Other Resources

Below are some helpful resources for those coping with a loss or facing the prospect of a loved one dying in the near future. These are reprinted from free Hospice brochures.

Symptoms of Approaching Death - A Guide for Family and Caregivers

A most difficult time

The Hospice staff realizes that this is one of the most difficult times for a family to live through. Often, fear of the unknown is greater than the fear of the known.

Our desire is to be as honest and straightforward as possible in helping you prepare and anticipate symptoms which are indicative of approaching death.

We want to relate each possible symptom in order to decrease your fear and so you will have some guidelines about what to do if one of these symptoms should suddenly appear.

Your physician, hospice nurse and hospice social worker are available to help you clarify your concerns about this information. Described are common ways in which the body prepares itself for death.

Symptoms may not occur in the order presented here, or they may not appear at all. Each circumstance is unique.

Common Symptoms

Increased sleep: Individual will gradually spend more time sleeping and at times may be difficult to arouse. This is a result of a change in the body's metabolism.
Try to spend more time with the patient during the times of greatest alertness.
Decreased need for food/drink: Body functions are gradually slowing down. There may be difficulty in swallowing solid food.
The nurse can give you some information on liquid food supplements which may be helpful in maintaining nutritional status. As the patient's condition declines, fluids alone may be administered.
Skin becomes cold, discolored: You may also notice the underside of the body becoming much darker in color. Arms and legs may become increasingly blotchy or develop light to dark purple discolorations.
These symptoms are a result of blood circulation slowing down and do not indicate that the patient is too cold. Usually the patient feels warm internally and does not need extra blankets.
Confusion: The individual may become increasingly confused about time, place and identity of people around him/her. This is also a result of metabolic changes.
Reminders as to what as to what day it is, what time it is and who is in the room will be very comforting.
Increased restlessness: Pulling at bed linens and visions of people or things may occur. This is a result of a decrease in oxygen circulation to the brain and a change in the body's metabolism.
Speaking calmly when confusion occurs will be reassuring. These visions are not necessarily frightening and are, in fact, comforting to the person.
Incontinence: Loss of control of urine and bowel movements may occur.
Your nurse or home health aide can help you obtain pads or chux to place under the patient for more comfort and cleanliness. Or your physician may order a catheter.
Oral secretions more profuse: Oral secretions may increase and collect in the lungs and back of the throat. This is a result of a decrease in heart and lung function and an increasing inability to cough up normal saliva.
Elevating the head of the bed with pillows or obtaining a hospital bed will make breathing easier. Cleansing the mouth with a soft, small toothbrush or sponge applicator is advisable.
Decreased urine output: If the individual has a bladder catheter in place, you may notice that the amount of urine will decrease and may become dark brown or red in color.
This is a natural result of slowed body functions.
Decreased hearing and vision: Clarity of hearing and vision may decrease. You may want to keep lights on in the room when visions decreases.
Never assume that the individual cannot hear you, since hearing is the last of the five senses to be lost.
Breathing changes: You may notice a change in breathing patterns. Breathing may become irregular with ten to thirty seconds of no breathing. This symptom is very common and indicative of a decrease in circulation and build up in body waste products.
Elevating the head of the bed sometimes relieves the person who has irregular breathing patterns.

How to know that death has occurred

Signs of death include:

No breathing
No heartbeat
Loss of control of bowel or bladder
No response to verbal communication or shaking
Eyelids slightly open
Eyes fixed on a certain spot
Jaw relaxed and mouth slightly open

If you think that death is close at hand or has occurred, please contact your hospice provider.

Your hospice nurse will help you confirm that death has occurred and handle calls to the mortuary and your physician. DO NOT call the police, paramedics or the fire department.

Although this information may sound frightening, the hospice team's goal is to prepare you for what to expect.

Your physical and emotional well-being is as important to us as your loved one's. A member of the hospice staff is always available to help you.

The Journey Home

The Dying Process: A Guide For Families

Just as life is as unique as each individual, so the process of dying is a singular experience.

Death is the final destination in the journey of life. On this trip there are various courses which lead to the same destination. This booklet is simply an outline of some of the more common characteristics of the natural process of dying.

Each experience unique

The guidelines in this booklet are meant to help you gain understanding. Remember that not everything mentioned here will necessarily occur in your experience. All or maybe just one or two of the characteristics listed here may be present.

It takes months for some to separate from their physical body; for others, it may take only minutes. Keep in mind:

Death sets its own pace -- it comes in its own time and in its own way.
The dying process varies with each individual -- it is as unique as the individual experiencing it.

Approaching Death

How a person approaches death often depends upon how they faced life -- how much they participated in life and how willing they are to let go of this life and venture into an unknown, new one.

Fear and unfinished business are also two big factors in determining the extent of resistance to meeting death.

Understanding one's own mortality

The physical process of dying usually begins two weeks prior to death. However, psychological and emotional changes can often begin one to three months before death.

A transition occurs within the individual which takes them from a distant concept of "death" to an intimate rationalization of their own mortality. Whether the person accepts it or not, they realize that they are dying.

The Dying Process

Stage I: Withdraw

(one to three months prior to death)

As the knowledge that "I am dying" becomes real, the person begins to withdraw from the world around them. This is the beginning of separation:

Separation from the world -- no more interest in newspapers, television, or events of the world
Separation from people -- no desire for visits from friends or neighbors: "I don't feel like company today"
Separation from loved ones -- a desire not to see children, grandchildren, or sometimes even spouse

Turning Inward

This is a time of withdrawing from everything outside one's self, and focusing more and more on the inside. This is an important time for them to sort out, evaluate and review their life. It is something that the person can only do alone.

This mental processing of one's life is usually done with the eyes closed, so sleep increases. A morning nap is added to the usual afternoon nap. Staying in bed all day and spending more time asleep than awake becomes the norm.

While this appears to be just sleep, there is actually serious work being done inside on a level of which we cannot fully comprehend.

Less need to communicate

With withdraw comes less of a need to communicate with others. As the physical life is slowly being left behind, words lose their importance.

Touch and nonverbal contact takes on more meaning.

Loss of appetite

Since it is food that energizes the body and keeps us alive, it is perfectly natural that eating should stop when a body is preparing to die.

Although the person may have occasional cravings, it is normal for eating habits to gradually decrease throughout the dying process. The person usually does not feel like eating because foods just do not taste good. When they do eat, liquids are preferred over solids.

Meats are the first to go out of the diet, followed by vegetables and other foods that are hard to digest. Eventually the person will not even eat soft, easily digestible foods.

One of the hardest concepts for a family to accept is that it is okay for their dying loved one not to eat. From this point it is spiritual energy that sustains more than physical.

Stage II: Disorientation

(one to two weeks prior to death)

Most of the time is spent sleeping now. The person cannot seem to keep their eyes open. However, they can be awakened.

The person often becomes confused, talking to people, and about places and events that are unknown to others. They may see and converse with loved ones who have died before them. It seems they have one foot in this world and one in the next.

They may pick at their bedclothes and flail their arms. Their physical activity is seemingly aimless and their focus appears to change from this world to the next.

Physical Changes

Physical changes begin to signal that the body is losing its ability to maintain itself. Common changes in the body include:

Lowering of blood pressure
Changes in pulse beat -- either increasing from a normal of 80, to upward of 150, or decreasing anywhere down to undetectable
Body temperature fluctuates between fever and cold
Increased perspiration, accompanied by clamminess
Skin color changes -- skin may appear flushed with fever or bluish with cold. Approaching death often brings a yellow paleness (not to be confused with jaundice). The nailbeds, hands and feet are often pale and bluish because the heart cannot circulate blood at a normal flow.
Breathing changes and congestion -- Respiration may increase from a normal 16-20 breaths per minute to nearly 40-50 per minute, or decrease to nine or even six breaths per minute.
There can be puffing or blowing of the lips on exhaling. Rhythmic breathing may actually stop, only to resume again. This generally occurs during sleep.
A rattly sounding congestion in the lungs and upper throat may also be present. Coughing often accompanies this, but usually nothing can be brought up.
Changes in breathing and congestion tend to come and go. Any or all of these symptoms may be present one minute; breathing may be clean and even the next.

Stage III: Death

(one to two days/hours prior to death)

A surge of energy

Near the end the person sometimes experiences a surge of energy. For example, they might rally enough energy to speak clearly and alertly, when before there had been disorientation.

A favorite meal might be asked for and eaten when nothing has been eaten for days. The person might visit with friends and relatives when they had not wanted to see anyone for awhile.

The person often expends this renewed energy on a final time of physical expression before moving on. Examples like the ones mentioned above are not always noticeable as they occur. Later, as you reflect back, you may be able to recognize certain activities that may have been the result of a brief spark of renewed energy.

Physical characteristics from Stage II become more intense as death approaches.

Restlessness can increase due to lack of oxygen in the blood.
Breathing patterns become slower and more irregular. Breathing may stop for 10-15 seconds, or even 30-45 seconds before resuming again.
Congestion continues to come and go and can be very loud. It can be affected by positioning on one side or the other.
The eyes may be open or semi-open but not seeing. There is a glassy look to them, often tearing.
The hands and feet appear purplish. The knees, ankles, elbows, underside of the arms, legs, back and buttocks can be blotchy.

The person becomes nonresponsive (unable to respond to their surroundings) sometime just prior to death. The separation becomes complete when breathing stops.

What appears to be the last breath is often followed by one or two long spaced breaths and then the physical body is empty.

This life is past... A new life is just beginning.

Glossary of Terms

Casket/Coffin - A box or chest for burying human remains.

Cemetery Property - A grave, crypt or niche.

Cemetery Services - Opening and closing graves, crypts or niches; setting grave liners and vaults; setting markers and long-term maintenance of cemetery ground and facilities.

Columbarium - A structure with niches (small spaces) for placement of cremated remains in urns or other approved containers. It may be outdoors or part of a mausoleum.

Cremate - To reduce (as a dead body) to ashes by burning.

Crematorium - Exposing human remains and the container encasing them to extreme heat and flame and processing the resulting bone fragments to a uniform size and consistency.

Cremains - The ashes of a cremated human body.

Crypt - A space in a mausoleum or other building to hold cremated or whole human remains.

Disposition - The placement of cremated or whole human remains in their final resting place. A Permit for Disposition must be filed with the local registrar before disposition can take place.

Endowment Care Fund - Moneys collected from a cemetery property purchasers and placed in a trust for the maintenance and upkeep of the cemetery. The state monitors the fund and establishes the minimum amount that must be collected; however, the cemetery is permitted to collect more than the minimum to build the fund. Only the interest earned by such funds may be used for the care, maintenance and embellishment of the cemetery.

Entombment - Burial in a mausoleum.

Funeral Service / Parlor Service / Ceremony - A service commemorating the deceased with the body present.

Funeral Services - Services provided by a funeral director and staff, which may include consulting with the family on funeral planning; transportation, shelter, refrigeration and embalming of remains; preparing and filing notices; obtaining authorizations and permits; and coordinating with the cemetery, crematory or other third parties.

Grave/Plot - An excavation for burial of a body; a burial place.

Hearse - A vehicle for conveying the dead to the grave.

Inurement - To place (as cremated remains) in an urn.

Memorial Service - A service commemorating the deceased without a body present.

Niche - A burial container to place cremated remains in a cemetery.

Fremont Chapel of the Roses • 1940 Peralta Boulevard • Fremont, CA • (510) 797-1900
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Fremont Memorial Chapel • 3723 Peralta Boulevard • Fremont, CA • (510) 793-8900
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