If you are companioning a loved one as they leave this world I hope this can act as a sort of road map. Death is highly individual but has some similarities. Not everyone will exhibit all these symptoms but everyone wil have some of them, unless it is a sudden death.
I like to think of things in terms of the elements. The Buddhists believe that a very intricate series of processes happen as the soul unties itself from the bonds of the body. If you are interested in this subject I recommend reading Dying with Confidence by Anyen Rinpoche.
The first element to leave the body is earth. Your ability to walk, stand and even get out of bed and contact the earth leaves you. Your body loses the ability to support itself. This is a slow process and happens over the course of weeks. It is during this time that people become slowly disinterested in eating food. Ultimately the food just rolls around in the mouth with not enough saliva to process it. I will never forget my husband Rob looking at me with a mouth full of food and a sad look on his face. He said, "Its disgusting." We switched to smoothies or fresh fruit that had a lot of liquid of its own. As a hospice volunteer I see a lot of anxiety around food, and a lot of dying people trying to eat to soothe their worried caregivers. Please, please let the person decide for themselves what feels right. Forcing them to eat is not going to prolong their lives, but it may make some of that precious time "disgusting". Sometimes as people lose the ability to be ambulatory they go thru a very restless stage. They can't get comfortable. There is a lot of moving from chair to bed, or writhing around on the bed. This is part of the process of dying. Rob described it as "the most miserable flu ever". I did a lot of back rubs, foot rubs and palm rubs, but its a stage and they have to go thru it.
The second element to leave is water. The mouth dries, and eventually they lose the ability to swallow, tears dry up, Its important at this time to keep the lips moist with vaseline and hospice will give you biotene mouth swabs. Biotene is a lubricant that also freshens the mouth. Ice chips are also helpful. Towards the very end they have their last output of urine and it is frequently very dark.
The third element to leave is fire. Frequently people spike a fever or chills at the end as their body loses the ability to regulate temperature. Hands and feet can get cold as blood starts to be shunted to the organs. A cool washcloth on the forehead or an extra blanket can be all they need.
The final element to leave is the breath. Breathing goes thru many changes as death nears. It can be labored, shallow and rapid and everything in between. As a companion it can be alarming, especially the "death rattle". This is caused by secretions being trapped because they can't be cleared by swallowing anymore. You can turn people on their sides, ideally the left side to help clear this. But be comforted by knowing that it does not bother them. There are also medications to dry the secretions up. The Zen hospice center will sometimes do a meditation where they place their hand lightly on the persons chest and lean close and audibly exhale with every exhale of the person as a way to slowly calm their breathing if it seems anxiety driven. Or place their hand over the persons chest and say "I am here. You are here. We are here." Obviously this is something you would have to ascertain whether the person would be soothed by this ahead of time. One thing about the breath that first timers might be surprised by is that the inhaled breath can stop and there can be quite a lag before the final exhale. Sometimes up to what feels like a minute and then a loud sigh/exhale. It can come as quite a surprise.
The Buddhists believe that for some people the soul leaves through the crown of the head. For this reason they give a light tug to the hair on the top of the head to encourage the soul to move in this direction. Sometimes death shows up in the face. The face can take on a bluish hue or the cheeks can be red from ruptured blood vessels. Others have death show up in the feet and hands. They swell and become cold and then mottled purple and dark blueish. The signs of death are many and varied. Even with signs it is highly unpredicatable. People can hang on for days and weeks perhaps because they feel they have unfinished business. For this reason it is important to have those conversations while they are still lucid and able to talk. Ask them "Is there anything you are afraid of?" "Anything you are worried about?" "Anything you want to do with the time you have left?" Don't worry that you will be 'giving up' on them. In general dying people know they are dying and want to be seen as such.
Remember afterward there will be regrets about things you did or didn't do. Try and forgive yourself, your loved one would not want you to waste one moment in regret. Most likely they were deeply thankful for having you by their side. This is one of the reasons I recommend people facing the end of their lives to write a letter to their health care proxy absolving them of any and all regret/guilt. There are many right ways and everybody is just doing their best. Amen.
I have a pin on my jean jacket with a classic Grim Reaper and it says, "Born to die". As strange as this sounds, I think he is the guy who helps us get to the peaceful, accepting, beatific smile that most of us are shooting for as we prepare to make our exit.
I was speaking at a gathering recently and a man asked, "How do you help a younger person face death? It is so much harder than if they are at the end of a long, satisfying life," His question gave me pause, and I don't think I answered it very well. What I wish I would have said is something to the effect of, "That is where the Grim Reaper comes in."
I think the way to prepare to die at any age is much the same, it is to lose our attachments. Its these attachments that make it difficult to leave this place. I like to picture the Grim Reaper as a large man, like 12 feet tall. He is imposing but not scary, stern but patient and wise. I like the idea that I can curl up inside death. I am no longer in control. He is taking it one step at a time. Death is huge, all encompassing and vast.
He is beckoning with his long bony finger and there is no refusing him. First he shatters your world. He takes away your illusion that you have more time. Its so easy to forget that we are so fragile and that our time is so fleeting. By making your time short he also gives you the gift of seeing your life and priorities crystal clear. Its as if he has a giant sifter and pours your entire life through it, all the people, all the responsibilities, all the worries and shakes them out on your front lawn. There will be things that you no longer consider worthwhile to carry.
Next he takes your energy. Your physical body starts to slow and as you move more slowly you realize you have to decide what things to save your energy for. You lose your attachment to racing around and doing unnecessary things, like keeping your bathroom spotless or staying in a conversation with a narcissist.
Later he comes around and asks for the keys to your office. He takes your job and with it the part of your identity attached to it. This really slows the world down and takes the future with it. You are forced to live in the present maybe for the first time in a long time. There is a gift here too, the simplest things like a good meal, the weather, playing with the dog, your kids, drinking a cup of coffee and reading the newspaper become sublime.
Later he comes around and beckons you to handover the passcodes and usernames. Someone else is taking care of the taxes, the financial aid applications, the leaky roof, and the crab grass in the lawn. This in effect makes you a child again. Free to focus on what is starting to appear on the horizon, the next place.
He comes around next for your family members, you no longer have the energy to interact with them. You must say goodbye, but first "Please forgive me, I forgive you, Thank you and I love you." Your hearing is the last sense he will take so you can still revel in their presence but they are receding from you. This is a time when the living can feel abandoned and hurt that the person passing seems to look right thru them. This is part of the process, as the physical body dies, the spiritual body rises.
And finally he comes for your body. And with this last one he frees your soul.
This taking your life one step at a time has the ability to transform you. It gives one the opportunity to feel gratititude for the life they lived and revel in the simple things. He is benevolent because he prepares us to move on. He strips us back to our elemental nature.
I encourage you to create your own personal Grim Reaper. Maybe a kindly older woman in flowing robes, maybe an actual person from our past who will ready us for the next place. Whoever it happens to be make friends with them today. I guarantee that it will make you more fully in your death and thus more fully in your life.
This quote can be attributed to some Zen master, sadly I can't remember which one. The first time I read it, it didn't make sense to me immediately. But as I sat with it a picture of Rob came to mind. He was standing with his back to the lake in Central Park. He is looking up, not exactly skyward but up and he has a smile on his face that I don't recall ever seeing before. It could best be described as beatific which is defined as "imparting holy bliss". The fact that he never had this smile during his life was significant. Rob was someone who took the work of being a good human very seriously, which is odd because he was a deeply funny man. But he carried the weight of responsibility squarely on his shoulders through out his life. And he was a worrier. On his death bed he regretted that he had spent so much of life worrying. So how did he get to be the guy with a beatific smile on his face, seemingly without a care in the world even though it was the last month of his life?
I think the answer lies in the belief that when we know we are dying and time is short there comes an opportunity for deep transformation. It is important to note that it is an opportunity it does not happen automatically. Rob chose to live in the present and be consumed with gratitude for what he had been given in life. He did not want to die but he was able to accept it. The palliative care doctor B J Miller put it another way when he was describing his time in a burn unit after a horrific accident where he was electrocuted. One of the nurses smuggled in a snowball for him, he says, "I cannot tell you the rapture I felt holding the snowball in my hand. The coldness dripping onto my skin, the miracle of it all, the fascination as I watched it melt and turn into water. In that moment just being on any part of this planet in this universe mattered more to me than whether I lived or died. That little snowball packed all the inspiration I needed to both try to live and be OK if I did not. It was a moment of sensuous, asthetic gratification where I was rewarded for just being." I think this is the ground in which a beatific smile can sprout. He goes on to say "There are mountains of sorrow and one way or another we will all kneel there. But so much of living in that shadow comes down to loving our time by way of the senses, by way of the body, the very thing doing the living and dying."
I was companioning an elderly woman who was as sweet as can be. She was tiny and greeted every caretaker that entered her room with a warm hello. She and I became fast friends. She would lean close to me and say "Its a shame we didn't meet 20 years ago, think of the fun we could have had." I looked forward to being at her side as this experience unfolded for her. I was very surprised one day when she grabbed my arm and looked pleadingly into my face and said, "I don't deserve this." I said, "Tell me more." She said, "I don't deserve to die. What did I do to deserve this?" I was speechless. She was 87 had a very loving family and by all accounts had led a life much like many of us. It makes me sad that so many see death as a punishment or something horribly wrong, even at the end of a good life.
One of my favorite quotes on this subject is something to the effect of "The adult afraid of death is not some odd bird, but someone whose culture has not knit them the protective garments to withstand the icy winds of mortality." Our culture is most assuredly not in the business of knitting us cozy cocoons to enter our deaths in a calm and accepting way. We are animals after all. We have completely lost connection with our animal selves who are of the natural world. Think of woodland creatures who go off to some quiet shade under a big oak to quietly slip away under the great big sky. Animals know when their time is here and go off on their own to peacefully exit. There are some cultures of the human kind that have similar death rituals. The Inuit come to mind. Their elders chose when it was their time and headed out onto an ice floe under a midnight sky and drifted out to sea. The contrast between these stories and our own culture are profound. It is as if we have forgotten that we know how to die. We know how to do this.
After my sweet friend passed, I was talking with a nurse at the facility about her feeling that death was a punishment. I asked if he had seen this before. He said, "She did not do her homework. When people come here and they haven't thought about death or prepared for it, they aren't ready for it and they hang on. Some people have done their homework and make a peaceful exit." He went on to tell me that his mother had died when he was 9, right in front of him. He had sat with her dead body for a while before anyone else arrived. He was from somewhere in Africa. He went on to tell me that because of this he had a great fear of dead bodies. He knew he had to face this fear to be comfortable working in the healthcare field as well as face his own eventual mortality. He prepared himself and eventually confronted his fear and moved beyond it. He said we all have to face our own demons in our own way, but if we don't they will still be there for us at the end. His words have been swirling around my head ever since. I want to be clear that I am not blaming my client or anyone who has trouble accepting that they will one day die. But I think it behooves us all to think about it because it will inform the way we live our lives and that is death's greatest gift. What is the homework we have to do around death? How do we go about knitting our own cocoons that make death more acceptable?
"Wildness...It is perennially within us, dormant as a hard-shelled seed, awaiting the fire or flood that awake it again." Gary Snyder courtesy of WeCroak.
There is a new app on the market. It is called WeCroak and it'll cost you .99 for a lifetime. It gives you 5 random reminders that you are going to die, everyday. They look just like normal calendar reminders. It also provides you with a death related quote. It is just the tool I was looking for to keep my inevitable death present and thus the fragility of my life front and center. Just this week it helped me to change my frame of mind from overwhelmed and resentful to grateful and present. That sounds cliche even as I write it but there is no other way to describe it. My mother had a bad fall and landed in the hospital. I had been with her 3 of the previous 4 days and was feeling maxed out. I was busy driving my child to and fro and trying to wedge in some time at the hospital. I was on my way up the long walk to the hospital, when my phone chimed. A reminder: You are going to die. It brought me to a standstill. I noticed for the first time the blue, blue sky and the bright sun. Took some deep breathes and thought that was it. But I went on to have a delightful time with my mother. I give all credit to WeCroak and its ability to give me some perspective. I have no idea how long my life is going to be, so I better be awake for it today.
I spend an inordinate amount of time thinking about how I can normalize death. For everyone. T shirts that say "Soon Dead"? or "Most of the people are dead, the rest are on deck." But my favorite fantasy is that everyone is visibly pregnant with their own death. We prepare for birth. We read books, we decorate rooms, we talk with friends and family and hear their stories, we interview doctors and midwives and personalize the experience. It is culturally appropriate to talk about it and engage with strangers, in line at the supermarket- about the upcoming experience.
I love to envision all of us walking around at varying stages of rounded belly and planning for our exit. I imagine the conversations to run the gamut. "So have you decided where your funeral is going to be?" "I'm thinking maybe hydro cremation now. I used to be sold on regular cremation but then I went to a funeral at the hydro cremation facility and it was so beautiful and its so much better for the environment." "I just revised my obituary, I like to do that every year on my birthday just to keep it current." "I just had a great idea about my funeral. I am keeping a file of all the cute poems and projects that my grandkids do in school. I am going to have the kids read them at my service." "I just heard some great Gregorian chants I'd like to listen to as I ease into the next phase. I am making a playlist specifically for that time."
Imagine how easy and natural it would be to engage each other on the subject when we had been talking about it all along. Imagine how much more fulfilling death vigils could be if we prepared for them? Why is it such a radical idea to plan for it when the seed of our deaths is implanted in us at birth?
When I first started studying astrology I encountered the idea that we are here to evolve our souls. This is something I hadn't given much consideration to. But if one's primary job here on earth is to grow one's soul, the next obvious question is, "How does one do that?" I think initially I thought that the path was through religious study. Say becoming a Buddhist. But the more I live the more I believe that the path to soul expansion and wisdom is through loss. And it doesn't have to be capital L LOSS, but the every day losses we all encounter as well as the big lifetime losses.
I recently read a book about a minister who lost his mother, his wife and his four year old daughter in one horrible night. He was involved in a head on car crash and sat and watched all three of them leave this world. The grief he was plunged into is unfathomable to most of us. But garden variety loss is a common part of life on earth, and plenty painful, One doesn't need to look to the most dramatic example, the loss from a divorce, or having a child that lies outside the 'normal' range, or caring for an aging parent are examples of pain that can call forth a persons mettle.
The minister in the book goes on to explain that he sees the soul as a balloon. Experiencing grief is what makes your soul expand. It is not a choice to grow in that way but rather it is life calling to you, asking more than you want to give. But as you work your way thru that pain, what you expect or even want from reality changes. This is the gift of grief. Your balloon is full, much more full than before and the sorrow is eventually replaced with gratitude for much smaller things, you are able to find joy and grace in the simple events of life that you once overlooked. Your ability to feel compassion for others is expanded and slowly your soul is expanded and evolves.