In caring for a loved one who has advanced cancer you may be present at the time of death. The following is intended to remove some of the mystery that surrounds the end of life by looking at the process of dying.

Consciousness

Some people are unconscious for hours or even days before death, while others may be clear and alert up to the last few moments. Usually there is a gradual development of confusion and semi-consciousness over a few minutes or hours. Pain is one of the first senses to decline in death. Even though patients may no longer be able to express their pain, it is important to continue medication up to the end of life. Speech may become quiet; thoughts expressed may be quite unrelated to the events or people present. Often, the semiconscious person can still hear, although he is unable to respond. Your own words of endearment and support may still be understood and appreciated. Touching, caressing, holding, and rocking are all appropriate.

Fluids

Ice chips, water, or juice may be given as requested but should be stopped if there is difficulty swallowing. Since the purpose of nourishment is no longer necessary, solid foods should be avoided. If the person is too weak to drink from a cup or a straw, a teaspoon may be used. Care of the mouth is important. Vaseline or some other lubricant applied to the lips will prevent drying. Secretions from the mouth can be removed with the tip of a towel by turning the person to his side.

Temperature

As the circulation of blood begins to decline, the hands and feet are the first to be affected. They become cool and darker or more pale than usual. Later the same changes are seen in the face. Although the skin is cold and either dry or damp, the dying person is usually not conscious of feeling cold, and light bed coverings are enough.

Breathing

Breathing is usually easier with the person on his back or slightly to one side with a pillow under his head, but any position which makes breathing easier is acceptable, including sitting up with good support. A small child may find relief by being held in your arms. Whatever position is best, it should be relaxed and comfortable. Oxygen may benefit some patients but for others it is of little value. Often breathing assumes a peculiar pattern, alternating gradually between rapid and slow. Rattling or gurgling with each breath is from secretions in the back of the throat. These may be distressing to listen to but cause no discomfort.

Involuntary movements

Occasionally involuntary or reflex movements may take place. These are rare but may involve any muscles, particularly an arm, leg, or face muscle. In addition, there may be a loss of control of the bladder or the bowels as these muscles relax. When breathing and the heartbeat have stopped, the eyes become fixed in position and the pupils dilate. After death, there is no rush to do anything and you may sit with your loved one as long as you want. Many families find this is an important time to pray or talk together and reconfirm your love for each other as well as for the person who has passed away. At home, the responsibility for calling the proper people is yours and someone in the family should find out in advance what must be done. Regulations concerning proper notifications and removal of the body differ from one community to another and your doctor or nurse can get this information for you. If you have completed funeral arrangements, notifying the funeral director and doctor are all that is necessary.

Signs and symptoms of approaching death

Your cancer care team will talk with you about what to expect as the patient's condition declines. Talk with your doctor about hospice care. Not all of the following symptoms will occur, but it may be comforting to know about them.

Metabolism changes which may occur:

• periods of sleep may increase during the day
• difficulty in waking or rousing from sleep may occur
• patient may be confused about time, place, or people
• patient may be more restless or may pick or pull at bed linen
• patient may have more anxiety, restlessness, fear, and loneliness at night
• patient's needs for food and drink may decrease in body's effort to conserve energy

• plan your times with the patient when he/she is most alert or during the night when your presence may be comforting
• remind the patient who you are, and what day and time it is when talking with patient
• when speaking with a confused person, use calm, confident tones to reduce chances of startling or frightening the patient even more
• apply cool, moist wash cloths to head, face, and body to help relieve dehydration

Secretion changes which may occur:

• mucus in the mouth may increase and collect in the back of the throat (this is often a very distressing sound and is sometimes called a "death rattle").
• thick secretions may increase due to a lower fluid intake and the inability to cough

What to Do

• if oral secretions increase, keep them loose by adding humidity to the room with a cool mist humidifier
• if patient can swallow, ice chips or sips of liquid through a straw may thin secretions
• change patient's position - turning to side may help secretions drain from mouth

Circulation changes which may occur:

• arms and legs may feel cool to the touch
• skin of arms, legs, hands, and feet may deepen in color and appear mottled
• other areas of the body may become dusky or pale

What to Do

• keep patient warm with blankets
• avoid use of electric blankets, heating pads, etc.

Sensory changes which may occur:

• vision may become blurry or dim
• hearing may decrease, but most patients are able to hear you even after they can no longer speak

What to Do

• leave indirect lights on as vision decreases
• never assume the patient cannot hear you
• continue to speak with and touch patient to reassure him/her of your presence

Respiratory changes which may occur:

• breathing may be irregular due to decrease in circulation of blood and build-up of waste products in the body
• 10 to 30 seconds may occur with periods of no breathing (medical term is apnea)

What to Do

• raising patient’s head might give some relief
• use pillows to prop head and chest at an angle or elevate head of a hospital bed

Elimination changes which may occur:

• urine may become darker in color and decrease in amount
• loss of control (incontinence) of urine and feces may occur when death is imminent

What to Do

• pad bed beneath patient with layers of disposable pads
• if patient has a catheter, nurse will teach you to care for it

Signs that death has occurred:

• respirations (breathing) will cease
• pulse stops

What to Do

• call appropriate authorities in accordance with local regulations