Stages of Dying in the Terminally Ill
WHEN DEATH APPROACHES, Part 1
Many of us caring for our ailing parents or family members wonder how to perceive when Death begins His approach. Predictions from physicians are reluctantly given, and are at best, an estimate. Statistics cannot provide specific dates. However, knowledge painfully accumulated over time by many, many caregivers supports the following framework for impending death.
There are two phases of death[i], the first being the “preactive phase of dying.” This stage may last weeks or months as with my father who has slipped in and out of the preactive phase for the past two months. In this phase the body begins the final process of shutting down: a gradual series of physical changes occur as the body prepares to stop. These are not medical emergencies requiring invasive procedures and your best response is to promote comfort. [ii]
The preactive phase includes a number of signals. Your loved one may withdraw from social activities and desire time to think about what lies ahead. Often this is a period for self-analysis, a review of one’s life, that leads to an effort to both ‘settle up’ and impart advice.
Another sign is edema, a swelling caused by fluid retention - excess fluid trapped in the body's tissues as the circulatory system declines. It usually occurs in the feet, ankles and legs, but it can involve the entire body.[iii] Other indicators might include a noticeable lack of hunger or thirst, an inability to heal from wounds or infections and increased restlessness.
He or she will experience an increase in sleeping times. Frequently, lethargy develops. Possibly the patient will inform you that he or she is dying. Do not be surprised if your loved one sees people who have already passed away.
The second phase is called the “active phase of dying” and usually occurs over a three day period but can last for a number of weeks. During this stage the patient is unresponsive to outside stimuli somewhat similar to a semi-coma. He or she may develop abnormal breathing patterns such as apneas, or cyclic changes in breathing [slow to rapid inhalations that recur], or shallow breaths followed by deep breathing in a repeat pattern. Often there is an inability to swallow liquids or a refusal to eat.
Another indicator in the active phase of dying occurs when the patient breathes through a wide open mouth continuously and at times lacks the ability to speak even when awake. As the heart weakens, circulation declines and the extremities become quite cool to your touch, or appear bluish or splotchy. Blood pressure drops 20 – 30 points below normal range and/or
their systolic blood pressure drops below 70 and diastolic pressure below 50. Fluid builds up in the lungs causing respiratory congestion. The saliva catches in the throat as the swallowing ability declines causing the “death rattle”. Although this sound is distressing and unforgettable, medical personnel assure us that it is not painful to the patient.
While the patient comes to terms with their approaching death, you too need time to reflect on the manner in which you will cope. Some wonderful resources exist for further research. Below are just a few of the many web sites that address the topic of death and dying.
- 1. Hospice Patients Alliance
- 2. Hospice, http://www.hospicenet.org/index.html
- 3. On Death and dying. By Kubler-Ross E. New York:Macmillan; 1969.
- 4. “A Dying Person’s Guide to Dying”. By Roger C. Bone.