When Death is Near / Final Days or Hours

The health care team, the patient and the family together need to consider several factors before making any change in medications. All these questions need to be answered:

What are the patient’s or family’s goals for care?

This may be the most important question. The goals must be realistic and achievable. For example, it may not be realistic to give medications to increase appetite when the patient isn’t hungry and eating won’t change the course of the illness.

What is the patient’s condition?

For example, often oral medications are stopped if the patient has trouble swallowing or is no longer alert.

What is the benefit of the medication?

In late stages of an illness, when maintaining comfort is a goal, it’s common to stop any medications that are not essential for comfort.

What will the patient feel if the medication is stopped or decreased?

If the person is still feeling pain, then medications that relieve pain are still helpful. If the person can’t swallow, then medications can be administered some other way.

There usually comes a time when medications that are not directly needed for comfort are discontinued. This happens when a person is no longer able to swallow or becomes unconscious. At this point discussions with the health care team will include which medications to continue and how those medications will be administered. Often medications to treat symptoms such as pain can be administered in other ways.

There are several signs that can indicate that someone is nearing death:

• physical condition;
• eating;
• breathing;
• mental condition.

Physical condition

Deterioration in physical condition is usually the first sign that someone is near the end of life. The deterioration may be gradual or quick, and is reflected in the person’s level of energy and range of activity. There are four stages that a person usually passes through as death approaches:

Stage 1    performs regular activities;
Stage 2    tires quickly with exertion;
Stage 3    spends most of the time sitting or in bed;
Stage 4    doesn’t get out of bed at all.
 

Eating and drinking

People who are approaching death usually lose appetite and thirst and, as a result, lose a lot of weight. When someone is no longer eating or drinking, he or she usually has a few days to live, but may live as long as a few weeks if the person has reserves of energy.

Breathing

Changes in breathing are common. Some people develop long pauses in their breathing known as apnea. If a person is unconscious and unable to cough, there may be a pooling of secretions at the back of the throat. These secretions can make a rattling sound when the person breathes. The secretions aren’t distressing to the person because they are unconscious.

Mental condition

Closer to death many people become confused or restless. Eventually they may become unconscious or unresponsive to things around them. Most people become quiet near the end of life. It may be that because they have less energy and are too tired to participate in conversations. Commonly, people become reflective as death approaches and they spend more time thinking than in interacting with others. The final hours of life may bring signs of delirium, which is a sign of changing brain function that makes people confused and restless or lethargic and withdrawn.

One approach to estimating how long someone has to live is referred to as the momentum of change. If someone’s condition is changing from week to week, it’s a good indication that there are only weeks of life left. If there are changes from one day to another, there are likely days of life left. When changes happen from one hour to another, there are usually hours left. This is a general guideline. Sometimes a health crisis develops and someone dies sooner than expected. Families need to prepare for this possibility.

Sometimes people who are in their final days or hours of life have a brief period of physical or mental improvement. It’s not clear why this happens, but these are some possible explanations:

1. A person near death may have spent a few days in an unresponsive state. This period without much activity may help the body rest, so the person may wake up and have some energy to draw on. This is a very small amount of energy, but it’s significant compared to the person’s previous state, and may seem like a remarkable improvement. The person may interact with others, and possibly eat and drink. This period can be deceptive both to health care providers and to the family. Everyone is preparing for death, and instead the person suddenly appears better. This period doesn't last long, however, and death commonly comes within a day or two.

2. When someone has cancer in the brain, they are usually unresponsive for a few days before dying. The person likely isn’t taking in any fluids during this time, which in turn may reduce the amount swelling in the brain. The reduced swelling may make the person more alert for a few days. The person deteriorates soon after, however, because the disease is still progressing.