"One Lone Tear", Dementia at End of Life

Dear Barbara, I lost my Mom in 2018 and I have regrets we were not at her side when she passed. She suffered from Cx for five years. After it moved to her brain, she slowly deteriorated over the next eighteen months until she passed. It started out with her forgetting a recipe she had made for years, to falling several times a week. The last fall almost killed her and she never came home – she went to rehab and then a nursing home. Once she fell, hit her head and got a nasty cut on her forehead, and another time in the garage. I don’t know why I am justifying our decision to move her to a nursing home, actually I do… I have a lot of guilt over it. She would not have wanted that, but we did not have another choice. This brings me to the tear. My Mom was in Hospice and we were well educated on the signs to watch for in the end. First she stopped eating and drinking, then she slept all day with her eyes half open. A few days before she passed the Hospice nurse was there with us and she was sharing how she was going through the process of leaving her body and how difficult it is for the body to go through that process. Right after she left I was on her bed holding her hands and she sat up a little, eyes wide open staring right at me and she tried to talk but all that came out was the sound a deaf person makes when they try and speak. I always think about that – what was she trying to say? was she scared? My dad was at her side every day, and I came by after work and would sit with her and hold her hand and tell her she could go and not to worry because I would take care of Dad. The day before she passed, we left her room around 7PM and told her we would be back in the morning. I got a call around 6:45AM the next morning from the nurse who said, “your mother has expired.” Yes, she used those words. When my dad and I got there, her body was still warm. I hugged her and she was so rigid. I could not believe how warm she was – I guess I expected her to feel cool to the touch. I had to leave the room. We sat out in the living area outside her room and the nurse came over and said, “It was the oddest thing. When I checked on your mom this morning and realized she had expired, there was this one lone tear on her check.” Like everyone else, I have thought about the tear daily. Was it joy for meeting her savior? Was she seeing her parents and others who passed before her? Was she sad? Did she know she was alone? I have so much guilt for not being there. One of us would usually get there around 8AM. No one could explain the tear, no one had ever heard of it. My best friend who is an MD had never heard of it. I don’t think my guilt will ever subside.

Although long, I’ve left this letter mainly intact for several reasons. One is because it shows so many of the challenges families are faced with when a loved one has dementia. The guilt, frustration, uncertainty, and helplessness of family caregivers is as much a problem to our healthcare system as the patient with dementia. Second, is that it displays the lack of knowledge of health care professionals about end of life, as well as how that ignorance has a lasting affect on families.

Let’s start with: “It was the oddest thing------- there was one lone tear” said by a nurse in the nursing home. That simple remark and remarks like that one, which was maybe thought to be comforting, can have a lasting impact on a family’s grief and memories of their loved one’s death. That comment was unnecessary on the part of the nurse. Nothing positive was accomplished by sharing that observation. It does show the lack of end of life knowledge not only of the nurse but the physician that said he had never heard of that happening.

The tear was probably not one of sadness and certainly not unusual. I have seen moisture from the eyes many, many times. When a person has their eyes partially open (which most people in their last days do), the body sends moisture - tears - to keep the eyes from drying out.

Another issue addressed in this letter is that the family was not with Mom when she died. We have limited control over the time that we die. If we are with someone at the moment of death we are there because they want us there. If they know our scheduling and die when we are not there they are protecting us. It is a gift of protection. Yes, we have that much control.

Important also in this letter are the feelings of guilt that mom was in a nursing home. With her wandering during the night, unless you have nighttime shift help who would simply watch her, there comes a time when there is no other option for keeping people with dementia safe but to put them in a nursing home. This situation is one that many families face and our healthcare system does not.

There are so many parts to this letter that people throughout this country experience and question. Mother sitting up in bed and making a loud sound while she was non responsive is just one of the many things people who are dying do that frightens us. It frighten us because we don’t have knowledge of how people die.

As people die they do a lot of strange things that we will never have answers to or reasons for. What I do know is during the dying days and hours the person’s thoughts and activities are not of this world. They can hear us but it as if from afar. We tend to think of people’s minds as being aware but just trapped inside a body. Not so. Their work is getting out of their body. Their minds are not tuned to the present or their environment.

Think of how our dreams are: symbolic, disjointed and with no time frames. That is the mind of a dying person. What comes out in the physical relates to what is going on inside of them, not outside. It doesn’t make sense to us watchers because we relate to what we see, not what the person who is dying sees in their “dream”.

I hope my thoughts have given you something to think about and brought some comfort. When we don’t know what is normal, what naturally happens as death approaches, we carry our misconceptions and the associated guilt inside us. Those thoughts complicate our grieving and in some cases we never mend.

Something More about.... "One Lone Tear", Dementia at End of Life

Watching a loved one in the dying process is full of intense emotions for families. An educated staff is key to a family's experience in hospice and in their grief journey. I encourage hospices to watch THIS IS HOW PEOPLE DIE each year for continued education and for every staff member to provide consistent education. How Do I Know You? is the booklet family members of those dying with dementia need.

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Carol Alix

You and others say that the dying wait until we are out of the room to leave to help us from the pain. My best friend died in 2013 from cancer. She was in hospice for 35 days. It was a slow and gradual decline daily. Susan had said to me early on, to not have her husband stay at the hospice center when I knew it was time for her to leave. Let him go on home. Susan said ‘it will be harder for me to go if Larry is here.’ I remember her words and it makes sense. Perhaps the dying just can’t let go either and when loved ones are out of the room it allows the dying – - to depart in peace.


Hi Louise, thank you for sharing your experience as your mother was dying. When will we who work with people learn that words matters. They convey meanings so far beyond the definition of the actual words. Of course you all would go to sleep after the exhausting, stressful days that you had as a family. Going to sleep certainly did not show a lack of love or grief, no guilt needed for your actions. Let it go and hold on to the gift you gave your mother in her last days. My blessings are with you and your family. Barbara


Hi Stacy, thank you for sharing your experience with your Nanny as she was living her challenge with dementia. She was fortunate to have her loving family support her during that time. Blessings! Barbara


Barbara, thank you. I’m a social worker and have worked in hospice care (now work with people with dementia and their loved ones) and I’m so grateful for your posts. I can relate to staff that say things that are not helpful and have a lasting impact. When my mother died my three sisters and I stayed with her the last three days of her life, when we brought her home to die. She was agitated the whole time, and we were treating her agitation with meds, but it continued and none of us were sleeping. She died on the third night, and the coroner came for her body, leaving around 3:00 a.m. We called the hospice answering service just to let them know, but we handled things on our own. We were exhausted from her care and the emotions, and we went to sleep, waking just before 8:00 a.m. to a phone call from the chaplain. He knew she died in the wee hours but he “knew you certainly wouldn’t be sleeping, given that your mother has just died.” I’ve never lost that comment. Even though I know we were physically exhausted and relieved for her, that she was no longer agitated and most definitely needed to sleep after 72 hours of no sleep, his comment always made me feel so guilty. I know it’s not rational, but it is there.

Stacie Inman

As I read this letter, I was shocked at how the nurse notified the family of the death and her comment about the lone tear. Barbara, thank you for validating my shock and surprise. People don’t expire, licenses and permits expire, people die. As a hospice social worker for almost 33 years, I have witnessed that lone tear so very many times with a patient. I hold the memory of my sweet mother’s tear as a message of comfort that she was being met by my dear Dad and others that had died before her and were welcoming her home as well as a goodbye to my brother and I and our families that she would miss us and her earthly life, but that it was time to move on. This letter was another reminder that we must continue to offer on-going education and support to staff that care for our patients, to their families and to our hospice team members. Thank you for all that you do. I will be ordering the How Do I Know You booklet for our staff and families. The Gone From My Sight is in our admission binders and I reference it with my families at each social work visit.

God Bless you,

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