however; more in-depth teaching may be required as death nears.
New medications may be introduced to control any end of life symptoms that arise. It is fairly common to need additional treatment for pain, anxiety, constipation, as well as medications to relieve shortness of breath and swelling.
Due to inactivity and the slow down in the body’s processes, fluid tends to build up. This can be generalized edema as well as a build up of oral secretions creating a “rattle” when breathing. Apnea, or periods of pause or no breathing, is likely to occur at this time as well. As the main goal of hospice is to keep the patient as comfortable as possible, the care plan is reviewed often and changes are made rapidly to ensure the goal is met.
Emotional and Spiritual Changes in the Middle Stage
In the middle stage, if the patient is still cognitively aware and able to communicate, there may still be periods of confusion, delirium, and even hallucinations. Loved ones may hear the patient “talk to” or “see” a friend or family member who has previously passed on. They may also express that they need to pack their bags, or that they are leaving on a trip. It is important at these times to just listen and accept what the patient is describing as being their reality. There is no need to try to reorient them or remind them that a loved one has already passed on.
If a loved one is no longer able to communicate verbally, they may also experience agitation, anxiety, confusion, and delirium. Behaviors such as moaning, calling out, picking at clothes or sheets and restlessness may indicate terminal agitation. The hospice staff will closely observe to look for any nonverbal signs so that they can offer support and any treatments to help maintain patient comfort.
Spiritual support can still be offered to patients regardless of whether or not they can communicate verbally. Prayers can still be offered, and other activities such as playing spiritual music can help keep them comfortable.
Hours to days are all that are left in the final stage of the dying process. The final journey is coming to a close. It is a time when the patient is doing the hard work of letting go of this physical world. Death is as unique as each birth. To some, death of the body is just the beginning of a whole new journey. Knowing the approaching signs of imminent death is helpful for family and loved ones to cope with their loved ones passing.
Physical Changes In The Final Stage
Recognizing the signs of imminent death are the key for caregivers to remain supportive when a patient reaches their final moments before death. Each patient will experience some variation and intensity of symptoms. Some cues that death is very near are:
- Coma like state
- Irregular breathing pattern
- Irregular heart rate
- “Death rattle”, noisy breath sounds
- Increased Apnea
- Mottling of hands and feet
- Eyes may stay half open and appear glassy and glazed
It can be difficult in the moments leading up to the death of a loved one. It also can be confusing for families to know for sure if a loved one has passed or not. Some signs that death has occurred are when there are no more breaths, no heartbeats, and no response to touch. The Hospice nurse will check for the physical signs to confirm that a patient has passed.
Hospice Las Vegas, NV
One important thing to consider is that there is support available for families and death doesn’t have to be faced alone. Hospice can provide the much needed knowledge, medical expertise, and support services throughout the entire process and beyond. At Siena Hospice, we help patients and their families through the final journey. Our goal is to provide excellent, compassionate, and competent care.
If you are in the Las Vegas area and are in need of hospice services, please contact us so that we can assist you and your family.