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Do you ever wonder what it’s like to die? Are you curious what happens in the body during death, or how doctors actually declare death?
Dr. Ann Jennerich, an assistant professor in the UW Medicine Division of Pulmonary, Critical Care and Sleep Medicine, is used to answering questions like these. Aside from caring for critically ill patients and explaining what’s happening to their family members, she also teaches nurses what to expect in patients who are at the end of life.
For Jennerich, teaching about death is important to normalize the process and help people understand what’s happening.
“It’s scary to talk about it, like by talking about it you make it real, but it’s real whether you talk about it or not,” she says.
All of us will have to face death at some point — our own and the deaths of people we care about. It’s sad and frightening, but learning more about death can make it a little easier to deal with.
What happens in the body during dying?
“Death is not an event as much as it is a process. There are shared features of this dying process for all human beings, even though each experience is different,” Jennerich explains.
What she means is that even in a sudden death caused by trauma — like a car crash — the body still takes time to fully shut down.
The most sensitive organs in the body are the brain, heart and kidneys, Jennerich says, which mean they start to decline first.
Heart failure means the heart can’t pump enough blood to supply the body’s needs; in some cases, it can also lead to fluid buildup throughout the body, called edema, which causes the body to swell. As the lungs stop working, oxygen levels decrease as carbon dioxide levels rise in the body.
There are visible signs of oncoming death, too, such as skin discoloration and mottling, drooping of the face and a breathing pattern known as Cheyne-Stokes breathing, where short, fast breaths are followed by moments of no breath.
The person’s pulse may become irregular and their body temperature may drop. They may stop needing to eat, drink and go to the bathroom.
The person’s eyes may glaze over, and they may become unresponsive, though they may still be able to hear. Some people may be fairly aware until very close to the end, whereas others will have hallucinations and become restless.
How quickly death comes depends on why the person is dying, Jennerich says.
“If someone is in the ICU and on medications and mechanically ventilated, if we were to stop those things, their death may happen within minutes. Whereas someone who had a more chronic condition, in a regular part of hospital, and who wanted to pursue comfort as opposed to medical interventions, they could take days to weeks to die,” she explains.
How do doctors declare death?
In 1980, the American Medical Association approved the Uniform Determination of Death Act, which was then adopted by all 50 states in the United States. The act outlines what death is and how it can be declared.
There are two types of death that can be declared: Heart/respiratory death and brain death. The first type of death means an irreversible stopping of heart and lung function, whereas brain death means an irreversible stopping of brain function.
Brain death can be complicated, because while someone’s brain may not be working — and they will not regain consciousness — other parts of their body, such as their heart, may still function.
“A lot of factors could confuse a diagnosis of brain death, such as medication, blood pressure or oxygen levels,” Jennerich says. “At UW Medicine we have protocols in place to determine if someone has developed brain death. It is complicated for medical professionals to understand, much less family.”
Some cultures and religions, she adds, don’t accept brain death as death, which can make things even more complicated.
Heart and respiratory death occur more often, Jennerich says, though brain death is more common in people who have sustained head injuries, experienced a significant time without blood flow to the brain or have had medical emergencies involving the brain, such as a ruptured aneurysm.
What is dying in a hospital like?
Dying in a hospital isn’t on most of our lists of things we want to do. But it also has a worse reputation than it deserves; after all, many people do end up dying in hospitals, where doctors and staff do everything they can to make the person comfortable during their final days.
First off, there’s one misconception Jennerich wants to correct: In general, doctors do not do anything with the intention of hastening the dying process, and they don’t automatically give dying patients medications like opioids.
“We try to allow as natural a dying process as possible. We use medications to treat pain, anxiety or breathlessness during the dying process, but if someone doesn’t appear to be in distress, we don’t just reflexively give medications,” Jennerich explains.
When a patient is dying, the care team does what they call “transitioning to comfort measures only,” Jennerich says. This means that the team will not make any interventions to try to save the person’s life, because they know that the person cannot be saved (or perhaps because the person stipulated in their advance healthcare directive that they do not want these interventions to be made).
During this time, the team — especially the nurses, who spend the most time with the patient — do everything in their power to give the patient and their family a meaningful experience.
“Physicians, nurses, respiratory therapists, spiritual care — we all work together to preserve human dignity, manage symptoms and support the emotional and spiritual needs of family and patients,” Jennerich says.
What this looks like varies from person to person and what their final wishes are. Nurses may take a patient outside — no easy feat for someone on a ventilator — to smell fresh air and see the sun again. They may work to bring a patient’s pet into their hospital room, or provide patients with items that matter to them, such as a quilt made with fabric in their favorite colors.
Sometimes, the team goes even further. If a loved one is about to get married, for example, they may work to arrange a special ceremony at the hospital so the patient can witness it.
“Usually when things like that happen, there isn’t a dry eye on the unit,” Jennerich says.
They also work with family to do legacy work, which involves finding ways to memorialize their loved one, such as solidifying their handprint in clay or clipping a lock of hair to preserve.
Why you should talk about death with your loved ones
For someone like Jennerich, who may see more death in a week than most people will see in a lifetime, the dying process eventually becomes normalized — and she sees this as a good thing.
“It’s important to talk about how death-averse our culture is. I think death feels very remote to our society: many people haven’t seen an animal die, much less a human. That makes it seem mysterious,” she says.
She uses her experience witnessing death as a way to help educate others about it, to demystify the process and help them cope.
One thing she regularly discusses with patients and families is how impending death can bring about a sense of lost control that is hard to deal with. This loss of control is at the root of the fear of death many people feel — and Jennerich has a recommendation for people can manage it: planning.
This means composing legally binding documents such as an advance directive and a POLST Portable Medical Order, but it also means informally talking with your loved ones about what your wishes are.
It’s not an easy conversation to have, and if you’re relatively healthy you may feel like it’s not one you need to have anytime soon. But Jennerich believes there’s no wrong time to talk about it.
“Helping your loved ones understand your wishes about end-of-life care gives you a little sense of control even though you don’t know when and where you will die,” she says.
To get started, she suggests asking yourself questions such as:
- What quality of life do I value?
- Do I want to be resuscitated (such as with CPR) if my heart stops?
- Would I ever want to be on a ventilator?
- What do I want done with my remains, such as cremation or burial?
Once you know your own wishes, talk about them with those closest to you. It may seem like a macabre subject to bring up, but it’s helpful for your loved ones, so they know what you want and don’t have to agonize over making decisions when the time comes.
Plus, there’s no avoiding death; it will happen eventually, so you might as well have as much control over it as you can and minimize your fear of it so that fear doesn’t outweigh the beauty of living.
“I don’t fear death. It’s just a part of life, we’re all going to die, and there’s no mystery about it to me. I don’t see it as something abnormal. To me, instead of just thinking about the loss, I think about all the contributions that person made during their life and how they’ve contributed to other peoples’ joy,” Jennerich says.
