Life`s Last Few Moments

Our mission
The CSSS du Suroît is responsible
for maintaining and improving the
health and well-being of the population
within its territory, and for making
available a range of health care and
social services, including prevention,
assessment, diagnosis, treatment,
rehabilitation, support, and long-term
care. In addition, these services should
be integrated and of high quality.
Life’s Last
Few Moments...
Better guide you
150, rue Saint-Thomas
Salaberry-de-Valleyfield (Québec) J6T 6C1
Téléphone : 450 371-9920
Sans frais : 1 800 694-9920
www.santemonteregie.qc.ca/suroit
GRM75217-E108-0712
In collaboration with our localnetwork partners, the CSSS du Suroît
undertakes to ensure that services
are delivered within its territory in an
organized, coordinated manner that
provides ready access to quality care
with continuity of delivery. The CSSS
du Suroît also undertakes to promote
research and education in order to
better meet the needs of the population.
Table of Contents
This moment of life... ........................................ 4
What about hope? ............................................. 5
The importance of the last moments ................. 6
Accompanying a person at
the end of life. Yes, but... ................................... 8
The end of life... ................................................ 10
One to two weeks before death... ....................... 11
A few days to a few hours before death... .......... 13
Frequently asked questions ............................... 15
Bibliography ...................................................... 22
Internet resources to consult ............................. 22
This brochure has been prepared for relatives
and friends accompanying a person near the end
of their life. It offers information and support during
periods which can be difficult.
It encourages reflection about hope and life’s last
few moments and talks about some of the possible
physical and psychological signs of approaching
death. Recognizing that accompanying someone
at the end of life can be overwhelming, we have
suggested ways that you can care for your loved
one… Please note that, in this document, the
masculine gender is used to refer to both sexes,
without any intent to discriminate.
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Prepared by the Palliative Care Nurse Consultants:
Chantal Courtemanche, CSSS Champlain
Karine Rodier, CSSS Richelieu Yamaska
Chantal Rochefort, CSSS du Suroît
Carole Roy, CSSS Vaudreuil-Soulanges
Claudette Tremblay, Administrative Officer, CICM-RCM
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This moment of life...
What about hope?
“Accompanying someone does not mean going
ahead and showing him the way, imposing an
itinerary, or even knowing which direction he will
take; it is walking by his side, leaving him free to
choose his path and the pace of his steps.”
Present at all stages of life, hope allows us to
accept and adapt to a situation. For persons at the
end of life, hope represents a positive future, an
inner strength that enriches life and allows one to
go beyond the pain and suffering and which helps
each dying person to live their life until their death
(Herth & Cutcliffe, 2002 - translation).
— (Patrick Verspieren - translation)
Death is not an unfortunate accident, nor is it a
medical failure or social affliction. Death is the last
stage of life, the ultimate destination of man. During
this stage, everyone hopes to be accompanied by
persons who can help and will therefore allow the
end of life to occur with serenity.
It is often the relatives and close friends who, with
the assistance and support of the health care team,
can best offer this accompaniment. Their presence
brings concrete meaning and value to the sense
of life of this unique being, in spite of a great
vulnerability. A deep respect for the person’s beliefs,
confidences, silences and withdrawals demonstrates the value we assign to him as a human being.
In spite of the announcement of the end of life,
hope continues, but in a new way. Different for each
individual, some may hope to feel better, no longer
suffer, die peacefully, live until the next season, or
have the chance for a reconciliation. The person
may also hope that his loved ones will recover from
his death.
At times, for the family and friends, hope may
appear unrealistic, but it is this glow that keeps them
alive during days, weeks or months. Its expression
must therefore be allowed.
“Recognizing that hope is not the same thing
as a promise, means that we have nothing to fear
in offering encouragement.”
— (Coulombe, 2008 - translation)
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5
The importance
of the last moments
“The last moments of life, composed of a
succession of losses and relinquishments,
can also be extremely enriching for the person
who is dying as well as his family and friends.
It is the time for some final words, the last views
on self and life as well as the moment for some
final shared thoughts. But it cannot take place in
a context of the “unspoken”, avoiding, running
away or a conspiracy of silence.”
— (De Hennezel, 1996 - translation)
The importance
of the last moments (cont.)
A difficult but inevitable passage, the approach of
death encourages thoughts concerning the meaning
of the person’s life. Listening and offering a loving
presence creates an atmosphere of calm reflection.
It allows the story of a life to be told and handed
down, good memories may be relived or shared.
Dreams, regrets, sadness and fears may also be
expressed. “The time that remains to live can take
on its full significance through this time of putting
things in order.” (De Hennezel, 1996 - translation). Therefore it is important to listen, not interrupt
and to try to leave space for confidences.
These are moments during which we say farewell
and offer forgiveness while recognizing the emotional legacy left behind. This will not only help the
person who is at the end of life, but also family and
friends in dealing with their grief.
Accompanying a person
at the end of life. Yes, but...
The end of life of a person we love can result in
many changes and emotions that can disturb the
balance between satisfying the needs of the dying
person and the needs of the caregiver. Your wellbeing is important. Here are a few suggestions:
• Take care of yourself;
• Use some of the time you have for you,
without feeling guilty. It is not selfish.
It is an strategy that will enable you to take
better care of the person who needs you;
• Recognize the limits of your endurance
and strength by asking for help, even if the
person who is dying is reluctant;
• Show and express your joy, your anger,
your sadness and your frustration;
• Feel proud of what you are doing for
this person;
• Pursue activities you enjoy in order to
replenish your strength.
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The end of life...
Each person has his own way of living this
final stage, bringing a unique dimension to this
experience. As the person becomes truly aware that
they are going to die, a process of separation begins
and the following psychological signs may appear.
The person may:
• Look back over his life;
• Lose interest in activities;
• Turn inwards, beginning to withdraw
from the world around him;
• Sometimes, he may have a desire to see
all his friends;
• To say farewell to relatives and friends,
and to places he loved;
• Give gifts, withdraw from his worldly property;
• Express sadness;
• Speak openly about death with one or
more people.
One to two weeks
before death...
Certain physical and behavioural changes may be
observed because the body’s vital functions are
slowing down. There may also be changes in the
person’s circulation and metabolism.
• A change in appetite;
• Moving around is more and more difficult;
• Difficulty breathing;
• Muscle weakness;
• Oedema (swelling) in the extremities;
• Difficulty sleeping (reversing day and night);
• Disorientation (confusion);
• Pulling/picking at clothing and sheets.
However, these signs do not appear in a particular
order and may not all be present.
On the physical level, the body finally slowly begins
to stop functioning. It no longer has the same needs
and a general weakness gradually takes over.
For some people, the signs which precede death
appear a few weeks before, while for others, it
may only be a few days.
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11
One to two weeks
before death... (cont.)
A few days to a few hours
before death...
The care suggested focuses on the patient’s
comfort and respects the wishes of the person at
the end of life.
• Be present;
• Offer foods that the person prefers;
• Offer ice cubes or frozen juice (popsicles);
• Do not force the person to eat or drink;
• Offer mouth (oral) care;
• Place the person in a comfortable position
and offer help to move around;
• Gently massage and warm the person’s
extremities;
• Say who you are instead of having
the person guess;
• Speak calmly, in a natural manner;
• Do not try to limit movements;
• Read to the person out loud;
• Play some music that he likes;
• Place familiar objects and photos in the room;
create a pleasant atmosphere;
• Air out the room;
• Continue to respect the person’s preferences
and wishes, such as sleeping with his socks
on, putting on make-up, keeping his pyjamas
on...
Some people regain energy. Following which, the
signs observed for the past one or two weeks may
intensify and other symptoms appear:
• The person may no longer be able to walk,
sit, turn, on their own;
• Their body temperature may change
(fever, low temperature);
• Extremities may become mottled and cold;
• Sweating may increase;
• Oedema (swelling) sometimes decreases
or disappears;
• Eyes may become glassy, tearful,
and remain half-open;
• Difficulty swallowing;
• Minimal absorption of liquids
• Dry mouth;
• A decrease or lack of urination;
• Loss of control of the bladder and/or intestines;
• Breathing can become irregular, superficial,
with pauses;
• Terminal rales: noisy breathing caused by
abundant secretions;
• Agitation or inertia;
• Loss of consciousness.
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13
A few days to a few hours
before death... (cont.)
In addition to the care already suggested, the
following suggestions may also be useful:
• Stay close to the bed;
• Hold the person’s hand;
• Speak softly, even if the person is
unconscious;
• Apply damp compresses to semi-open eyelids;
• Apply artificial tear drops;
• Direct a fan set to low on the person’s cheek;
• Offer mouth care;
• Explain what you are going to do before
you begin.
Frequently asked questions
How can I help my loved one go through
this period?
Very simply by listening to what he has to say
without interrupting. Do not try to fill moments of
silence, even if they appear heavy. Allow him to talk
about his life, his regrets, his losses, his sadness
and his dreams. Listening will help the person who
wants to confide.
What should I do if my relative cries?
Allow him to express his emotions whether it is
pain, anger, regret, remorse, feelings of guilt, anxiety
or others. Do this without trying to change his ideas
or wanting to make him feel better. Allow yourself to
cry as well. Tears express emotions and sometimes
liberate tensions.
Why does my relative no longer eat or drink?
A loss of appetite and thirst is caused by the
metabolism slowing down. The body no longer
has the same needs and indicates that it no long
desires or can tolerate food and liquids. It is therefore important to respect the person’s appetite.
Even if your relative no longer eats, you need to keep
his mouth moist and remember that mouth care is
an important comfort measure.
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15
Frequently asked questions (cont.)
Frequently asked questions (cont.)
Is installing an intravenous drip (solution)
a good idea?
The intravenous solution is composed of salt or
sweetened water and does not contain any medication or vitamins. The solution increases the fluids
in the body, particularly those of the respiratory
system, and can therefore contribute to the duration
of discomfort.
How can we evaluate the level of discomfort
when the person can no longer express himself?
Facial expressions, groans, changes in behaviour,
are signs of discomfort. The body may also become
rigid. These manifestations are possible signs of
discomfort. If you observe these signs, do not hesitate to discuss these with the staff.
Should we give him oxygen?
Before beginning or continuing the use of oxygen,
you need to ask yourself whether it makes the person more calm and comfortable. Sometimes, using
oxygen can help reduce difficulty breathing and/or
anxiety. On the other hand, you need to consider the
discomfort related to the tubes and noise of the air
circulating.
Why is the breathing noisy at the end of life?
A person at the end of life may have difficulty in
swallowing their saliva and getting rid of secretions.
Rales are therefore the sound of secretions and the
air passing across the relaxed vocal cords. This
noise usually bothers the people around the patient,
rather than the patient himself. We hope to ensure
the greatest possible comfort for the patient and the
members of the health care team will do everything
they can to ensure the person’s comfort.
How can we solve this problem?
In the case of abundant secretions in the back of the
throat, position the patient comfortably by raising
the head of the bed. Turning the person on their side
can help. We can also give medication to reduce
the production of new secretions. Using suctioning
equipment to remove secretions is usually ineffective and can be disturbing for the person.
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Is my loved one going to die more quickly
with the administration of morphine?
Some people believe that morphine causes death
since, in the past, it was mainly given during the end
of life. Nevertheless, morphine is a safe medication,
and when used properly, it eases pain and makes
the patient more comfortable. It is not only effective
in relieving pain but also helps with other symptoms
of discomfort such as difficulty breathing. In fact,
some people use it regularly for several years while
remaining active.
Should we delay using morphine?
No. Morphine can be used as soon there is pain
and it relieves the person’s discomfort. It is often
advantageous to treat these symptoms from
the very beginning because if we wait too long,
the pain and discomfort can become more difficult
to manage.
Is there a quantity of morphine that
we must not exceed?
No. The appropriate quantity is that which controls
the pain and discomfort. The quantity is adjusted gradually, which is why it is important to use
smaller doses between the regular doses.
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Frequently asked questions (cont.)
Frequently asked questions (cont.)
At the end of life, is it still necessary to continue
giving medication, checking blood pressure,
temperature, blood sugars, blood samples, etc.?
At the end of life, the benefits versus the disadvantages of treatments are considered. The objective
of all care provided is the person’s comfort. For
example, taking vital signs and blood sugar measurements may be less useful near the end of life,
particularly if these interventions disturb the person.
Should we stay with our loved one?
This is a personal question that depends on you and
your loved one’s actual state, his needs and expectations. What matters is that you have the desire, the
possibility, the capacity and the availability to stay,
while looking after yourself.
If the person has a great deal of difficulty swallowing, it is necessary to stop giving medication by
mouth and to give those that need to be continued
in another way.
Why does my loved one have a fever?
At the end of life, the temperature control centre no
longer functions properly. The person’s temperature
will vary. The use of medication against fever will
have little effect, but could help ease the discomfort
caused by the increased temperature.
Why is my loved one agitated?
There are several reasons: it could be due to pain,
discomfort, the progression of the disease or
the manifestation of fear as death approaches.
You can help him relax with music, reading, massages, or by sharing memories. A calm attitude and
warm presence are reassuring. Medication can also
facilitate relaxation.
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Does my loved one hear me?
At the moment, no research has confirmed the fact
that a person continues to hear until the end. On
the other hand, previous experience has shown
that certain persons become calmer with the sound
of a familiar voice. It may be beneficial to continue
to speak to him gently.
What should I do when my loved
one is unconscious?
Simple gestures are often reassuring and comforting. These should be chosen according to the person’s preferences and what they were accustomed
to. For example, touch or talk to him gently, play his
favourite music.
How much time is left?
No one can answer this. In spite of certain attempts
at predicting the moment of death, it is always a
secret and the way it will occur continues to be
mysterious in many regards.
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Frequently asked questions (cont.)
Frequently asked questions (cont.)
Why talk about death to young children?
How can we accompany our adolescent
during this difficult time?
An adolescent understands the principle of death,
but experiences it in a different manner. He is pulled
between the desire to spend time with his family and
spending time with his friends. Generally we expect
adolescents to act like adults and to support the
other members of the family. But it is important to
avoid giving them too many housekeeping or family
responsibilities. Do not try to make them assume the
role of an adult. Social expectations often result in a
lack of support for the adolescent. They need caring
adults who confirm that it is okay to feel a range
of emotions and contradictory feelings (sadness,
anger, fear, worry, pleasure with their friends, etc.).
“It is not talking about death that traumatizes
children, but how we talk to them about it.”
— Elizabeth Kubber-Ross - translation
Children have a tendency to react better when
they are informed and there are no surprises. So
the explanations provided to children are extremely
important. Kept in the dark, their fertile imaginations
can alter and amplify reality. It is preferable to make
them part of the family’s experience.
How can we accompany young children
in this difficult time?
Adults prepared to speak openly about death help
children to understand that it is natural to be sad
when losing a loved one. Children need warmth
and understanding. Explaining that it is all right to
feel sad, cry or feel angry allows them to validate
their experience. This caring attitude facilitates
and encourages children to express their feelings.
Nevertheless, it is important to take their age into
account. Simple answers help them to understand
and accept the situation.
How can we experience or express
our spirituality?
By expressing the significance of a belief, or lack
of belief, values and life experiences, death and
after-death. For some people, these inner reflections
and significant rituals are comforting and provide
support by making this period a little more serene.
Depending on the availability in your centre, various
spiritual support persons can accompany you.
Contacts
Each situation is unique; do not hesitate to
speak to the staff for more information.
CLSC de Salaberry-de-Valleyfield
450-371-0143, ext. 3146
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Bibliography
• Canadian Hospice Palliative Care Association,
Charte de droit des aidants naturels.
www.acsp.net.
• COULOMBE, Manon. 2008 - L’espoir: une flamme
à entretenir même dans un contexte de fin de vie,
première ligne. 12 (1), 9-13.
• CSSS de Laval. 2007 - Guide de pratiques
cliniques en soins palliatifs à l’intention
des intervenants.
• De Hennezel. 1996 - Sens et valeur du temps qui
précède la mort. La fin de la vie, qui en décide?
Forum Diderot, Paris: Presses universitaires de
France, 16-28.
• Montreal Jewish General Hospital, Palliative Care
Advisory Team, Les étapes du processus de
la mort.
• HAMILTON, Jean. 1999 - Quand un parent est
malade: comment expliquer la maladie grave
aux enfants. Canadian Cancer Society.
• CH de Granby, 2002 - Quand la maladie grave
survient, s’informer, comprendre, agir.
Internet resources to consult
• Canadian Hospice Palliative Care Association
www.acsp.net
• Association quebecoise de soins palliatifs
www.aqsp.org
• Canadian Virtual Hospice
www.carrefourpalliatif.ca
• La Maison Victor-Gadbois
www.palli-science.com
• www.traverserledeuil.com
• www.maisonmonbourquette.com
• _______________________________________
• _______________________________________
• _______________________________________
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I am standing on the sea shore,
A ship sails in the morning breeze and
starts for the ocean.
She is an object of beauty and I stand watching her
Till at last she fades on the horizon and
someone at my side says: «She is gone.»
Gone! Where?
Gone from my sight that is all.
She is just as large in the masts, hull and spars
as she was when I saw her
And just as able to bear her load of living
freight to its destination.
The diminished size and total loss of sight
is in me, not in her.
And just at the moment when someone
at my side says,
«She is gone»,
There are others who are watching
her coming, and other voices take up
a glad shout: «There she comes»
And that is dying!
— William Blake