There are two phases which arise prior to the actual time of death: the “pre-active phase of dying,” and the “active phase of dying.” On average, the pre-active phase of dying may last approximately two weeks, while on average, the active phase of dying lasts about three days.
We say “on average” because there are often exceptions to the rule. Some patients have exhibited signs of the pre-active phase of dying for a month or longer, while some patients exhibit signs of the active phase of dying for two weeks. Many hospice staff have been fooled into thinking that death was about to occur, when the patient had unusually low blood pressure or longer periods of pausing in the breathing rhythm. However, some patients with these symptoms can suddenly recover and live a week, a month or even longer. Low blood pressure alone or long periods of pausing in the breathing (apnea) are not reliable indicators of imminent death in all cases.
Signs of the pre-active phase of dying:
- increased restlessness, confusion, agitation, inability to stay content in one position and insisting on changing positions frequently (exhausting family and caregivers)
- withdrawal from active participation in social activities
- increased periods of sleep, lethargy
- decreased intake of food and liquids
- beginning to show periods of pausing in the breathing (apnea) whether awake or sleeping
- patient reports seeing persons who had already died
- patient states that he or she is dying
- patient requests family visit to settle “unfinished business” and tie up “loose ends”
- inability to heal or recover from wounds or infections
- increased swelling (edema) of either the extremities or the entire body
Signs of the Active Phase of Dying
- Inability to arouse patient at all (coma) or, ability to only arouse patient with great effort but patient quickly returns to severely unresponsive state (semi-coma)
- severe agitation in patient, hallucinations, acting “crazy” and not in patient’s normal manner or personality
- much longer periods of pausing in the breathing (apnea)
- dramatic changes in the breathing pattern including apnea, but also including very rapid breathing or cyclic changes in the patterns of breathing (such as slow progressing to very fast and then slow again, or shallow progressing to very deep breathing while also changing rate of breathing to very fast and then slow)
- other very abnormal breathing patterns
- severely increased respiratory congestion or fluid buildup in lungs
- inability to swallow any fluids at all (not taking any food by mouth voluntarily as well)
- patient states that he or she is going to die
- patient breathing through wide open mouth continuously and no longer can speak even if awake
- urinary or bowel incontinence in a patient who was not incontinent before
- marked decrease in urine output and darkening color of urine or very abnormal colors (such as red or brown)
- blood pressure dropping dramatically from patient’s normal blood pressure range (more than a 20 or 30 point drop)
- systolic blood pressure below 70, diastolic blood pressure below 50
- patient’s extremities (such as hands, arms, feet and legs) feel very cold to touch
- patient complains that his or her legs/feet are numb and cannot be felt at all
- cyanosis, or a bluish or purple coloring to the patients arms and legs, especially the feet and hands)
- patient’s body is held in rigid unchanging position
- jaw drop; the patient’s jaw is no longer held straight and may drop to the side their head is lying towards
Although all patients do not show all of these signs, many of these signs will be seen in some patients. The reason for the tradition of “keeping a vigil” when someone is dying is that we really don’t know exactly when death will occur until it is obviously happening. If you wish to “be there” with your loved one when death occurs, keeping a vigil at the bedside is part of the process.
The Gifts of the Last Hours
The last hours filled with signs of impending death can feel very special. They can be like a moment of hushed silence in the middle of a busy street. Like the sense of wonder just before a sunrise on the ocean. Like a holy moment in church full of imagined angels singing. Like a long prayer deeply soothing us.
They have a similar quality to the time right after a baby is born. That same feeling. That same sense of wonder.
As if they are like gateways. Gates to the other side. Gates to our souls.
The last sense to go, is hearing, which means your loved one can hear you even up till the very end, even though he or she cannot respond by speaking. Your loving presence at the bedside can be a great expression of your love for your loved one and help him to feel calmer and more at peace at the time of death
Some Signs of Death
Amongst the signs of death actually having occurred are things such as:
- There is no response to either questions or touching.
- ·No more breaths in or out.
- The jaw is relaxed, the mouth slightly open.
- No heartbeat is to be felt.
- There might be a sudden release of bowel and/or bladder.
- The eyes are staring fixedly on one spot.
- Most likely, the eyelids are slightly open.
- The pupils may be enlarged.
- No more blinking for the eyes.
These signs of death are pretty simple and straight forward. The life force has left the body. The body is not functioning any more. The body is dead. There is death.