Dying

Dying is the final stage of life which will eventually lead to death. Diagnosing dying is a complex process of clinical decision-making, and most practice checklists facilitating this diagnosis are based on cancer diagnoses.[1]

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Signs of dying

The National Cancer Institute in the United States advises that the presence of some of the following signs may indicate that death is approaching:[2][3]

  • Drowsiness, increased sleep, and/or unresponsiveness (caused by changes in the patient's metabolism).
  • Confusion about time, place, and/or identity of loved ones; restlessness; visions of people and places that are not present; pulling at bed linens or clothing (caused in part by changes in the patient's metabolism).
  • Decreased socialization and withdrawal (caused by decreased oxygen to the brain, decreased blood flow, and mental preparation for dying).
  • Decreased need for food and fluids, and loss of appetite (caused by the body's need to conserve energy and its decreasing ability to use food and fluids properly).
  • Loss of bladder or bowel control (caused by the relaxing of muscles in the pelvic area).
  • Darkened urine or decreased amount of urine (caused by slowing of kidney function and/or decreased fluid intake).
  • Skin becoming cool to the touch, particularly the hands and feet; skin may become bluish in color, especially on the underside of the body (caused by decreased circulation to the extremities).
  • Rattling or gurgling sounds while breathing, which may be loud (death rattle); breathing that is irregular and shallow; decreased number of breaths per minute; breathing that alternates between rapid and slow (caused by congestion from decreased fluid consumption, a buildup of waste products in the body, and/or a decrease in circulation to the organs).
  • Turning of the head toward a light source (caused by decreasing vision).
  • Increased difficulty controlling pain (caused by progression of the disease).
  • Involuntary movements (called myoclonus), increased heart rate, hypertension followed by hypotension,[4] and loss of reflexes in the legs and arms are additional signs that the end of life is near.

Culture

How humans understand and approach the process dying differs across cultures.[5] In some cultures, death is the complete termination of life.[5] In other cultures, death can include altered states of being, like sleep or illness.[5] In some traditions, death marks the transition into a different kind of existence, or involves a cyclic pattern of death and rebirth.[5] These cultural differences affect people's lifestyles, behaviors, and approach to death and dying.[5]

For example, in some cultures of the South Pacific, life is believed to leave a person's body when they are sick or asleep, making for multiple "deaths" in the span of one lifetime.[5] In Christian belief, death occurs only once, but the person leaves their bodily form to continue to in spirit, either to heaven or hell.[5] In Hinduism, people are believed to die and be reborn with a new identity.[5] In Chinese Buddhism, it is said that dying patients will experience phases between the state of torment and the state of exultation, and that caretaker must help the dying patient remain in the state of exultation through Nianfo prayers. For some Native American groups and in some parts of Buddhism, the dead and living exist together, with the former having power and influence over the lives of the latter.[5]

Given these varying definitions of death, there is much controversy surrounding the process of dying and of caring for the dying. For example, in the United States and other Western societies, a pervasive "death-defying" culture leads to resistance against the process of dying.[5] Death and illness are often conceived as things to "fight against."[5] In contrast, because some Eastern societies view illness, dying, and death as a transition into another form of life, it is believed that death is not something to fight, but something to accept.[5] Many other belief systems exist, and taken together, they construct a multi-faceted and complex view of what dying is and how it should be approached. Furthermore, cultural beliefs surrounding the process of dying may not align with the medical definition of death, and can further complicate medical decision-making and options for care when a person is dying.

Medicalization

Resuscitation

Resuscitation is the act of reviving of someone and is performed when someone is unconscious or dying.[6] Resuscitation is performed using a variety of techniques, of those the most common is Cardio Pulmonary Resuscitation (CPR). CPR is a procedure consisting of cycles of chest compressions and ventilation support with the goal of maintaining blood flow and oxygen to the vital organs of the body.[7] Defibrillation, or shock, is also provided following CPR in an attempt to jump start the heart. Emergency Medical Services (EMS) are often the first to administer CPR to patients outside of the hospital. Although EMS is not able to pronounce death, they are asked to determine the presence of clear signs of death and gauge whether CPR should be attempted or not. CPR is not indicated if the provider is at risk of harm or injury while attempting CPR, if clear signs of death are present (rigor mortis, dependent lividity, decapitation, transection, decomposition, etc.), or if the patient is exempt from resuscitation. Exemption is typically the case when the patient has an advanced directive, a Physician Orders for Life-Sustaining Treatment (POLST) form indicating that resuscitation is not desired, or a valid Do Not Attempt Resuscitation (DNAR) order.[8]

End-of-life care

End-of-life care is oriented towards a natural stage in the process of living, unlike other conditions. The National Hospice and Palliative Care Organization (NHPCO) states that hospice care or end-of-life care begins when curative treatments are no longer possible, and a person is diagnosed with a terminal illness with less than six months to live.[9] Hospice care involves palliative care aimed at providing at comfort for patients and support for loved ones. This process integrates medical care, pain management, as well as social and emotional support provided by social workers and other members of the healthcare team including family physicians, nurses, counselors, trained volunteers, and home health aides.[10] Hospice care is associated with enhanced symptom relief, facilitates achievement of end-of-life wishes, and results in higher quality of end-of-life care compared with standard care involving extensive hospitalization.[11]

See also
Wikimedia Commons has media related to Dying.

References
  1. Kennedy, Catriona; Brooks-Young, Patricia; Brunton Gray, Carol; Larkin, Phil; Connolly, Michael; Wilde-Larsson, Bodil; Larsson, Maria; Smith, Tracy; Chater, Susie (September 2014). "Diagnosing dying: an integrative literature review". BMJ Supportive & Palliative Care. 4 (3): 263–270. doi:10.1136/bmjspcare-2013-000621. ISSN 2045-435X. PMC 4145438. PMID 24780536.
  2. "Physical Changes as You Near the End of Life". www.cancer.org. Retrieved 2020-04-30.
  3. "End-of-Life Care: Questions and Answers". NCI Factsheet. 30 October 2002.
  4. Linda LE, Ferris FD, von Gunten C. "The Last Hours of Living: Practical Advice for Clinicians". Medscape. Archived from the original on 28 January 2017. Retrieved 17 November 2017.
  5. Gire, James (2014-12-01). "How Death Imitates Life: Cultural Influences on Conceptions of Death and Dying". Online Readings in Psychology and Culture. 6 (2). doi:10.9707/2307-0919.1120. ISSN 2307-0919.
  6. "resuscitation", The Free Dictionary, retrieved 2022-09-19
  7. "Cardiopulmonary resuscitation (CPR): First aid". Mayo Clinic. Retrieved 2022-09-19.
  8. Libby, Christopher; Skinner, Robert B.; Rawal, Amit R. (2022), "EMS Termination Of Resuscitation And Pronouncement of Death", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 31082157, retrieved 2022-09-12
  9. Huffman, Jaime L.; Harmer, Bonnie (2022), "End of Life Care", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 31334996, retrieved 2022-09-12
  10. Tatum, Paul E. (November 2020). "End-of-Life Care: Hospice Care". FP essentials. 498: 26–31. ISSN 2159-3000. PMID 33166104.
  11. Tatum, Paul E. (November 2020). "End-of-Life Care: Hospice Care". FP essentials. 498: 26–31. ISSN 2159-3000. PMID 33166104.
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