As the various systems of the body begin to slow down, pain can be felt by the dying. These pains may persist or may be transient, an experience that is as unique as each individual. Many choose to alleviate these discomforts with pain medicine (i.e. morphine / roxanol) and some also or exclusively choose integrative alternatives like Reiki (energy work), gentle massage or essential oils. THC or CBD (the non-psychoactive component of marijuana) can be very effective at managing pain as well. It is important to honor the wishes of your loved one and leave judgment at the door. People generally die as they lived, meaning if they lived strong willed, they will likely transition this way as well. Embracing your loved one for who and how they are can ease their transition for all involved.

Anxiety can be common in those with a terminal diagnosis. The physical dying process can produce unsettled feelings which can also exacerbate pain the dying body may be experiencing. Anti-anxiety medications like ativan (lorazepam) can help with this or practices such as meditation, guided imagery, breathing exercises or talk therapy.

As the physical body moves through the dying process and nears death, it can heat up in the form of a fever. Fever can also be present, but not necessarily be an absolute indicator that body death is near. Cool compresses with a light or no sheet coverage can be helpful. If your loved one is still awake, ice chips or small bites of something cold like ice cream or sorbet can be refreshing.

The physical body can also cool down, starting with the hands and feet, as the body shunts blood to more vital organs like the heart and lungs. This can make nail beds appear bluish or purple in color. Sometimes patches of skin throughout the body can become cooler and change color, a process called mottling. This may or may not happen during the body death, but rest assured it is a painless process.

When the body begins to actively die, this can affect the body’s heart rate and breathing pattern. The heart may race or it could be so slow and soft that it is difficult to tell if it is beating. This is a normal process. 

Breathing may move through a number of shifts. It is very normal for breathing to speed up for a period of time before it slows down. It may also become not rhythmic, with periods of apnea or pause in between breaths. This is a natural process and indicates that the final hours or minutes are approaching.

Some may develop a rattle as they move through these respiratory changes. You can elevate the head of the bed or gently turn them on their side. This may not alleviate the rattling noise, but rest assured it is not causing the dying person distress. It can, however, be quite distressing for the caregiver and those around so make sure to give yourself small breaks if necessary.

Sharing food and drink together is comforting and brings us all together as family and friends and for many can be their “love language”. As the body begins the dying process, the drive for food and drink decreases dramatically. If the dying is able to eat, we can offer them as much or as little as they want. Often these are very small bites and sips, called “comfort feeding”. People often gravitate toward ice cream, sorbet, ice water or maybe even a small sip of their favorite spirits. Remember people will die as they lived, so honor their requests or lack of requests for food and drink and never force a person to eat or drink. Remember the body has a wisdom and the decreased drive to eat and drink is a normal and natural process as the gastrointestinal (digestive) system begins shutting down. For many cultures, and particularly in Hawaii, food and drink is our way of connecting and showing our aloha (love). Try to remember, that force feeding food (mea’ai) or drink (inu) during this time may only cause distress to the dying and potentially cause food or drink to accidentally go into the lungs, causing distress to the dying. Excess fluids during this time may also make the rattling sound worse as the body has stopped processing food and drink and it has nowhere to go.

As the body approaches death, the various bodily systems will begin to slow. This can affect your loved one’s elimination in that the kidneys slow production of urine and will eventually cease to make urine. Bowel elimination may also slow as decreased oral intake increases. 

It is quite common for individuals to appear confused during the last few days or hours as body death approaches. Terminal delirium can be quite distressing and even exhausting for the caregiver / family members as continual re-direction and assurances need to be made to your loved ones. Please note that terminal delirium often manifests in your loved one insisting they get out of bed to the toilet or to tend to something / someone when it is often not safe for their weakening bodies to get out of bed. Medications for agitation like Haldol (Haloperidol) can help your loved one as they move through this phase. Take comfort in knowing that this phase will pass and is generally rather brief, lasting only hours to a day or so.

As the body moves through the dying process, your loved one may be sleeping most, if not all of the time. This is a normal and natural response partially caused by the separation from their body as well as the medications often used to maintain comfort. It is normal for your loved one to see or talk to those that may have already passed on. It is also common for loved ones to reach out their hands or arms to someone / something not visible to the family / caregiver. Try not to be alarmed by this, but instead support your loved one’s process and separation from their body. Know that hearing is believed to be the last sense to dissipate so talk to them as much as you need / want. Many families choose to move their loved one’s bed into a central area of the house so that their loved one can be around the routine of meal sharing and conversation. It can be quite comforting for your loved one to be amongst gathered ‘ohana (family), laughter and reminiscing.

Sleep rhythms can shift and similar to when we were newly born, your loved one may sleep all day and be more awake at night. This is a normal and natural phenomenon. There is often less activity and distraction at night and your loved one may experience more pain or anxieties during this time.