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to go back to the landmarks list:
Breathing Changes
  *  The final stage involves a change in the patient's breathing, usually very
             easily detected

   *  Breathing may grow more labored and much faster...or more faint and
             much slower (some caregivers have reported hearing only 10 breaths
             per minute)

   *  Breath sounds may grow louder (sometimes audible even from another
             room) or softer and much harder to hear

   *  A mucousy sound may develop, causing a sort of snore-breathing

   *  What some people refer to as the "death rattle"---loud breathing that
             resonates from deep within the chest---may begin hours before death

   *  The most important change is change itself---whenever there is a new
             breathing pattern, the caregiver should be vigilant, and if the patient
             has shown most of the other signs and has consumed very little or
             no water in recent days, death may be imminent within hours or
             within the day

   *  Most patients are in a form of coma when they reach this stage, and
             it is believed that they are protected from pain; however, if care-
             givers believe that labored breathing may be an expression of
             discomfort, discuss with hospice or the physician whether morphine
             or another pain management measure would be appropriate
  
   *  Some believe that end-stage patients may be able to choose the time of
             their death---holding out for a special anniversary, waiting for a
             loved one to arrive, or even waiting for caregivers to be out of the
             room in order to "spare them"---but because the patient is probably
             in an end-stage coma at this time, it is unlikely that the timing of the
             death is voluntary

   *  For most patients, the last breath is a quiet, gentle sigh, making the
             transition surprisingly less difficult to witness than caregivers may
             have anticipated 
What the Patient May Be Feeling

   *  Unlikely to be awake or alert

   *  Most likely to be in an end-stage coma, so that there is no conscious
             thought

   *  Unlikely to be experiencing pain, although with labored breathing the
             caregiver may want to discuss this issue with the hospice nurse
             or the physician

   *  Probably feels relaxed comfort and total unawareness of the surroundings

   *  May be aware, on a subconscious level, of the loving presence of the
             primary caregiver and others close to him or her, through a fading
             sense of hearing or touch
What the Caregiver May Be Feeling

   *  Uncertain about whether to call the hospice nurse and when to do so,
             "since they won't really be able to do anything"
  
   *  Afraid that the final hours may be difficult or painful for the patient

   *  Worried that the patient will linger at this stage for an unnecessarily
             long period of time

   *  Disbelieving that "this is it"

   *  Experiencing swirling thoughts about logistical concerns (eg, How will
             the body be handled once the death has occurred? Will long-distance
             loved ones arrive on time? How do I handle specifics about the final
             services?)

   *  May wish that certain arrangements had been handled in advance, as a
             long list of things to do begins to form itself mentally

   *  Unaware of fatigue or hunger while focusing on the patient in his or
             her final hours

   *  Desperate to express all loving thoughts and promises in hopes that the
             the patient is able to hear them

   *  Emotionally strong, focused, and resolved to make the final hours
             count---a rush of maternal/paternal protective instincts or of
             adrenaline perhaps (as described by those who have accomplished
             amazing selfless rescues)
    
   *  Afraid to doze off or "blink and miss it"

   *  May entertain guilty thoughts as to missed opportunities in the final
             weeks, wishing to go back in time and recapture special moments
             or say things that may now go unheard

   *  May wish that he or she had recognized the nearness of death sooner
             in order to accomplish more somehow

   *  If children are involved, concerned about how they will handle news of
             the imminent death or the loss itself
  
   *  Delaying dealing with his or her own feelings because "there's so much
             that needs to be done" or because others seem to require more
             emotional support at the moment\

   *  Numb, in shock, or "on auto-pilot"
Tips

Phone hospice or the physician when a serious change of breathing has begun. Hospice will generally dispatch a nurse, but it may take an hour or more for him or her to arrive. The hospice nurse will be able to pre-certify the death when it occurs and will assist you in contacting the funeral home or crematory. The funeral home is dispatched accordingly, and the representatives tend to be quick, respectful, and discreet.

If a medical professional is not present at the time of death, note the time in case he or she would like to record it on the necessary forms.

Experts say that the sense of hearing is the last to go. This may be true as well for the sense of touch. Continue to express your love by talking comfortingly to the patient and holding his or her hand or performing gentle massage.

Some caregivers have found comfort themselves in climbing into the bed alongside the patient during this final stage, where they feel they can hold him or her more easily and comfortably than they can from the side of the bed.

Turn off all background sounds like those from a TV or radio while speaking to the patient, as they may minimize what the patient may be able to hear. To maximize comprehension, should the patient still be able to hear, speak in short sentences and thoughts separated by pauses:

             Not:      "Honey, you've always been the very best son two
                         parents could ever ask for. We've always been so
                         proud of you. We know it's so hard for you to keep
                         fighting, but you have been so brave through all of
                         this. We will never stop loving you."

             Better:   "Mike...the best son...proud of you...hard to fight...
                        
so brave...love you."

Family members and close friends who would like to express farewell in person should be quickly alerted to this final change.

Some family members who are unable to be there due to distance have found comfort by having the local caregiver hold the phone to the patient's ear and communicating their love in that way.

If young children have expressed a wish "not to be there at the end," this would be the appropriate time to allow them a final goodbye before leaving with a prearranged caregiver.

As hard as it may be to come to grips with, there may be family members who find it too difficult to be present at the time of death. This is not the time to debate how others "should" handle this surreal moment. Each person comes to the situation in his or her own way, and trying to understand others' motivations can be exhausting and counterproductive during an imporant time like this, when families should draw close, not pull apart. Some personal issues like these can best be addressed later, with or without the help of a grief counselor. Most important is to give to the experience whatever will best help you to move forward in your healing later.

Avoid leaving the room or falling asleep during this critical time, as some patients have been known to open their eyes once more before the last breath. If physically exhausted, however, stay close but give in to the sleep without guilt. If another caregiver is present, he or she can keep watch and wake you if needed. At this point, household obligations can wait, as the minutes are truly numbered.

Don't worry about the logistics of final arrangements and the travel arrange-ments of others until after the death has occurred. Most funerals are not held until 2-3 days after the death, and although there will be much to do, there will be a lot of time and probably extra hands to help get everything accomplished.

If the death occurs when you are not present, don't take it personally. With your loving ways, you were very much present by caring when it mattered most, and your loved one will be moving on with
no doubt about your feelings for him or her.