**NOTICE** In no way is this article a tool for diagnosis or meant to serve in lieu of a doctor’s advice. Please consult the appropriate medical personnel if it applies to you or a loved one. It is informational only!
There are a lot of cliches writers fall back on which have basis in medical fact, but not necessarily accurate in the way it’s portrayed in popular film, television and literature. In a series of blog posts, I’m going to try to help writers find balance between dramatic license and medical fact for a variety of topics.
In my non-writing life, I am a nurse. I worked in a hospital medical-surgical unit for seven years, a wound care clinic, a post-partum and women’s surgical unit and briefly, school nursing. For the last three years, I’ve been a hospice nurse.
I personally rely on dark humor to help me cope – a lot of medical personnel do, in a ‘laugh or go crazy’ kind of way. My husband is a paramedic (he will also help me contribute to these posts for EMS descriptions), and we kind of …forget…that we can’t talk about the things we see when we’re out in public. The conversations we have at times would make most people flee in self-defense. Our kids are used to this sort of thing after a lifetime of dealing with our jobs. They just roll their eyes and tell us, “Mom, Dad—you’re scaring the normal people.”
In later posts, my husband (we’ll call him EMT Thor) and I will address some of these processes from a trauma standpoint. “It’s Just a Flesh Wound!” will be the next topic. We’ll discuss blood loss, blunt force trauma, and cavitation injury, among other things.
We’re happy to answer questions or take requests for subjects if there is something specific you want to know.
In this post I’ll discuss natural death in general, either at the end of a long life, or due to an acute disease process. I’m going to do it as simply as possible, without a lot of gory detail. (That isn’t to say I won’t share gory detail if you think it’s critical to your writing. Just ask… and I won’t promise the rest of the articles will be quite as respectfully presented.)
Post # 1 : Realistic observations about the dying process
One of the things I have learned in my hospice nursing is: death is an incredibly individual process for each patient.
How we deal with death and dying is also a personal experience, and there are no ‘wrong’ reactions. However… If the subject bothers you, please stop reading now. Again, this is a generalized description and does not necessarily happen for every individual.
Early symptoms of the dying process
After a chronic illness or disease process can no longer be controlled by medical intervention, we begin to look for trends that alert us vital organs are beginning to be compromised.
The heart and lungs are arguably the most important organs in the body. When they fail, every other organ falls in line. The heart delivers oxygen-rich blood to the brain and the rest of the body after its trip through the lungs, and if that perfusion is compromised, other organ function begins to decline.
Common trends on vital signs at the end of life: the blood pressure goes down. The pulse goes up, and the respirations go up. Extremely low blood pressures, usually below 80s/40s, are not unusual, and keep dropping as the body shuts down peripheral circulation to the extremities. Hands and feet may become cool to the touch and pulses in the wrists and feet may become weak and thready, or absent all together, especially in the feet.
Average pulse rates for an adult are between 60 and 100. At the end of life, the heart is working twice as hard to deliver oxygen to the brain and vital organs, and heart rates can soar. I’ve seen them as high as 160 beats per minute in the hours before death occurs, but usually, it is somewhere between 120 and 140.
Respirations get faster as the lungs try to provide oxygen for the blood the heart is trying to pump. Normal respirations are 12-20 for most adults at rest. At the end of life, respirations usually are in the 30’s, perhaps even the 40s, at rest. A person may use more of their accessory muscles to breathe: muscles in the throat, between the ribs, and in the abdomen. Less chest rise, more belly rise.
Sometimes, we see a pattern called Cheyne-Stokes respirations. This is a pattern of breathing that starts out shallow, works out to a crescendo of deep breaths, tapers back to shallow, followed by a pause in breathing called apnea. Then, the whole pattern starts all over again. I’ve usually seen this in patients with neurological compromise, like brain injuries or strokes, but it can happen to any patient. Apnea can last up to a full minute at times.
As the brain becomes starved of oxygen, or toxic chemical levels in the body rise due to kidney failure, something called terminal restlessness may occur. This can happen hours before or even up to two weeks before death: the patient becomes confused, delirious, can’t relax, and sometimes becomes combative.
A fever unrelated to infection is not uncommon during the early stages of dying, and can be quite high. The body's metabolism is changing and the thermostat is malfunctioning.
Something else that happens as circulation begins to shut down is mottling. The skin develops a diffuse, purplish discoloration as the blood pressure lacks the sufficient hydraulic pressure to return deoxygenated blood to the cardiovascular system. We usually see this start in areas of the body where capillaries are numerous, such as kneecaps, the fingers and palms of the hands, and the soles of feet. This can also happen across the bridge of the nose. It can progress to all parts of the body. It is a clear sign the circulatory system is failing. Lividity can also happen before death—the blood pools in the lowest areas of the body, like the buttocks. There is a clear reddish level to the skin where the blood has settled—a bit like red liquid in a white plastic pitcher. It’s more common for this to happen after death, but it can happen a few days before.
“Death rattle” refers to sound made as fluid collects in the lungs. The circulatory system is one big hydraulic pump. When blood pressure drops, it lacks the pressure needed to draw interstitial fluids back into the bloodstream to be redistributed, and it goes naturally to the paths of least resistance. The lungs are built to let oxygen flow back and forth between tissues and the bloodstream, but fluids are not able to move back out once this process is compromised. It may collect in the respiratory system and cause a coarse, rattly, or even bubbling sound as the patient breathes. Expirations may become prolonged, and that sound becomes drawn out. Unfortunately, this may go on for days during the dying process. Medications can be given early to dry up these secretions and keep the patient more comfortable.
Agonal breathing, or “guppy breathing” refers to respirations that are entirely governed by reflex. The mouth and tongue may move, the throat may flex, but very little if any air is being drawn into the lungs. These are usually the last few breaths a person takes. Again, each person’s death is different. Some just…stop. There simply aren’t any more breaths after the last.
The bowels can evacuate in a large movement just prior to or after death. Urine production generally declines as the kidneys lose their oxygenation, and while a person becomes dehydrated during the dying process.
Quickly after death, changes begin in the body. Color drains from the face as circulation ceases. The eyes do not always stay closed, even when we move the lids into place. The jaw drops as the muscles become flaccid. We will often roll a towel beneath the chin to keep the mouth closed. A few hours after death, rigor mortis begins to set in and the body becomes stiff. This passes somewhere around twelve to eighteen hours after death.
Although there are common signs and symptoms of dying most people go through, it’s never a ‘classic textbook’ experience. People die in the same way they lived—in their own time, and their own unique manner.