SAN­DRA L BLOOD

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“Near­ing death and death are nat­ur­al, healthy and bi­o­log­i­cal el­e­ments of the life cy­cle,” ex­plains Cross­roads Hos­pice and Pal­lia­tive Care (CH­PC), head­quar­tered in Tul­sa, USA.

They ex­plained that while death is a nat­ur­al process of life, peo­ple die in dif­fer­ent cir­cum­stances, which at times pre­vent the wit­ness­ing of the near­ing-end process, and while there are gross near­ing-death oc­ca­sions, there are al­so oc­ca­sions that are tran­quil and pleas­ing.

Ad­di­tion­al­ly, while some peo­ple sud­den­ly or un­ex­pect­ed­ly clin­i­cal­ly die (no heart, brain or pulse ac­tiv­i­ty), no body dies in­stan­ta­neous­ly.

Near­ing death oc­curs in var­i­ous ways de­pend­ing on the per­son’s life ex­pe­ri­ences, but some char­ac­ter­is­tics are in­evitable, which eas­i­ly in­di­cate to trained pro­fes­sion­als that a per­son is near the end.

They said sup­port of prac­ti­cal needs and emo­tion­al tran­si­tions helps pro­vide com­fort, dig­ni­ty, and a sense of pre­pared­ness dur­ing life’s fi­nal stage. There are both phys­i­cal, emo­tion­al and spir­i­tu­al end-of-life in­di­ca­tors/signs, but whichev­er, the pa­tient/per­son re­quires com­fort, love and sup­port, and their dig­ni­ty main­tained. The per­son is said to be com­plet­ing sig­nif­i­cant work but on an­oth­er lev­el.

Phys­i­cal Signs: De­creas­ing body tem­per­a­ture, es­pe­cial­ly of ex­trem­i­ties; mot­tling skin ow­ing to the body’s cir­cu­la­tion slow­ing down and vi­tal or­gans shut­ting down; dis­ori­en­ta­tion, which at times re­sults in feel­ings of fear, frus­tra­tion or anx­i­ety; in­creased sleep­ing; in­con­ti­nence: un­con­trolled uri­nary and/or bow­el func­tions; rest­less­ness; con­ges­tion from se­cre­tion build-up in air­ways that re­sults in gur­gling sounds termed Death Rat­tle; de­crease and change in urine colour that can be caused by fail­ing kid­neys or med­ica­tion; de­crease in ap­petite and thirst; changes in breath­ing that in­clude shal­low breaths or Cheyne-Stokes breath­ing or no breath­ing for sec­onds, or rapid, shal­low pant­i­ng; and fever ow­ing to a se­ries of in­ter­nal changes, in­clud­ing un­der­ly­ing in­fec­tions.

Emo­tion­al and Spir­i­tu­al Signs: Giv­ing away be­long­ings and mak­ing fu­ner­al arrange­ments; be­com­ing with­drawn or un­re­spon­sive; vi­sion-like ex­pe­ri­ences or hal­lu­ci­na­tions: en­coun­ters with peo­ple who are al­ready de­ceased, or de­scrib­ing hav­ing been places or see­ing things not vis­i­ble to oth­ers; com­mu­ni­ca­tion changes: ex­press­ing spe­cif­ic de­sires and needs; say­ing good­bye—their fi­nal gift.

CH­PC’s ad­vice on what can be done.

For Phys­i­cal Signs: Sit qui­et­ly with the pa­tient; speak in calm tones; hold their hand; ad­just the pa­tient’s po­si­tion or med­ica­tion as war­rant­ed; reg­u­lar­ly change soiled cloth­ing and bed­ding and use pro­tec­tive un­der­gar­ments; gen­tly wipe mouth with a moist cloth; don’t force them to eat or drink, but give small chips of ice or frozen juice chips, which at times sup­ply hy­dra­tion; el­e­vate the pa­tient’s head, ap­ply a cool, moist cloth to the fore­head to help re­duce body tem­per­a­ture or to re­lieve dis­com­fort as­so­ci­at­ed with fever.

For Emo­tion­al Signs: Re­spect and sup­port the in­di­vid­ual’s au­ton­o­my and de­ci­sion-mak­ing process at this time; of­fer gen­tle in­ter­ven­tions, in­clud­ing soft, kind words to pro­vide com­fort and con­nec­tion be­cause, while ap­pear­ing un­re­spon­sive, hear­ing re­mains; even though com­mu­ni­cat­ing with or vi­sion­ing the-al­ready-passed may be chal­leng­ing, con­fus­ing or even scary, ap­proach the pa­tient with em­pa­thy, re­spect, open­ness, and re­as­sur­ance that it’s com­mon and nat­ur­al that these things hap­pen; do not get an­gry if they do not men­tion you as some­one they want to see. That in­di­cates to them, your task is ful­filled and if you are men­tioned, it means your sup­port/per­mis­sion/af­fir­ma­tion to let go is still need­ed – give them per­mis­sion; say­ing good­bye (the fi­nal gift): hug them or hold their hand, lis­ten and say what­ev­er you think you need to say, which should be al­ways some­thing good in­clud­ing ‘I love you,’ or ‘thank you’, even amidst shed­ding tears, which is an ex­pres­sion of love and helps to let go.

CH­PC said there’s no par­tic­u­lar time­line for the end-of-life jour­ney. Dy­ing may take hours or days. Time of death is un­pre­dictable even if the per­son is ex­hibit­ing typ­i­cal end-of-life signs and symp­toms.

Near­ing death is al­so ob­served via med­ical mon­i­tors; so too is death, where wave­forms in­di­cate the be­hav­iour of vi­tal signs, but which can­not legal­ly or clin­i­cal­ly de­clare death. Some peo­ple have al­so re­port­ed hav­ing re­cov­ered from clin­i­cal death.

T&T’s Lil­ia Mootoo, for­mer se­nior hos­pice ad­min­is­tra­tive man­ag­er, ex­pressed: “Pal­lia­tive care or end-of-life/ter­mi­nal care is for pa­tients who have been di­ag­nosed with lim­it­ed life ex­pectan­cy. Such pa­tients are to be cared for, par­tic­u­lar­ly can­cer pa­tients. Se­nior cit­i­zen homes are more preva­lent where dai­ly liv­ing as­sis­tance is pro­vid­ed, and pa­tients re­quire 24-hour care, com­fort, pain-free, and com­pas­sion­ate at­ten­tion. Rel­a­tives’ pres­ence is en­cour­aged, and a doc­tor, se­nior nurse or oth­er qual­i­fied staff’s med­ical at­ten­tion would be need­ed as nec­es­sary. If the pa­tient is not com­plete­ly bedrid­den or co­matose, en­cour­age­ment to be ex­posed to the sun­shine/out­er space is ad­vised.”

“Be­ing a Reg­is­tered Nurse (RN) in pal­lia­tive care isn’t just a pro­fes­sion,” ex­pressed RN Can­dice Bai­ley-Con­nell of lo­cal and in­ter­na­tion­al mul­ti-award-win­ning Liv­ing Wa­ter Com­mu­ni­ty. “It’s a call­ing de­fined by qui­et grace, deep em­pa­thy, and hu­man con­nec­tion. While it’s a hard job and car­ries an in­her­ent weight, the work is pro­found­ly re­ward­ing. Pro­vid­ing holis­tic, com­pas­sion­ate care means build­ing gen­uine bonds with pa­tients and their fam­i­lies, mak­ing it nat­ur­al to form at­tach­ments. When that tran­si­tion time comes, the grief is re­al, and feel­ing sad is sim­ply a nat­ur­al re­flec­tion of the heart put in­to every mo­ment of care.

Bai­ley-Con­nell said even though she isn’t Catholic, she deeply ho­n­ours the in­sti­tu­tion­al be­liefs and tra­di­tion.

Con­sis­tent with the fa­cil­i­ty’s phi­los­o­phy, “No One Dies Alone,” shared LWC’s ad­min­is­tra­tor Shinelle Rid­dess, Bai­ley said, “Stand­ing at the bed­side to pray the Di­vine Mer­cy chap­let as part of their last rites brings a sa­cred, calm­ing still­ness to the room. In those fi­nal, qui­et mo­ments, shar­ing a gen­tle prayer of­fers a sense of com­fort, dig­ni­ty, and peace for the pa­tient cross­ing over, for their loved ones, and for my­self as a nurse priv­i­leged-bound to walk them home.”

Death: Cir­cu­la­to­ry-res­pi­ra­to­ry pro­nounce­ment

As it re­lates to pro­nounc­ing a death (con­firm­ing ces­sa­tion of cir­cu­la­tion and breath­ing), high­ly cer­ti­fied fam­i­ly and sports med­i­cine physi­cian, Dr Keno Carter-Guy of Al­lied Fam­i­ly Care and Nex­gen Clin­ic, said the WHO (World Health Or­gan­i­sa­tion) stan­dards of cir­cu­la­to­ry-res­pi­ra­to­ry pro­nounce­ment, as stat­ed by the IL­COR/AHA (In­ter­na­tion­al Li­ai­son Com­mit­tee on Re­sus­ci­ta­tion/Amer­i­can Heart As­so­ci­a­tion), are fol­lowed.

Re­gard­ing the min­i­mum stan­dard: “Ab­sent pal­pa­ble pulse, ab­sent breath sounds, and ab­sent heart sounds on aus­cul­ta­tion; ab­sent res­pi­ra­to­ry ef­fort or chest wall mo­tion; loss of pul­satile ar­te­r­i­al blood pres­sure non­in­va­sive­ly and loss of any ar­te­r­i­al line wave­form, if avail­able; and fixed, di­lat­ed pupils.”