Caring for adults
Caring for adults

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Caring for adults

5.2 Signs that death is near

In the next activity you will continue to follow Frank and Grace in his last days. The National Council for Palliative Care website has a page on Signs that death is near [Tip: hold Ctrl and click a link to open it in a new tab. (Hide tip)] . Being able to recognise these signs can help relatives and others close to the person to prepare for what is to come and to say goodbye.

Activity 6

Timing: Allow about 10 minutes

Part 1

Read the National Council for Palliative Care list of indications that someone is approaching death.

As death approaches, you may see some or all of the following changes:

  • Physical changes

    In older people the skin can become paper-thin and pale, with dark liver spots appearing on hands, feet and face. Hair can also thin and the person may shrink in stature. Teeth can discolour or develop dark stains.

Described image
Figure 3 Hands can show physical changes as people age
  • Shrinking world

    The person’s external world begins to diminish until the dying person no longer wants to leave the house or their bed and may not want to talk very much. Their mood, character and behaviour may change. For example, some may become more anxious. Others who have held atheist views may suddenly want to explore religious or spiritual teachings.

  • Increased sleep

    The person begins to sleep for long periods. This can be distressing for relatives, but it’s important to understand that even the mildest physical exertion for someone approaching death can be exhausting, and for the moment all effort is being put into staying alive. Nearer the end, the dying person may increasingly drift in and out of consciousness.

  • Appetite reduction

    Appetite reduces as the body knows it no longer needs fuel to keep it going so those who are dying often lose their desire to eat or drink. They can begin to lose weight, sometimes rapidly. It’s important not to force food or drink onto someone who no longer wants it.

  • Expression

    There may be changes of expression where the person may start to talk about ‘leaving’, ‘flying’, ‘going home’, ‘being taken home’, ‘being collected’, ‘going on holiday’ or making some kind of journey. They may also begin to express heart-felt gratitude to their carers and to their family as a preparation to saying their farewells.

  • Special requests

    The person might make special requests, such as asking for something special, wanting to visit a particular place, or wishing to be surrounded by their favourite flowers. They may want to hear certain music, to have family photographs nearby or to make contact with someone who has been important in their lives. Some special requests might be difficult to fulfil, especially if they are unusual or illegal such as the choice of disposal of the body. It would be helpful to discuss unusual or illegal requests with a professional who might be able to clarify what can be done, and what alternatives might be considered.

Described image
Figure 4 Those being cared for may request to see family photographs

Part 2

Read about Frank’s last days before answering the questions that follow.

Case study: Frank and Grace

Frank now prefers to stay in his bed most of the time where he is most comfortable. He has carers visiting three times a day to provide personal care. It includes repositioning him to avoid damaging tissue at pressure areas. His physical comfort has been given priority. At one stage it was thought he was retaining urine but since then he has been incontinent several times. He has also appeared to be in pain and has groaned in his sleep while trying to move.

As swallowing was obviously difficult for Frank, a syringe driver became necessary to ensure his morphine-based pain relief is effective. During a regular check on vulnerable areas it is revealed that the skin at the bottom of his spine is looking red and very dry. Grace feels guilty about this as she has always observed and monitored the carers adjusting Frank’s position in bed.

Frank had been in bed for eight days. During this time Grace was vigilant for any deterioration in his condition. His medication was increased so that he was drowsy most of the time. He drifted in and out of consciousness. When Frank woke for a few minutes he appeared disorientated and Grace was not sure that he knew who she was. He mumbled but his speech was slurred and unclear so Grace could not understand what he was saying.

He did, though, appear to be looking at something. She observed that the periods of unconsciousness were more prolonged. Frank’s respirations were shallow and he sounded chesty. Holding his hand, Grace noticed that he was cold. By the time of his death, Frank had been unconscious for twenty-four hours. He had not taken any fluids or other nutrition during this time.

  • In what ways did Frank show signs that his death was near?

Reread the indications and the case study if you need to, and make some notes in the box below.

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Comment

Being most comfortable in bed is one sign that Frank might be near to death. Recognising signs of death can help make his last days and hours as comfortable as possible.

Many of the items in ‘Signs that death is near’ are reflected in what Frank and Grace experience. You would have been aware of some of the physical changes: Frank’s skin, for example, and the shrinking of his world.

Frank slept more but this might have been as much to do with his medication as impending death. His appetite was probably reduced. Being drowsy, to feed him might have entailed further physical interventions that would make him less comfortable.

Frank seemed to have had no special requests at the last moments, although we cannot be certain. He appeared to want to say something. His change of expression, looking for something, might suggest a desire to make a special request.

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