The Final Hours Before Death

I have noticed concern by medical workers as to what to do during the hours to minutes before death. Here are some ideas to consider.  When the patient is hours to minutes before death they may be experiencing some or all of the following things. Not responding to the environment, mottled, breathing irregular, maybe breathing like a fish, slight agitation, murmuring words but not making sense. Family and significant others are gathered in anticipation of death occurring soon. What do we as professionals do to assist the family in having a positive experience?

* Consider yourself a Conductor. Your job is to be as invisible as possible
yet get everyone working together and feeling supported.

* Fear is what most in the room are experiencing. Fear of the unknown,
fear of pain, fear of what they are seeing, fear of what they think will
happen. Reassure family that what is happening is normal and natural. It
is your job to assure them nothing bad is happening, to neutralize the fear
everyone has brought to this experience.

* Knowledge reduces fear. Begin gently explaining what is happening.
“Mom is doing a good job. She is doing what she is supposed to be
doing”. Go over each thing Mom is doing and explain simply what is
happening (don’t use medical terminology, speak at a 5th grade level) and
that it is all normal. “Her breathing is 10 times a minute and her blood
Pressure is 60/40. This tells me her body is slowing down.” “This is how
you die, and she is doing just what she is supposed to be doing’”

* Explain what is going to happen next. “Mom will start breathing like a fish
breaths. Her breaths will get slower and slower until she stops, then she
may take a couple of long spaced out breaths.”

* Encourage the family and significant others to individually talk to the
person who is dying. To spend some quiet time and share their thoughts
and their goodbyes. Reassure the family that the person can hear.

* Tell the family they can lay on the bed, hold their loved one, talk to them,
cry with them.

* Music played softly is often comforting to everyone present. I would pick
music that the patient enjoyed during their life. It doesn't have to be
classical, hymns, or harps.

* This is not a medical event. You are not doing medical interventions

1. The patient’s restlessness is a danger to themselves.

2. Their congestion is excessive and positioning is not effective. Don’t
use suction but you can use a Scopolamine Patch.
(It probably won’t help, but if its causing the family distress you can try.)

3. If pain has been a part of the disease process, then continue giving
pain medication until death. If pain has not been a part of the disease
process then there is no need to give a narcotic just because the person is
approaching death. Dying itself is not painful, disease causes pain.

4. If respirations are severely labored due to the disease process,
then you can use small amounts of morphine. Remember as death
approaches congestion and labored breathing are normal.

* This is a challenging time for medical professionals. We are used to
fixing, to doing something. Now we are not fixing or doing. When I have
taken a person’s blood pressure for the third time and it is 60/40 that tells
me I am nervous and wanting to do something. You don’t need to know
what the blood pressure is once you have taken it the first time. You know
death is approaching and all the tools we were taught to rely on in health
care no longer apply. Education, support, and guidance are the tools we
now bring to the room.

* If labor (those hours before death) becomes long I would encourage the
family to share stories, look at scrapbooks, and reminisce while in the
room. Have a normal, natural family gathering.

* Explain that we have some control over the time that we die. If you are
with someone when they die you are there because they want you there.
If you are not, even while you tried to be, then know you were given a gift
of love and protection.

* Because we can hear and have limited control over the time that we die
we need to gently tell the person who is dying what is going on in the
room. Who is entering, who is leaving. “It is 12:00 and I am going to bed
now. I will be back in the morning. I love you. If you need to leave before I
return I understand.”

When someone is dying a gradual death from disease and is hours to
minutes from death they don't need a doctor, nurse, social worker, or even
a chaplain. They need someone who understands the normal, natural dying
process and can gently guide and support the family to help create a
sacred memory from this very sacred experience.

Something more about The Final Hours Before Death...

My book, The Eleventh Hour, details more specifically how to conduct a vigil before someone's death. It is quite helpful not only for the caregivers but the family of the dying as well.


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I wish i had found this information a month ago, I went through this by myself. My husband was kind of out of it for part of the day, then rallied to rewrite/update his will. after that was finished, he kicked all the children (age 30to 44) out and let me stay , he calmed and an hour or o later took his final breathes. I told him I ’d be ok , a nurse told me I had to make a decision, I did and my husband took three breathes and went on his terms.

BK Books replied:
Hi Liz, thank you for sharing your final time with your husband with me. Sounds like he made sure his family was taken care of and then relaxed and let go. Blessings to you and your family. Barbara

Christine A.

My ex husband is here in my home on hospice.married 28 years divorced 2.He wanted to be here.For him and my children I wouldn’t have it any other way. Today he is active dying.liver failure liver from cirrhosis and liver cancer. I’m scared for him.he feel asleep 6 days ago.with only a few short awnsers to food and water and to state any of 3 days ago.cannot eat to tired too weak.early this morning sat up in bed few words spoken and this lasted 4 hours.He then feel back asleep with a soft moan and labored fast breathing turning sometimes to his side..and now this as it’s called “death rattle” is not what I would call a tattle.It is bubbling secrations that continue with each breath.he is non responsive.i called the hospice nurse and administered morphine.this has him now not moving at all.I was afraid of morphine, believing it speeds the death but I realize it’s calming and devastated for him and for my children.i pray God takes him soon.i truly do not want my children to witness this.Im so thankful he is not in pain.He just turned 58.Thoughts of our love and fond memories fill my heart.And I hope he knows how much he’s loved.
BK Books replied:
From what you have described your ex-husband’s labor is close to being over, maybe by the time you read this. I see nothing pathological in what you have described. It’s work to get out of our bodies. You have given him a beautiful gift of acceptance and having his family close. Blessings to you all. Barbara


Charles, I hope by the time you read this your father is at rest. The labor of dying is indeed hard work and also very hard on us the watchers. I’m holding you both in my thoughts. Blessings! Barbara

Charles Owen

My Dad is dying right now. He has not moved or opened his eyes all day. All of a sudden he seems to be physically agitated, Moving his arms, breathing is shallow and the rattle is loud. He is 86. No one should have to die like this.

Demi Mills

My mom is in hospice now as I type this post. Thank you for this information. It has helped me understand more of what to expect and to be able to help my sister who is here with me. The COVID-19 kept all 7 of us siblings from getting to be with her at the same time. I was so happy and proud that we could take the shifts and spend them with mom and accept this was just how it has to be although we wish we could all be with her.

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