The Last Hours of Living: Practical Advice for Clinicians

Linda L. Emanuel, MD, PhD; Frank D. Ferris, MD; Charles F. von Gunten, MD, PhD; Joshua M. Hauser, MD; Jamie H. Von Roenn, MD


March 24, 2015

In This Article

When Death Occurs

No matter how well families and professional caregivers are prepared, they may find the time of death to be challenging. Families, including children, and caregivers may have specific questions for healthcare professionals.

Basic information about death may be appropriate (eg, the heart stops beating; breathing stops; pupils become fixed; body color becomes pale and waxen as blood settles; body temperature drops; muscles and sphincters relax, and urine and stool may be released; eyes may remain open; the jaw can fall open; and observers may hear the trickling of fluids internally) and can be provided in conversation or in the form of a handout used by many hospice and palliative care programs (Table 2).[61,62]

Table 2. Signs That Death Has Occurred

The heart stops beating
Breathing stops
Pupils become fixed and dilated
Body color becomes pale and waxen as blood settles
Body temperature drops
Muscles and sphincters relax (muscles stiffen 4-6 hours after death as rigor mortis sets in)
Urine and stool may be released
Eyes may remain open
The jaw can fall open
Observers may hear the trickling of fluids internally, even after death

No universally applicable rules govern what happens when a patient dies, regardless of setting. If the patient dies an expected death at home, there is no need to call for emergency assistance. If a hospice program is involved, have the family call the hospice. If a hospice program is not involved, determine in advance who should be notified. Unless death is unexpected or malice is suspected, involvement of the medical examiner's office is usually not required. State and local regulations vary. Healthcare professionals will need to familiarize themselves with the regulations in the areas in which they practice.

When an expected death occurs, the focus of care shifts from the patient to the family and those who provided care. Even though the loss has been anticipated for some time, no one will know what it feels like until it actually occurs, and indeed it may take hours to days to weeks or even months for each person to experience the full effect.

Many experts assert that the time spent with the body immediately after death will help people deal with acute grief.[63,64,65] Those present, including caregivers, may need the clinician's permission to spend the time to come to terms with the event and say their good-byes. There is no need to rush, even in the hospital or other care facility. One caveat is that some facilities may have policies about how long a patient's body can remain on the floor before needing to be transferred to the morgue or funeral home. It is helpful to know these policies at your institution and also when an exception can be made. Encourage those who need to touch, hold, and even kiss the person's body as they feel most comfortable (while maintaining universal body fluid precautions).

Because a visually peaceful and accessible environment may facilitate the acute grieving process, a healthcare professional, usually the nurse, should spend a few moments alone in the room positioning the patient's body, disconnecting any lines and machinery, removing catheters, and cleaning up any mess, to allow the family closer access to the patient's body.[66,67]


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