HOW WILL I KNOW WHEN SOMEONE IS GETTING CLOSE TO DEATH?
Just as doctors cannot pinpoint the precise day when a baby will be born, they cannot predict the exact day or hour when you or your loved one will die. You might need reassurance that it is simply not always possible to know when death is near. Some illnesses, for example, make prediction difficult. However, many illnesses have a few hours or a few days when it is evident that death is close. The person dying usually is no longer eating or drinking, except perhaps a few sips of liquid now and again. The person may be sleepy or confused most of the time and is usually in bed. If the person is dying from cancer or a progressive failure of an organ, he or she will usually have lost a substantial amount of weight. If life support is being stopped, the physician should be able to tell you what to watch for to estimate about how long it will be before death.

Many people near death have cool hands and feet and a persistent purplish discoloration in the parts of the body resting on the bed. Many also will have uneven breathing, sometimes stopping for many seconds and other times breathing quickly. This kind of breathing and discoloration can persist for a few days or may be seen within hours of death. Some people have some jerking motions or even seizures near death. As disturbing as it may be for you to watch this happen, your loved one will probably not be aware of it. Involuntary motions usually do not need treatment and do not cause problems for the patient. Seizures can often be treated with rectal medications to be sure that they are not distressing to the patient or family.

If the person has been taking opioids, these will be continued because stopping such medications abruptly can lead to uncomfortable symptoms. If the person is no longer able to swallow, opioids can be given by suppository, injection, skin patch, subcutaneous infusion, or IV. Probably half of patients develop very noisy breathing near death, sometimes called a "death rattle." This is the result of physical changes and does not cause the person to feel as though she is struggling to breathe. In fact, most dying patients are not aware of this noisy breathing. However, if family or caregivers find it unnerving, the doctor or nurse can help reduce the noisy sound, either by giving medication or repositioning the dying person in bed.

WHAT SHOULD FAMILY AND FRIENDS DO WHEN DEATH IS CLOSE?
You and your loved ones will need to answer this question for yourselves. Many patients are frightened of being alone or just want a loved one nearby to help ease the passage. A few simply want to be alone. Some family and friends find comfort in reading, reminiscing, saying prayers, or singing. Some just want to be there, sharing the precious time. What any one patient or family member wants may change over time or as other visitors come and goes. Unless it is absolutely unavoidable, family and friends should not spend much time on medical treatment decisions at this point. It is best to have had any such discussions earlier in the course of a disease or at least limit the time spent on them now.

Remember, too, that this can be a good time to call on spiritual support, including the hospital chaplain. Music is very helpful for some patients and families. Some prefer gospels or modern music, but most families and patients seem to benefit from some kind of music. This is a very good time to say farewells and to ask forgiveness, if these things have not already been done. Often it seems that dying people can still hear, even when they no longer seem to be awake. So saying things to a person who seems to be asleep is not unreasonable, and it can be important for those left behind. Some patients and families have a sequence of people who, one-by-one, come through to say goodbye. Others have more unplanned visits. Some have religious rituals to follow; others make up their own style as they go.

IS IT IMPORTANT TO BE THERE AT THE MOMENT OF DEATH?

Many people feel that they should be present at the very moment that a dying loved one draws his last breath. However, whether this is important depends on the preferences of family and loved ones. Trying to be there can be quite draining, since the exact time of death is impossible to predict. People sometimes keep up a death watch for days and finally have to get some coffee or some sleep. Often, this is when the person finally dies. Perhaps he was "waiting" or just needed to be "on his own" a little before letting go. Perhaps the timing was just chance. Important things are rarely said just at the time of death, so it is not likely that survivors will miss hearing something important if they are not there.

Families and patients should give instructions to caregivers in hospitals and nursing homes about who should be called, if possible, when death is close, and who should be called when the person has died.

HOW DO YOU KNOW THAT THE PERSON HAS DIED?

Usually the patient takes a last breath and sighs or shudders and is dead. Many people have another effort or two at breathing but really are not moving air. A few have movement of limbs or trunk for up to ten minutes. Still, how will you know that the person has died? If there is no air moving, the person is dead. There is no urgency to making the determination, so you can just sit and watch for a few minutes. Family and friends may want to spend a few minutes crying, praying, or meditating. Many of us are too unfamiliar with death to be comfortable deciding that it has happened. In hospice or regular home care, a nurse can usually come to the home within an hour or so.

If the death is at home, the family really needs to plan ahead so that no one calls 911 or involves the emergency rescue system. Emergency technicians will often find it difficult to size up the situation quickly, so just when the family needs comfort and time, they instead have to explain themselves to an outsider. Many people really need to hear someone else say that the person is dead. "Pronouncing" a person dead is important. Even if it is perfectly obvious, family should still be able to ask "Is he dead?" and hear from someone else that he is. Again, talk with the doctor or hospice nurse about how this will be done.

DECISIONS AND ACTIVITIES JUST AFTER DEATH

After a death, there are more decisions and activities than most families really expect. Take some time to remember the person who just died, to be in touch with loved ones, to pray, or to do whatever is significant and helpful to you.

Within a few hours, usually, someone will move the body to a location that handles the dead bodies, such as a hospital morgue, a funeral home, or a government medical examiner's morgue. If a person expects to die at home, make plans ahead of time with a funeral director.