Last hours

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Last hours.

It is not always easy to spot the fact that the patient has reached the end of the road. Signs to look for are the body “settling” more deeply into the bed; less coherent thinking when s/he is awake; longer periods between waking when deeply asleep; sometimes (but by no means always) a loss of bladder control. Sometimes it seems as if the patient knows very clearly that they are dying and will soon be dead. Often at that point they ask to be held.

At the very end, you will notice a change in the breathing pattern, with longer pauses between the intake of breath. The pulse becomes weak and fluttery (though it may well seem unduly intrusive to feel for a pulse at this stage.)

It is all too easy to assume at this point that the patient is no longer conscious of your presence. That is a dangerous and misleading assumption. It is often said that hearing is the last faculty to close down and whether or not that is literally and universally true, it is well to remember that there is a real possibility that the patient can still process at least some of what s/he hears. So speak to her/him gently, warmly, reassuringly. Tell them you love them, will always be grateful to them, will always treasure your shared memories.

Sometimes, the patient will die with a deep sigh, a last outpouring of breath. More often (at least in our experience) they just seem to slip away and for a minute or two you may not be sure whether they are alive or dead. If you need immediate clarity, put a hand (or better, a hand-mirror) under the nose. You will feel any passage of breath or the mirror will mist slightly, if there is still some movement in the lungs. (Medics will shine a light on the pupil of one eye, but this seems intrusive for the lay person.)

Rigor mortis will set in quite quickly, often with eyes wide open and the mouth agape. The colour will drain from the face which will become sallow. Best now to leave it to whoever is going to take responsibility for “laying out” or preparing the body for the undertaker. Your task is complete.

A personal account

The last hours are a very precious time and at the same time they can be disturbing. We never know when the final breath will come and especially if a loved one is in pain the feelings are strong and complicated. In some situations I have known the family being so insistent on the dying one recovering that they have almost stopped them from passing on. A friend of mine remarked that they had pleaded with her father not to die before the first granddaughter was born and he did hold on but my friend said that it was only when he had died that she realised just what it had cost him. In some circumstances people almost need permission to go - to pass peacefully. When death is inevitable the gift of the living is to let go graciously so that the dying person passes without regrets and without the feeling that they are leaving their loved ones in a perilous position. On one occasion I arrived unexpectedly into a house where my good friends lived. He had been ill at the time but I hadn't realised how terminal it was. The whole family were around him on his death bed and couldn't bear him to go. I was able to say that it was time and to allow himself to drift away. This man had an amazingly strong faith and his countenance changed from being worried and anxious about those he was leaving behind to peacefully passing from this world with hope.