Death and Dying

Definition
Death is the one great certainty in life. Some of us will die in ways out of our control, and most of us will be unaware of the moment of death itself. Still, death and dying well can be approached in a healthy way. Understanding that people differ in how they think about death and dying, and respecting those differences, can promote a peaceful death and a healthy manner of dying.
The primary course of action when death is near is to fulfill the dying person's wishes. If the person is dying from an illness, ideally, they will have participated in decisions about how to live and die. If the requests made do not seem practical to the caregiver, options should be raised with the dying individual to try to accommodate his request and still provide adequate care. If the dying individual has not been able to participate in formulating final plans, you should strive to do what this person would want.
If the individual is in a hospice, he may most likely desire a natural death. In this situation, the aim will be for the final days and moments of life to be guided toward maintaining comfort and reaching a natural death.
Symptoms
Cardiopulmonary criteria have traditionally been used to declare death. When breathing ceased and the heart no longer beats, the person is said to have died.
Brain death
Brain death is another standard for declaring death that was adopted by most countries during the 1980s. The brain death standard was originally recommended in 1968 by a Harvard panel of experts that studied patients in irreversible coma. They concluded that once a patient's whole brain no longer functions and cannot function again, the brain is dead. Cardiorespiratory death invariably follows.
Dying
If an individual is dying from a chronic illness as he is nearing death, each day the person may grow weaker and sleep more, especially if his pain has been eased.
Near the very end of life, the person's breathing becomes slower—sometimes with very long pauses in between breaths. Some pauses may last longer than a minute or two. The final stage of dying is death itself. You will know death has happened because the individual's chest will not rise and you will feel no breath. You may observe that the eyes are glassy. When you feel for pulse, you will not feel it.
The individual dying and facing eventual death may go through two main phases prior to actual death. The first stage is called the pre-active phase of dying and the second phase is called the active phase of dying. The pre-active phase of dying may last weeks or months, while the active phase of dying is much shorter and lasts only a few days, or in some cases a couple of weeks.
Pre-active Phase
Person withdraws from social activities and spends more time alone
Person speaks of "tying up loose ends" such as finances, wills, trusts
Person desires to speak to family and friends and make amends or catch up
Increased anxiety, discomfort, confusion, agitation, nervousness
Increased inactivity, lethargy or sleep
Loss of interest in daily activities
Increased inability to heal from bruises, infections or wounds
Less interest in eating or drinking
Person talks about dying, says that they are going to die or asks questions about death
Person requests to speak with a religious leader or shows increased interest in praying or repentance
Active Phase
Person states that he is going to die soon
Has difficulty swallowing liquids or resists food and drink
Change in personality
Increasingly unresponsive or cannot speak
Does not move for longs periods of time
The extremities—hands, feet, arms and legs—feel very cold to touch.
Not all people show these signs. These signs of death are merely a guide to what may or often happens; some may go through few signs and die within minutes of a change being noticed
Causes
Treatment
As a family member or friend of a dying individual, you may aim to do the following:
Help with comfort and rest (back rubs, holdings hands, reading and background music can be very comforting and help decrease a person's sense of being alone)
Prepare for physical problems (lip balm or salve prevent chapped lips, for example)
Welcome visitors and children, or ask the person whom he would like to see and invite those people
Prepare a list of people to call near the time of death
Talk with a friend about your feelings
Feel free to say good-bye at the place of death
Avoid calling 911 or an emergency team
Guidelines are also suggested for the person who is dying. Foremost is taking care of himself. Other suggestions are to think ahead about what could happen—and about how you will deal with problems if they do occur—and to create a better quality of life for yourself and for the people who love and care about you. Ideally, death and dying should be peaceful and healthy for you, the dying person and for the people who love and care about the dying individual. Helping friends and family deal with your death may help you find peace and comfort. If you are not at peace with death, you should seek advice from your health care provider.
More specific guidelines for the dying individuals include:
Be grateful and accept help
Don't be afraid to ask to be alone, time to be by yourself is necessary
Be your own counsel—no one, including your physician, religious counselor, spouse or friends can understand 100 percent what you want and need
Some people may treat you differently after learning that you are dying. Be patient; they may be more bearable after a brief adjustment period
Slow down, and ask your family and friends to slow down: There may not be a lot of time, but there is sufficient time, except in the most extreme cases, to think, plan and prepare
Search for, and then trust in, a single individual. This does not mean you should not listen to and follow reasonable directions and advice. But focus on one individual as the final helper. When you do, make certain that your family doctor knows whom you've appointed to serve in that role.
Ask your health care provider to explain what is being done to you so that you can understand why things are being done and what benefits you can expect. Call the health professional if you are concerned or uncertain and need more explanation.
You should be aware that nurses and other hospital staff may not know that you are dying. This fact may not be written in your chart—and can lead to conflicts between families and hospital staff. It's OK for your family to tell the hospital staff that you are dying.
Pre-planning will give your loved ones both assurance that your wishes are being followed and peace of mind from the knowledge that decisions have already been made.
Consider getting a durable power of attorney in which you name one or two people to make decisions or choices on your behalf if you should become incompetent or incapable of making decisions. Read the Do Not Resuscitate policies of your hospital. Under the U.S. Patient Self-Determination Act, every U.S. state must have a mechanism for allowing people to express their wishes for their death and dying, and healthcare providers are obligated to follow their patient's instructions.
Use resources that are available from the health care community. These include social services and psychological, financial and religious counseling, as well as hospital financial counseling.
Sources
The Significance of Dying Well. Illness, Crisis & Loss
British Medical Journal
You Cannot Die Alone, Elisabeth Kubler-Ross
Death and Dying: Mount Sinai School of Medicine, New York. Encyclopedia of Life Sciences
A Dying Person's Guide to Dying, Roger C. Bone, M.D. The American College of Physicians
American College of Physicians; What to Do Before and After the Moment of Death.
Hospice Patients Alliance
Harvard Adhoc Committee on Brain Death