240 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse Providing Care in the Last Days and Hours Physical changes often occur during the last days and hours when a person is actively dying. Not all dying people experience every change, nor do they experience the changes in any specific order. Share information about such changes with the family so that they can anticipate them and participate in providing care. The following sections about the common changes that may occur during the last days and hours suggest ways that, together with those discussed in Chapter 5, “Enhan- cing Physical Comfort,” you can support the person and the family. Decreased Physical Strength and Increased Drowsiness As death nears, the dying person’s strength decreases and the time spent sleeping increases, until eventually the per- son is sleeping most of the day. This is a natural change in the dying process. Supporting the Dying Person Adapt the care plan to meet the needs and changing pri- orities of the person. For example, sleeping may be more important than a daily bed bath, and visiting with the family may be more important than visiting with friends. Keep the care team informed of the changing needs and priorities. Supporting the Family The dying person’s increased need for sleep can be dif- ficult for their family members, who may feel they are missing time with their loved one. You may hear them say, I knew she was dying in a few weeks, but I did not realize she would be sleeping most of that time. You can acknowledge that it is common for people to sleep more as death nears. You might say, It is normal for a dying person to sleep more and more as time passes. If the family expresses concerns that medication may be causing their loved one’s drowsiness, review the goals of care and the rationale for medications, explore the con- sequences of decreasing medications, and, if necessary, talk with the physician/nurse practitioner about adjusting medications for a trial period. Share information about the dying person’s patterns of wakefulness. Let the family know what times might be best for visiting. Explain that even enjoyable visits can be exhausting for the person, and discuss ways to limit visitors or the length of visits. These are some other ways to sup- port the family when the person is drowsy and needs rest: • Help the family find ways of being with their loved one whose energy is low. Depending on the interests of the person, this could include playing their favorite music, reading a special book, or reminiscing about good times. • Encourage family members to continue talking with the dying person and one another, because hearing familiar voices may comfort the person. The person’s hearing might be the last sense to go. • Explore the person’s preference for touch. Even if a person is too weak to respond, they may find it re- assuring to have physical contact. Reduced Intake and Difficult Swallowing In the last days and hours, a person’s intake naturally de- creases and changes from solids to fluids, from a mouthful to sips of fluids, and from sips to nothing by mouth. The person may begin having difficulty swallowing, followed by forgetting to swallow and then becoming unable to swallow. Supporting the Dying Person You can help the dying person in these ways: • If the person has difficulty swallowing clear fluids, try offering thickened fluids. • If the person forgets to swallow, remind them to do so. • If the person is unable to swallow and/or chokes on fluids or coughs after swallowing, do not give any- thing by mouth. • Provide excellent and regular mouth care to help keep the person’s mucous membranes moist.