A Doctor Explains the Last Hours of Life

Most people who look for this are not curious. Somebody they love is dying. So this is written for the person in the chair beside the bed.

The most useful thing to know is this. Almost everything that families find distressing at the end is not distressing for the person who is dying.

It begins with sleep

Long before the last hour, a person sleeps more, wakes less and takes less interest in the room. This is not depression and it is not giving up. The body is reducing what it spends.

Eating stops mattering

This upsets families more than anything. Feeding somebody who is dying does not extend their life and can make them uncomfortable. They are not starving. The hunger mechanism has switched off.

Offering food is love. Not eating it is not rejection.

The last days

Skin. Blood is kept for the heart and the brain. The hands and feet become cool and mottled, starting at the feet. It looks alarming. It is not painful.

Breathing. It becomes irregular, with long gaps that can last many seconds.

The rattle. In the last day or two there may be a loud rattling sound with each breath. It is a small amount of saliva at the back of the throat, because swallowing has stopped.

The person is not choking and is not drowning. It distresses the room. It does not distress the patient.

By then they are almost always unconscious.

The last hours

Response to speech fades before response to touch. Holding a hand becomes the whole conversation.

Hearing is widely believed to be among the last senses to go, and there is some evidence for it. Nobody can promise they heard you. It costs nothing to say it anyway.

The last minutes

They are quieter than almost anybody expects. Breathing becomes shallow and slow. There may be a few deep, sighing breaths a long way apart. Those are reflexes. They are not a struggle.

There is often no single moment. It is a gradual absence, and families often cannot say exactly when. That is normal.

Morphine does not shorten life

Many families fear that morphine will end things sooner, so they ask for less.

Given properly for pain and breathlessness, it does not shorten life. This has been studied repeatedly. The doses are small and matched to the symptom.

Refusing it protects nobody. If you are worried, tell the nurse. It is the question they answer most often.

What you can do

• Moisten the mouth with a sponge or a little water. A dry mouth is one of the few things that causes real discomfort.
• Keep the room quiet and the light low, with few people.
• Say who you are when you speak.
• Touch. An arm, a shoulder, a hand held.
• Take turns. The people who regret it most are the ones who did not sleep for four days.

How long?

Nobody can answer that. Doctors are poor at predicting it, and the usual error is optimism.

What can be said is roughly which stage a person is in: weeks, days or hours. Ask what stage, not how long.

Does it hurt?

Dying of an illness can hurt, and that pain is treatable. Treating it is the job of palliative care.

The process of dying itself is not painful for most people. The body releases its own opioids, and rising carbon dioxide is sedating. People who have come close to death and returned most often describe it as peaceful.

Say the ordinary things

Thank you. I am here. I love you. It is all right.

Say the difficult thing too, if there is one. Regrets afterwards are almost never about something said. They are about something left unsaid.

When the breathing stops

You do not have to do anything at once. There is no emergency any more. You can sit for as long as you want.

When you are ready, tell the nurse or call the number you were given. The exact steps depend on where you live, and the care team will guide you through them.

Afterwards

Relief. After a long illness, relief is one of the most common feelings there is. It is not a betrayal.

Replaying the last hour. Many people die in the few minutes when somebody steps out of the room. Palliative nurses see it so often that they consider it ordinary. You did not leave at the wrong moment.

The short answer

The cold hands, the mottled skin, the gaps in breathing and the rattle are all expected, and none are painful. Talk to them. Whatever you feel afterwards is a normal thing to feel.

If somebody you love is close to this, ask the palliative care team anything. It is a gentler process than almost everybody fears.