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An understanding of the physical changes and pain management issues that

occur during illness and death are critical for any caregiver offering support

to dying persons and their families. Generally, patients portray specific physical

symptoms that indicate they are approaching death. 


Many of us who are involved in the care for someone have never witnessed someone dying. It is hard, both physically and

emotionally, to know and accept that someone we are caring for is near death. But if caregivers are aware of these symptoms,

then they will be better prepared to give their loved one the best care possible in the final days. Knowing the signs of death

will also help caregivers to prepare the rest of the family. Whether you are the caregiver, or anyone who is involved in the life

of the person dying, we hope that by knowing some physical aspects of the death process, you will be able to understand

what is happening with your loved one, and what you can do to help.


Physical/Emotional Symptoms and Appropriate Comfort Measures

A. Diminishing Appetite

When a body begins the dying process, hunger and thirst are not experienced in the same way that a healthy body does.

As a result, it is natural for your loved one to experience a decreased appetite, to state food no longer tastes good, or to have no

interest in eating meals. Typically, meats are the first food groups to no longer be appealing followed by fruits and vegetables.

A person’s diet may eventually become soft foods and then liquids only. Although a loss of appetite may be one of the most

difficult things for family members to accept, it is okay for a patient not to eat. In fact, eating may only cause more discomfort for

the patient.

Appropriate Comfort Measures:

• Do not force them to ingest food and fluids.

• Offer small, frequent snacks of the types of food being requested.

• Sponge swabs moistened with cool water or a favorite beverage can keep the mouth and lips moist and comfortable. Remember

   that appetite is the best indicator of what the body needs and can tolerate.

B. Socialization

Your loved one may want to be alone with few friends, family or just you. It is natural to feel this way when one is growing

weak and tired. This is how some people prepare for the separation that death brings. The important thing is to be aware of what the

dying person wants.

Appropriate Comfort Measures:

• Limit visits to those the person wants to see.

• Recommend short visits.

• It is not always important to talk with the person; holding a hand can be all that is needed.

• Keep lights soft; the person may feel uncomfortable under bright lights.

C. Sleeping

Your loved one may spend an increased amount of time sleeping and appear uncommunicative, withdrawn, or unresponsive.

Appropriate Comfort Measures:

• Plan to spend time with your loved one when they are most awake.

• Hold hands with your loved one, as touch is very important and can bring comfort.

• Speak normally though there may be no response.

• Do not say anything you would not want your loved one to hear.  Even in an unresponsive state, he or she may be able to hear you.


D. Changes in Pain Level

Your loved one may experience an increase in pain, decrease in pain, or no change at all. The body changes and so does the

way it perceives pain. Watch the patient for complaints or signs of pain. Do not change any pain medication without the direction

of the Hospice team.

Appropriate Comfort Measures:

• Call your hospice nurse for help. Our hospice professional staff will offer medications to alleviate symptoms of discomfort such

as pain, nausea, agitation, and labored breathing. It is our intent to provide comfort to the patient.


E. Incontinence

Incontinence and an overall decrease in urine output is normal and expected.  While troubling for some loved ones, it is

not uncommon for the patient to lose control of the bowel and/or bladder as muscles relax.

Appropriate Comfort Measures:

• Reassure your loved one that this experience is normal and that you are there to help.

• Discuss with your hospice nurse what will keep the patient clean and comfortable. Your hospice team can help you and your

loved one deal with this issue and provide the utmost dignity.


F. Disorientation

Your loved one may be confused about the time, place, and identity of people. 

Appropriate Comfort Measures:

• Identify yourself by name before you speak.

• Speak softly, clearly, and truthfully. For example: “It is time to take your medication, so you won’t have pain.”

• Do not try to force or trick your loved one into taking medications, even if you believe it is in the patient’s best interests. Trust

between the patient and caregiver is too important to jeopardize.

G. Restlessness

The patient may make restless or repetitive motions. Though it occurs frequently, do not interfere, or try to restrain such motions.

Appropriate Comfort Measures:

• Establish a calm atmosphere; eliminate bright lights.

• Speak in a quiet, natural way.

• Try other calming things—gently rub the back, stroke the arms or forehead, read aloud, or play soothing music.

• Give assurance that you are there and will remain.

H. Coolness and Skin Color Changes

The person’s face and extremities may be cool to the touch, or the skin may start to pale, become discolored, or appear

blotchy. These normal signs indicate that circulation to the body’s extremities is changing.

Appropriate Comfort Measures:

• Keep the person lightly covered.

• Avoid using an electric blanket.

• Socks may keep the feet warm.


I. Breathing Pattern Change

It is common for the regular breathing pattern of the patient to change.  Periods may be noticed when breathing stops for

several seconds.

Appropriate Comfort Measures:

• Elevate the head with a pillow or blanket.

• Turn the patient on their side, as this may also bring comfort.

• Hold hands, speak gently, and be reassuring.

J. Congestion

Your loved one may have gurgling or rattling sounds from the chest or throat. This is normal and sometimes due to an inability to

clear or cough up secretions. Congestion is distressing to listen to but may not indicate discomfort for the patient.

Appropriate Comfort Measures:

• Elevate patient’s head and gently turn it to the side, allowing gravity to drain secretions.

• Mouth care may be given as instructed by your nurse.

K. Fever

Your loved one may have a temperature, which is not uncommon.

Appropriate Comfort Measures:

• Place a cool, damp washcloth on the forehead or under each arm.

• Call your Hospice nurse to discuss other comfort measures that could be given to your loved one.

L. Withdrawal

Your loved one may seem withdrawn or in a coma-like state, which may mean they are detaching from this life.

Appropriate Comfort Measures:

• Since hearing remains to the end, speak to your loved one; he or she may hear you.

• Spend time with your loved one and hold hands.

M. Vision-like Experiences —Nearing Death Awareness

Your loved one may speak to persons or animals who already have died and claim to see places not visible to you.

Appropriate Comfort Measures:

• If you cannot gently re-orient him or her, validate the experiences; do not contradict or explain away these events.

• If these experiences frighten your loved one, explain that they are normal.

N. Surge/Rally

Your loved one may become energized and alert when earlier had been disoriented and confused. The patient may desire a

favorite meal and have an increased appetite, when prior had not eaten much at all. The patient may request visitors, when before

this surge of energy wanted few to none. Though these examples may be extreme, the rally is usually recognized.

Appropriate Comfort Measures:

• Give your loved one your utmost attention.

• This surge of energy may not last long and may not return, therefore it is important to devote quality time to your loved one.


O. Unusual Communication

Your loved one may make an out-of-character statement or gesture that may indicate he or she is ready to say good-bye and test to

see if you are ready.

Appropriate Comfort Measures:

• Accept this moment as a beautiful gift: kiss, hug, hold, cry, and take the opportunity to share love and forgiveness.


Summary of What to Expect

• The patient’s need for food and drink may decrease.

• Your loved one may want to be with few friends, family, or just you.

• Periods of sleep may increase during the day.

• Difficulty may occur in waking or rousing the patient from sleep.

• The patient may be more restless or may pick or pull at the bed linen.

• The patient may have more anxiety, restlessness, fear, and loneliness at night.

• Loss of control, or incontinence, of urine and bowel matter may occur.

• Urine may become darker in color and decrease in amount.

• The patient may express the need for spiritual care.

• Arms and legs may feel cool to the touch.

• The patient’s temperature may be elevated or subnormal.

• The patient may be confused about time, place, and people.

• Breathing may be irregular.

• Periods may be noticed when breathing stops for several seconds.

• Mucus in the throat may increase.

• Vision may become blurry or dim.

• There may be profuse sweating and the skin may feel cold and clammy.

• The patient may tell you that people or pets who have died before are visiting them.

• Skin on the arms, hands, legs, and feet may deepen in color and appear blotchy.

• The patient may have a sudden burst of energy and rally.

• The pulse of the patient is weak and difficult to find.


Please keep in mind your team at Bosque Trails Hospice is here to support you and your loved ones. 

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