A century ago, most people who suffered traumatic injuries or contracted serious infections, died soon afterward. Even those who developed heart disease or cancer had little expectation of a long life after the disease was diagnosed.
Death was a familiar experience and most people expected little more than comfort care from their doctors. Today, death is often seen as an event that can be ordered intermittently, rather than as an intrinsic part of life. The leading causes of death for people over age 65 years are heart disease, cancer, , Chronic Obstructive Pulmonary Disease (COPD),, and dementia. Medical procedures commonly extend the lives of people who have these diseases, often giving people many years in which quality of life and functions are quite good.
Other times procedures extend life, but the quality of life and functions decline. Death often seems unexpected even though the family knew that the person who died had serious illness.
To say that a person is dying typically means that the person’s death is expected to occur in hours or days. Also people who are very old and frail or who have a fatal(terminal) disease such as AIDS, cancer are not expected to live beyond certain days, they are said to be dying. People with cancer are said to be dying gradually. Most people with chronic diseases such as heart disease, certain cancers, emphysema, liver or kidney failure, Alzheimer’s disease, and other dementias live for years, although they become limited in physical activity.
Predicting when a person will die of a chronic disease is sometimes necessary. Health insurance often does not cover comfort care for chronic disease.
Doctors can make a fairly accurate short term prognosis for an average patient with certain conditions, based on statical analysis of large groups of patients with similar conditions. Often what we call medical inactivity, is brought to bear, when often the available choices are between dying sooner but remaining comfortable and living slightly longer, by receiving aggressive therapy, which may prolong the dying process, increase discomfort and dependence and decrease the quality of life. Nevertheless patients and their families may feel that they must try such therapies if any chance of survival exists, even when hope of cure is unrealistic.
Questions of Phylosophy, values and religious beliefs come into play when such decisions are made, by and for dying patient that is euthanasia(a topic for another day).
Dying may be marked by deterioration over a long period of time, punctuated with bouts of complications and side effects as in some people who have cancer. Usually, about one month before death, energy function and comfort decrease substantially. The person is visibly failing, and the fact that death is near becomes obvious to all.
Dying follows other time courses. Sometimes a person being treated aggressively for a serious illness in a hospital abruptly worsens and is known to be dying only a few hours or days before death. Increasingly common, however is dying with a slow decline in capabilities over a long period of time, perhaps with episodes of severe symptoms.
Neurologic diseases such as Alzheimer’s disease follows this pattern, so do emphysema, liver failure, kidney failure, TB and other chronic conditions. Severe heart disease disables people over time and causes severe symptoms intermittently, but it usually kills suddenly with a disturbance in the hearts rhythm (arrhythmia).
Knowing the likely time cause of a disease enables a person who has the disease and the family to make plans. When death from an arrhythmia is likely, they should be prepared for death at any time. For people who have cancer the decline that precedes death usually gives some warning that the final days have arrived.
In most people who are dying the body’s normal systems start to operate more slowly. The heart beats a little more slowly or with a little less forceq, and so blood is moved around the body more slowly. This means the brain and other organs receive less oxygen than they need, and do not function well.
When the brain receives less oxygen than it should, the way the person who is dying thinks and reacts to situations is also affected. The hormones produced by the brain are also affected with influences the way in which other organs function.
Most people who are dying feel tired. They want to sleep more often or for longer period. They may want to talk less, although some may want to talk more, eat less or eat different foods since their stomach and digestive system are slowing down.
Some people have a burst of energy in the 24 hours before they die, sitting up and talking normally for a short period. Some one who is close to death will spend most of the time asleep. They may not be able to communicate when they are awake because their senses are failing. However they may still be able to hear to speak, so speak to them normally.
Physical signs that death is near include.
A sudden burst of energy
Mottled and blotchy skin, especially on hands, feet and knees.
Blood pressure decreases.
They cannot swallow.
They make less urine.
Restlessness
Difficulty in breathing.
Congested lung.
In the hours before death most people fade as the blood supply to their body declines further. They sleep a lot, their breathing becomes very irregular and their skin becomes cool to touch. Those who do not lose consciousness in the days before death usually do so in the hours before death.
Most people are very calm and usually have introspection that they are dying. Some take it with equanimity, others may show reckless abandon. Some may be agitated, especially if they are finding it hard to breathe.
Other symptoms in hours before death include
Glassy eye, teary eyes that they may be half open.
Cold hands
Weak pulse
Hallucinations
Being fast asleep
Gasping, or periods where breathing completely stops.
In time, the heart stops and they stop breathing. Within a few minutes, their brain stops functioning entirely, and their skin starts to cool. At this point they have died.
The signs that someone has died are
There is no breathing or heartbeat.
They cannot be woken up
Their skin is pale and waxy
Their eyelids might be half open
Their pupils are fixed.
Their mouth may fall open.
You might feel all sorts of emotions from grief that they are gone, to relief that their pain is over, and any number of emotions in between. Take your time, it is fine to just sit with the person who has died for as long as you need to.
If the death occurs in the hospital, nursing home or hospice, support of sibblings and relatives might be needed to allow you take the requisite steps.
Death is equated to sorrow and it is better than fear, because while fear is a journey, sorrow is at least an arrival. Always be medically guided.
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