As an illness progresses, the body begins its natural course of slowing down. This varies from person to person and may take hours or a few days. The dying person may become very weak and sleepy and have difficulty staying awake. You may find you spend more time sitting quietly whilst they are asleep.

At the very end of life, people may be unable to respond, though they may move themselves from time to time. It is important that you still talk to them, even when they appear to be sound asleep. Towards the end they may still be able to hear you, as hearing is one of the last senses to go. It is important not to say anything in their room which you do not want them to hear.

You may have noticed a gradual decrease in their appetite, even for their favourite foods. We suggest that you do not try to force them to eat or drink as this may be difficult. Pressure to eat will be frustrating for them and you.

If they are still awake, you can offer moistened ‘foam sticks’ and use lip balm to prevent lips cracking.

It is important to remember that some people die without pain.

When pain is a problem, St Nicholas Hospice Care staff will closely monitor the effectiveness of painkiller medications. Signs of discomfort will be noted by the nurses and we also welcome your opinion. If a patient is not able to swallow tablets or syrups, our staff will ensure that the equivalent medicines are given by other means, such as injection or by a syringe driver. A syringe driver is a small infusion pump which gradually administers the medication.

Sometimes people are unable to control their bowel and bladder, which can become distressing and embarrassing. The nursing staff will do all they can to keep the patient as clean, dry and comfortable as possible. This may involve the use of pads or catheterisation.

You may notice the urine becoming darker and more concentrated, and decreasing in amount. This is because the patient is drinking less.

People may become confused and disorientated for a number of reasons. If you notice they become muddled, please do speak to St Nicholas Hospice Care staff about this.

Your loved one may occasionally say things that do not make sense or are out of character, or may see things or people that are not there. You may notice them pulling at bed linen, their clothes or thin air. This behaviour can be distressing to watch but does not always mean the person is distressed.

Sometimes a patient can become flushed and feel warm to the touch, or sometimes become cold. This can be due to the body’s internal ‘thermostat’ not working very well.

Feet and hands may become cold to the touch and very

sensitive, or you may notice their skin colour changing and feeling clammy. This is because of a decrease in circulation. Blankets can be used, but be careful that they do not become overheated as they may not be aware of feeling cold. If you think your loved one is cold, please let the nurses know.

When a patient is hot, fans or cool, wet flannels can be used. The doctors may also prescribe simple Paracetamol to help.

Sometimes fluid may collect in their lungs, making a person’s breathing have a slight groaning or rattling noise. This can be very upsetting for people around, but thankfully, it is not uncomfortable for the dying person themselves.

A patient may need medication, repositioning or occasionally suction to try and ease the problem. If it is not possible to prevent the rattling sound, we will still do all we can to maintain their comfort.

You may notice that a patient’s breathing becomes irregular, with long gaps in between breaths. There may also be times when they stop breathing for a few seconds and restart, building up to deep breaths. Changes in breathing often occur in unconscious or very drowsy people in the hours or days prior to death. It is a normal pre-death symptom.

Feelings can be very intense and difficult for a patient to bear. At other times, they may feel numb or disbelieving.

By allowing them to share the memories or feelings they are experiencing, you can offer support and comfort through this distressing time. Sometimes you may not feel up to offering that support. Please talk to a member of staff who will be happy to help.

When approaching the end of life it is often found that the dying person may review their life and talk about wanting to complete any unfinished business, such as:

• Resolving any problems with personal relationships
• Visiting certain places
• Sorting out personal belongings
• Giving gifts or special things away to family and friends
• Getting their Will and other financial affairs in order
• Seeing a religious or spiritual leader

As death becomes closer, the person may communicate less, be less aware of their surroundings and seem at peace. Just letting them know that you are there can be very comforting.

Being cared for in this way enables people to feel that their lives have been worthwhile and that they will be remembered well.

It may be important to reassure them that it is alright to ‘let go’ and die when they are ready. This conversation can be one of the hardest things for you to do.