End-of-Life Breathing Patterns

Facing the end of life is a profound and emotional experience for both individuals and their loved ones. In these challenging moments, it's essential to comprehend the various aspects of the dying process, including some common breathing patterns that often emerge at end of life. This blog post aims to shed light on end-of-life breathing patterns, exploring their manifestations, mechanisms, and the compassionate approaches available for treatment.

As individuals approach the end of life, changes in breathing patterns are common and can be indicative of the body's transition towards death. These alterations are part of the natural dying process and often occur as a result of the body's decreasing energy levels and organ systems shutting down. It's crucial to recognize that each person's journey is unique, and breathing patterns may vary. For some, these common patterns may be present, and for others none of these will occur.

Breathing Patterns Before Death

1. Normal Breathing Patterns: Before delving into the changes that occur at end of life, it's essential to understand the typical breathing patterns. Normal breathing is characterized by regular, rhythmic inhalations and exhalations. The rate of breathing can vary depending on factors such as age, physical activity, and overall health. In a relaxed state, adults usually breathe between 12 to 20 times per minute.
2. Cheyne-Stokes Respiration: One common end-of-life breathing pattern is Cheyne-Stokes respiration, characterized by alternating periods of deep breathing followed by gradually shallower breaths and temporary pauses in breathing altogether. This pattern can be distressing for loved ones to witness but is generally painless for the individual experiencing it. It can also be described as a crescendo-decrescendo breathing pattern. Physiologically, it is suggested to be caused by a buildup of carbon dioxide in the blood which in turn causes the brain to direct the body to breathe quicker. Eventually the body is too weak to keep breathing rapidly and then slows down until it rests, this then causes carbon dioxide to build back up again thus restarting the process.
3. Agonal or Irregular Breathing: Irregular breathing, marked by unpredictable pauses and variations in breath rate, is another common occurrence. It may seem erratic, with moments of rapid breaths followed by periods of slowed or irregular breathing. This pattern often indicates the body's diminishing ability to regulate breathing. Some providers may call this form of breathing mandibular breathing or guppy breathing as it appears like a fish out of water.
4. Noisy Breathing: As the body weakens, congestion and the accumulation of fluids may lead to noisy breathing, commonly referred to as the "death rattle" or “terminal secretions.” Though unsettling for caregivers and families at the bedside, this pattern, like the others above, also typically doesn't cause discomfort for the individual. The noise is a result of air passing through secretions in the airways.

Compassionate Approaches to End-of-Life Treatment

1. Maintaining a Calm Environment: Creating a calm and peaceful atmosphere is crucial for both the individual and their loved ones. Dimming lights, playing soft music, and surrounding the person with familiar items can contribute to a serene environment. Holding their hand, or having you place your hand on their chest can be comforting as well. 
2. Positioning and Comfort Measures: Adjusting the individual's position to enhance comfort can be beneficial. Elevating the head slightly or turning the person on their side can aid in relieving respiratory distress. Placing pillows under pressure points helps prevent discomfort. If a patient is having noisy breathing is it crucial to turn the patient every so often to allow gravity to help drain some of the secretions.
3. Hydration and Moisturization: Offering small sips of water or moistening the individual's lips with a damp cloth can help alleviate the sensation of dryness and contribute to their overall comfort. It's important to note that forcing fluids is not recommended in these situations as it make exacerbate breathing difficulties and secretion buildup. 
4. Pharmacological Interventions: Healthcare professionals may recommend medications to manage symptoms such as anxiety, pain, or respiratory distress. These medications are carefully chosen to provide relief without hastening the dying process. Such common medication includes an opioid like morphine or dilaudid which helps ease the rate and labor of breathing to a calmer and more appropriate rate. Rest assured that research shows that use of opioids does not hasten the dying process in any way. Anticholinergic medications are also another class of medications that are sometimes helpful for noisy breathing and are used to help decrease the amount of secretions in the airway.  
5. Oxygen Therapy: Supplemental oxygen may be provided to alleviate shortness of breath and improve oxygenation. However, it's essential to monitor oxygen levels carefully to avoid potential complications. In most cases using nasal cannula oxygen is enough to provide a comfortable flow of oxygen to the dying patient. If more oxygen is needed than non-Invasive ventilation techniques such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), or non-rebreather face masks may be used to support breathing and improve oxygenation. 
6. Emotional and Spiritual Support: Providing emotional and spiritual support is crucial during end-of-life care. Encourage open communication, share memories, and express love. Even if the dying patient cannot communicate verbally, it is widely believed they can still hear and experience the comfort of loved ones. Spiritual leaders, counselors, or hospice professionals can offer guidance and comfort to both the individual and their family during this time.

Understanding end-of-life breathing patterns is a crucial aspect of providing compassionate care to those nearing the end of their journey. It's essential to approach these situations with empathy, patience, and a commitment to maintaining the dignity and comfort of the individual. By combining medical knowledge with emotional and spiritual support, we can ensure that the final moments of life are as peaceful and meaningful as possible for both the person and their loved ones as they take their final breathes.