The Symptoms of Dying
You and I, one day we’ll die from
the same thing. We’ll call it different names: cancer, diabetes, heart failure,
stroke.
One organ will fail, then
another. Or maybe all at once. We’ll become more similar to each other than to
people who continue living with your original diagnosis or mine.
Dying has its own biology and
symptoms. It’s a diagnosis in itself. While the weeks and days leading up to
death can vary from person to person, the hours before death are similar across
the vast majority of human afflictions.
Some symptoms, like the death
rattle, air hunger and terminal agitation, appear agonizing, but aren’t usually
uncomfortable for the dying person. They are well-treated with medications.
With hospice availability increasing worldwide, it is rare to die in pain.
While few of us will experience
all the symptoms of dying, most of us will have at least one, if not more. This
is what to expect.
The Death
Rattle
“The graves are full of ruined
bones, of speechless death-rattles” (Pablo Neruda)
We suspected the patient wouldn’t
survive off the ventilator. A blood clot had crawled up one of the vessels in
the back of his brain, blocking blood flow to the area that controlled
alertness. He would die from not being awake enough to cough.
The beat of the death rattle
began when the breathing tube was removed and continued until life was done. It
was a gurgling, crackling sound, like blowing air through a straw at the bottom
of a cup of water. The average time between the onset of death rattles to death
itself is 16 hours. For him, it was six.
The death rattle is a symptom of
swallowing dysfunction. Normally, our tongue rises to the top of the mouth and
propels saliva, liquid or food backward. The epiglottis, a flap in the throat,
flops forward to protect the swallowed substance from entering the airway.
In the dying process, the
symphony of swallowing becomes a cacophony of weak and mistimed movements.
Sometimes the tongue propels saliva backward before the epiglottis has time to
cover the airway. Other times, the tongue fails to push at all and saliva
trickles down the airway to the lungs in a steady stream. The death rattle is
the lungs’ attempt to breathe through a layer of saliva.
Despite the sound’s alarming
roughness, it’s unlikely that the death rattle is painful. The presence of a
death rattle doesn’t correlate with signs of respiratory distress.
As often happens in medicine, we
treat based on intuition. To lessen the volume of the death rattle, we give
medications that decrease saliva production. Sometimes, we are successful in
silencing the rattle. More of the time, we placate our instinctive concern for
a noise that probably sounds worse than it feels. Without hurting our patients,
we treat the witnesses who will go on living.
Air Hunger
“You villain touch! What are you
doing? My breath is tight in its throat” (Walt Whitman)
The patient was a wiry woman in
her 80s who had smoked for seven decades. Cigarettes turned her lungs from a
spongelike texture to billowing plastic bags that collapsed on themselves when
she exhaled. It was like trying to scrunch all the air out of a shopping bag.
Air got trapped.
Air hunger — the uncomfortable
feeling of breathing difficulty — is one of the most common end-of-life
symptoms that doctors work to ease.
The treatment? Opiates, usually
morphine.
People sometimes ask why the
treatment for painful breathing is a medication that can depress breathing.
You’d guess that opiates would worsen air hunger.
The answer hinges on defining why air hunger is uncomfortable in the
first place.
Some researchers think the
discomfort of air hunger is from the mismatch between the breathing our brain
wants and our lungs’ ability to inflate and deflate. Opiates provide relief
because they tune our brain’s appetite for air to what our body can provide.
They take the “hunger” out of “air hunger.”
Others believe that the amount of
morphine needed to relieve air hunger may have little effect on our ability to
breathe. Since air hunger and pain activate similar parts of the brain, opiates
may simply work by muting the brain’s pain signals.
The patient traded her cigarettes
for a breathing mask when she came to the hospital. She quit smoking for the
umpteenth time and made plans to go home and live independently again. A few
days later, her thin frame tired. She died in hospice.
Terminal
Agitation
“Do not go gentle into that good
night” (Dylan Thomas)
My grandfather screamed two days
before he died. “Open that door and let me out! Right now! It’s a travesty!
Open that door!”
It was the scream of a lost child.
My grandfather’s eyebrows, which had been lost over the years from the outside
inward so that only a centimeter of long gray hairs near the middle remained,
tilted toward each other.
Until then, we were preparing for
missing and absence. Not for an agitated delirium. Not for rage.
A famous poet once wrote that
“dying is an art, like everything else.” For hospice doctors, the artists of
death, terminal agitation is the subject’s revolt against the shaper. It’s
uncommon, but it can be difficult to watch when it happens.
Instead of peacefully floating
off, the dying person may cry out and try to get out of bed. Their muscles
might twitch or spasm. The body can appear tormented.
There are physical causes for
terminal agitation like urine retention, shortness of breath, pain and
metabolic abnormalities. There are medications that quell it. Yet it’s hard to
discount the role of the psyche and the spiritual.
People who witness terminal
agitation often believe it is the dying person’s existential response to
death’s approach. Intense agitation may be the most visceral way that the human
body can react to the shattering of inertia. We squirm and cry out coming into
the world, and sometimes we do the same leaving it.
Sara Manning Peskin is a neurology resident at the University of Pennsylvania.
~ This is the first of two columns about what happens at the end of life.
- On death and the fear of dying, see also my post: STARING AT THE SUN, DEATH AND A THOUGHT FROM IRVIN YALOM
