An Answer For Lee

What happens when you die? 

This straightforward question seems so typical of commentator Lee, a New Yorker with a potty mouth and the most eloquent of emails. She sent me this question with a history. A history of never experiencing the lead up to someone close to her dying. 

Her father died suddenly at work from cardiac issues and her mother had a catastrophic stroke when on holiday. Lee was not at their bedside when they passed nor has she been at anyone else’s bedside since.

She called herself a death virgin

And they are not as rare as you think.

So Lee wanted to know, 

So what happens when you die?

In my experience the body compensates with illness, cancer, disability , trauma , whatever the problem is until simply put, it can’t anymore. The physical and emotional struggle becomes too much and the patient is what is often referred to and being on the landing. 

This euphemism is useful for it allows the patient and their relatives to understand where they are at. The landing is at the top of the stairs and the patient is about to deteriorate further. 

I’ve heard relatives use the word slippery slope too

The patient often will become very tired indeed and will sleep most of the time. They will become weaker, go off their legs and reduce the amount they eat and drink. 

They will interact less too and nursing needs will increase.

This is the time friends and family need to understand what could happen.

Medication cannot now be safely given in oral form and pain relief ,medications to aid comfort and reduce restlessness can be given, often in large dosages by syringe driver. The syringe driver administers a set amount of medication per 24 hours and can be monitored and changed by nursing staff as and when. 

As the patient deteriorates further, they will become more unconscious and less aware of their surroundings. Sometimes delirium and terminal agitation show themselves and although very normal in their presentation, these two stages of dying can be the most distressing for relatives to watch. 

Delirium is a complex psychiatric condition linked to encephalitis, infection, and organ failure and is a condition often worse at night. The patient can before restless and confused, sometimes angry and “ bothered” they are often difficult to cope with, may fall out of bed during the early stages and are not the loved ones everyone knows.

Terminal agitation is similar  and often shows itself as a constant restlessness and anguish and both situations although “ normal” need prompt and expert treatment. 

I often tell relatives that because of organ failure and disease progression these symptoms will arise and a prompt change of medication often will dampen down the distressing symptoms. 

Keeping relatives in the loop is vital for them to be able to cope 

The objective for any palliative care nurse is for their patients to be comfortable and there are several assessments that are done at the bedside to insure that happens.

At this time the patients are usually deeply unconscious . 

Now is the time you explain how the patients breathing may change. 

Over a period of time breathing can become shallower, more rapid then become slower with gaps appearing . Again it’s important to reiterate that this is perfectly normal  and medications such as morphine may be given to lessen the effort of breathing. 

Here often the worry of secretions and the presence of the “ death rattle” can be discussed. Noisy breathing frightens most loved ones, and it’s important for the relatives to know that it’s not distressing to the patient and may be only a tiny bit of fluid that is caught and unable to be swallowed. There is medication that can help dry up secretions too as well as judicial moving of the patient which can minimise the issue.

And so your patient has let go of the landing and is actively dying. 

Each one will do it in their own time, yet most hospice nurses will read the patient and will know when death is imminent .

With the appropriate meds on board, I’ve never witnessed a death that wasn’t peaceful but having said all that there are a good but smaller proportion of people who just die peacefully in their sleep without any interventions at all