What Happens to the Body in the Final Hours of Dying?

TL;DR

Dying is a natural, built-in process, not a foreign invader attacking an otherwise-fine body. As death nears, organ systems shut down one by one: fatigue and time in bed increase, hunger and thirst signals stop, and forcing food or fluid can cause pain. Delirium is common and should not be taken literally.

Transcript

On this podcast, we talk a lot about causes of death, right? People who listen to me are very familiar with the four horsemen and we know about cardiovascular disease and we know about cancer and we know about neurodeenerative disease and we can talk forever about these things but we don't really talk about the very very end perhaps with the except... Read More

Key Insights

• Death is a natural bodily function, not an external invader. Bodies are wired both to preserve life and to eventually die, so there is nothing wrong with a person for dying. The body already knows how to carry out this process on its own.
• Roughly 80-plus percent of people die of chronic illness, meeting the condition that eventuates their death well in advance. About 50% of myocardial infarctions are fatal, while the other 50% set up heart failure or other decline.
• The body shuts down organ system by organ system along a final common pathway, regardless of whether the underlying cause is cancer, heart disease, or neurodegenerative disease. This does not follow a neat or tidy sequence and can vary in timing.
• Loss of interest in food and fluid is a major sign of approaching death. A GI tract shutting down stops sending hunger signals, so forcing food or fluid into a dying body can cause pain, pooling in the lungs, or swelling.
• Prognostic clues include how much time a person spends in bed. Sleeping on the couch or bed 50% of the day, with progressively increasing fatigue in the context of chronic illness, usually signals the approach toward the end.
• Delirium at end of life is very common and often hypoactive, meaning quiet, subtle, and easily missed rather than the obvious agitated hyperactive form. It follows a similar pathway to hospital delirium seen in otherwise recovering patients.
• A delirious person is not themselves, so their words cannot be taken literally. Harsh or vulgar final comments have traumatized loved ones who did not understand delirium, when the person did not truly mean what they said.
• Final moments are subjective and complex, so interpretations should be held lightly. Families project meaning onto ambiguous statements and may never get clarity, which is why this work is often done in teams with differing perspectives.

Questions & Answers

Q: Why is death described as natural rather than a foreign invader?

One speaker stresses that living things die and bodies are supposed to die, so death should not be seen as a foreign invader that comes out of the woods and grabs an otherwise-fine person. Humans are wired to promote life and flee threats, but dying is included on the list of natural things a body does. There is nothing wrong with a person for dying; the body already knows how to do this.

Q: What happens to the body in the final hours of dying?

The body follows a final common pathway of shutting down organ system by organ system, regardless of whether the cause is cancer, heart disease, or neurodegenerative disease. This does not follow a neat, tidy sequence. Signs include increasing fatigue, spending more of the day in bed, loss of interest in food and fluid as the GI tract shuts down, and changes in mental status such as delirium. Sometimes it happens spontaneously in a moment; more often it is gradual.

Q: Why can food and fluid hurt someone who is dying?

When a body is trying to die, the GI tract stops sending hunger signals because it can no longer process food. If food is forced in, it sits in place and can cause pain. The same applies to fluids: forcing fluid into a body that is trying to die can pull and cause trouble, ending up in the lungs or causing swelling. The decision to push or withhold food and fluid should come from an ongoing dialogue with the patient, trying a little and pulling back if it causes harm.

Q: How can you tell how much time a dying person has left?

The speakers say that when trying to prognosticate, they look at whether the person is getting in and out of bed much. If someone is asleep on the couch or in bed about 50% of the day, and that pattern is progressive with more and more fatigue and tiredness, that usually indicates the approach toward the end in the context of chronic illness. Loss of interest in food and fluid is another major indicator that the body is beginning to shut down.

Q: What is delirium at the end of life and why is it often missed?

Delirium is a state of confusion and disorientation, such as a person thinking it is 1912 and they are in a forest when they are actually in a hospital bed. It comes in a hyperactive form, which is easy to spot because the person is agitated, and a hypoactive form, which is quiet, subtle, and often missed. At end of life, hypoactive delirium is more likely, and since the person is already sleeping a lot and may be silent, families and caregivers can easily overlook it.

Q: Why shouldn't you take a dying person's words literally?

Because a delirious person is not themselves, whatever they say cannot be taken literally. The speaker describes people traumatized for years because a loved one's final words were harsh or vulgar, even though the person, like a husband who never said a mean word in 50 years of marriage, did not truly mean them. Understanding delirium beforehand helps families avoid immense suffering from misreading these final statements, which do not reflect the person's real feelings.

Q: How should families interpret meaningful-seeming final statements?

Interpretations should be held lightly because final moments are subjective, personal, and complex. One speaker recounts a dying mother who opened one eye and told her daughter she loved her jacket; the daughter burst into tears because the mother had always been critical of her clothes. Families project meaning, expecting a person to finally say the thing they never said, and it may not feel good. Because clarity of what was truly meant may never come, meaning should be held carefully and lightly.

Q: Should delirium at the end of life always be medicated?

The medical speaker says he was taught that delirium is inherently a form of suffering and that being confused or disoriented is itself uncomfortable, so it was routinely medicated with antipsychotics like haloperidol or thorazine to shut it down. Over the arc of his career, as he diluted the purely medical view with other ways of thinking, he became less quick to shut it down, suspecting there may be something vital in it. The team also addresses environmental factors like lighting, noise, and interruptions to minimize and care for delirium.

Summary & Key Takeaways

• The hosts reframe death as a natural, built-in bodily process rather than a foreign invader that grabs an otherwise-healthy person. About 80-plus percent of people die of chronic illness, meeting their eventual cause of death well before the end, and the body already knows how to shut down.

• As death nears, the body shuts down organ system by organ system. Signs include increasing fatigue, more time in bed, and loss of appetite. Because the GI tract stops processing food, forcing food or fluid can cause pain, lung problems, or swelling and should generally be respected.

• Delirium is common at the end of life, frequently in a quiet hypoactive form that families miss. A delirious person is not themselves, so their words cannot be taken literally. Final moments are subjective, meaning should be held lightly, and closure is not guaranteed.