Deathbed visions

The teaching

As the hospice tradition of care for the dying teaches it.

The last weeks

Those who care for the dying teach families what to expect, because the last weeks have a pattern and knowing it takes away some of the fear. The dying person sleeps more and eats and drinks less, as the body needs less; nurses advise offering food and drink, never pressing them. Interest in news, visitors and the wider world narrows. This turning inward is not a rejection of the people in the room. Many dying people want only one or two faces near them, and quiet.

Nearing death awareness

Two hospice nurses, Maggie Callanan and Patricia Kelley, gave the name nearing death awareness to what the dying say and see in these days, and taught families to listen to it rather than set it aside as confusion. The dying often speak in images of travel: they need their coat, their ticket, a map; they ask when the train leaves or say that they must pack. Some say they will die soon, now and then naming a day. The nurses' counsel is to take this language as the person's own way of telling what is happening, and to answer within it: where are you going, who is going with you, what do you need for the journey.

Visitors

Many dying people say that someone has come: a mother, a father, a husband or wife, a brother, a friend, nearly always someone who has already died. They may see the visitor at the foot of the bed or in a corner of the room, speak to them, reach out, or smile at a place the family sees as empty. Most find these visits a comfort and grow calmer after them, and some say the visitor is waiting for them. The hospice counsel is to neither argue nor pretend, but to ask gently who is there and what they say, and to listen to the answer.

Telling a vision from delirium

Not every vision is of this kind, and the hospice teaching tells the two apart by their feel. A comforting vision comes to a person who is otherwise clear, is of someone known and loved, and leaves calm behind it. Delirium comes and goes through the day, confuses time and place, often frightens, and shows as picking at the sheets, trying to climb out of bed, or seeing insects and strangers. Delirium has causes a nurse can look for, among them pain, infection, fever, medicines, a full bladder and low oxygen, and it can often be eased, so it is always to be reported.

The clear hour

Sometimes a person who has been confused or silent for months or years becomes, for a little while, entirely themselves. A woman deep in dementia knows her daughter's name, asks after the grandchildren, makes a joke in her old way; a man who has not spoken for weeks talks clearly about his life. It may last minutes or hours, and it usually comes near the end. Those who have seen it counsel families to receive it as a gift and not to test it: do not quiz the person on dates or names, and do not spend the time on business. Say what you most want to say.

Hospice staff also speak of a rally in people without dementia, a day or two of new energy and appetite before the last decline. They teach families not to read it as recovery, but as a time to be together.

The moment of going

Nurses have often seen a dying person hold on until a son flies in from abroad or a birthday has passed, and have as often seen death come in the few minutes when the family stepped out of the room. The hospice teaching is gentle about both. No one can choose the moment for another, and a family that was not in the room at the end has not failed the person they loved.

What to say

The palliative care doctor Ira Byock taught four things to say while there is time: please forgive me, I forgive you, thank you, and I love you, with goodbye at the very end. They need not be said in those words, and some cannot be said at all; a hand held says much of it. Hearing is held to be among the last senses to go, so the hospice teaching is to speak to the dying as if they can hear, even when they no longer answer: say who you are, tell them what you are doing, and say what you came to say.

The signs of the last hours

In the last hours the breathing changes. It may grow shallow and then deep, with long pauses between breaths, and a rattling sound may come as the person can no longer clear the throat; nurses explain that this sound troubles those who hear it more than the one who makes it, and that turning the body can ease it. Hands and feet cool, and the skin of the knees and feet may grow blotched and purple. The eyes may stay half open. These are the ordinary signs of a body closing down, and the care team will say what each means and what can be done for comfort.

Keeping watch in the faiths

Each faith has its own way of keeping watch, and a family that knows the dying person's faith can ask its clergy to come. Jews say the Shema with the dying and do not leave them alone at the end. Catholics call a priest to anoint the sick and give the last communion, and other churches have their prayers of commendation. Muslims sit with the dying, turn them toward Mecca if they can, recite the Qur'an, often the chapter Ya Sin, and gently say the words of faith, there is no god but God, so that the dying may say them too.

Hindus give a few drops of water from the Ganges and speak the name of God. Buddhists chant, and in the Pure Land schools call the name of Amida. Sikhs recite hymns from the Guru Granth Sahib and repeat the name Waheguru.