When death is near

The prospect of dying, raises questions about the meaning of life and the reasons for suffering and dying. No easy answers to these fundamental questions exist. In their pursuit of answers, seriously ill patients of mine and their families can use their own resources, religion, counselors friends and research in quest for recovery and rejuvenation of life. They can talk, participate in religious or family rituals, or engage in diverse activities to assuage their feelings and emotions.

On Monday, July 10, 2023, I received a call, that my uncle›s wife was rushed to the Federal Medical Centre, Umuahia, after what was described as a partial stroke, which dovetailed to loss of consciousness. I remembered that when I spoke with her three days previously, she was hale and hearty. Now she was near death, and battling for her life. 

I called my wife immediately, asked her to get to FMC Umuahia, and keep me posted. My wife found out that my uncle’s wife was on oxygen, because her oxygen saturation level was low. Everybody that was somebody in our extended family was there, and all of them were confused. They were making frantic efforts and calling me to explain the situation. There were more than four versions of her state of health. 

   One thing we must note is that as the anticipation of death nears, the most important antidote to despair is often feeling cherished by others. According to my wife, when my uncle’s wife opened her eyes temporarily, and saw her and most of her children and grandchildren surrounding her bed, a fleeting smile lit up her face, and she raised her unencumbered hand briefly in defiance to the purported stroke. 

The torrents of medical diagnosis and treatments should not be allowed to obliterate the larger questions and the importance of human relationships. 

   Predicting the exact time of death is usually hard. Families are advised not to press for exact prediction or to rely on those that are offered by doctors, myself inclusive. 

Very fragile patients sometimes live a few days well past what seemed possible. Other patients die quickly. If a patient wants a particular person at his or bed side at the time of “near death”, arrangements should be made to accommodate that person for an indefinite time. 

Often there are characteristic signs that death is near which include:

• Consciousness may decrease. 

• The limbs may become cool and perhaps bluish and mottled. 

• Breathing may become irregular. 

• Secretions in the throat muscles can lead to noisy breathing, sometimes called the death rattle. 

• Re-positioning the patient, or using drugs to dry the secretions can minimize the noise – such treatment is aimed at the comfort of the family or care givers, because noisy breathing occurs at a time when the patient is unaware of it. This breathing can continue for hours.

• At the time of death a few muscle contractions may occur and the chest may heave as if to breathe. 

• The heart may beat a few minutes after breathing stops and a brief seizure may occur. 

Unless the dying person has a rare contagious infectious disease, family members should be assured that touching, caressing and holding the body of a dying person, even for a while after death, are acceptable.

   Generally, seeing the body after death is helpful to those close to the person, because it ensures a psychological closure, and counters the irrational fear that the person really did not die. 

   Patients› experiences at the end of life are influenced by their expectations about how they will die and the meaning of death.   

      Many people fear how they will die more than death itself. Patients report fears of dying in pain or of suffocation, of loss of control, indignity, isolation and of being a burden to their families. 

   All of these anxieties may be alleviated with good supportive care provided by an attentive group of caretakers.

   Death is often regarded by doctors, patients and families as a failure of medical science. This attitude can create or heighten a sense of guilt about the failure to prevent the patient from dying. Both the general public and doctors are complicit in denying death. Treating dying persons merely as patients and death, as enemy to be battled furiously in hospitals, rather than as an inevitable outcome to be experienced as part of life at home. As a result approximately 45 to 50% of the people in Nigeria die in hospitals through last minute emergency rush, like my uncle’s wife.

      Nigerians do not deliberately plan for good health. First, they rush to the chemist requesting that drugs be mixed for them. Then, if there is no improvement they will go to the nearest laboratory for test. Of course the laboratory technician or scientist, after the test will prescribe copious expensive drugs for them. Then, if they still do not get better, and almost moribund, they will then be rushed to the the hospital, expecting doctors to perform miracles. How can we be sick of self love? 

   Even, when doctors continue to pursue cure of potentially reversible disease, offering comfort and helping the patient prepare for death are foremost considerations.

   Patients at the end of life and their families identify a number of elements as important to quality end-of-life care. Which guides against, inappropriate prolongation of dying and denigration of dignity, to achieve a sense of control, relieving the burden on others and strengthening relationships with loved ones.

   When death occurs, it must be pronounced by an authorized person usually a licensed doctor, and the cause and circumstances of death must be certified.

   The family and close friends are fellow travellers with the dying person, and they too suffer. As the person is dying, the family should be told what is happening and what is likely to happen.

   A family also investigates the cause of a family member›s death. Family members, often women, at or past middle age, provide most of the care at the “end of life” for free. They should explore how professional caregivers can help them so that the burdens are tolerable. There are costs of giving employment as well as of drugs, home care, and travel.

One study showed that one third of families deplete most of their savings in caring for a dying relative. The family should talk openly about the costs with the doctor, insisting on reasonable attention to costs, and planning ahead to limit or prepare for them.

   Even before death, the family and loved ones begin to grieve. Building a life after bereavement depends on the nature of the relationship with the deceased, the age of the deceased, the kind of dying that was experienced, and the emotional and financial resources available.

   Also, the family needs to feel sure that they did what they should. Having a talk with the doctor, a few weeks after the death, can help answer lingering questions.

   The loneliness, disorientation, and unreality felt during the period near death improve with time, but the sense of loss persists. People do not “get over “ a death as much as they make sense of it and go on with life.

   After death, the family must settle the estate. Although discussing property and financial issues is hard to do, when death is impending. It is, however, a good idea. Doing so, often reveals things that could be signed or arranged by the patient, easing the burden on the family. Always be medically guided.

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