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June 23, 2017

This is how you'll die, according to one doctor

Daily Briefing

Editor's note: This story was updated on February 12, 2018.

While people die from a variety of causes, the hours immediately preceding "death are similar across the vast majority of human afflictions," Sara Manning Peskin, a neurology resident at the University of Pennsylvania, writes for New York Times' "Well."

Manning Peskin explains that people pass from all sorts of conditions and illnesses, such as diabetes, cancer, or stroke. However, "while the weeks and days leading up to death can vary from person to person," we in our final hours will "become more similar to each other"—no matter our cause of death—"than to people who continue living with your original diagnosis or mine."

Few individuals will experience all the traditional symptoms of death, she adds, but we all most likely will experience at least one. Here's what you can expect:

1. The death rattle

The death rattle, according to Manning Peskin, is a "gurgling, crackling sound, like blowing air through the straw at the bottom of a cup" that presents when a dying patient loses the ability to swallow correctly. "In the dying process, the symphony of swallowing becomes a cacophony of weak and mistimed movements" that lets saliva slip into the airway to the lungs, she writes. Ultimately, the "death rattle is the lungs' attempt to breathe through a layer of saliva."

According to Manning Peskin, "the average time between the onset of death rattles to death itself is 16 hours." However, she notes that while the condition sounds painful, "the presence of a death rattle doesn't correlate with signs of respiratory distress."  So, "as often happens in medicine, we treat based on intuition," Manning Peskin writes, explaining how doctors will often administer drugs to decrease saliva production—not just to treat the patient, but to harmlessly quell the worries and fears of witnesses to the death "who will go on living."

2. Air hunger

"Air hunger—the uncomfortable feeling of breathing difficultly—is one of the most common end-of-life symptoms that doctors work to ease," Manning Peskin writes. And while the use of opiates can depress breathing, potentially worsening air hunger, Manning Peskin explains that providers typically administer such a drug, namely morphine, because the benefits outweigh the risks.

According to Manning Peskin, the counterintuitive treatment stems from research suggesting that "the discomfort of air hunger [comes] from the mismatch between the breathing our brain wants and our lungs' ability to inflate and deflate." Opiates lessen that discomfort by "tun[ing] our brain's appetite for air to what our body can provide," she writes.

Moreover, she explains that some experts do not think that the quantity of morphine required to ease air hunger significantly affects an individual's ability to breath. Rather, she writes, "since air hunger and pain activate similar parts of the brain, opiates may simply work by muting the brain's pain signals."

3. Terminal agitation

"Instead of peacefully floating off, the dying person may cry out and try to get out of bed," a condition called "terminal agitation," Manning Peskin writes. She explains that while it's uncommon, it can be difficult to witness, involving muscle spasms and the impression of physical torment.

"There are physical causes for terminal agitation like urine retention, shortness of breath, pain, and metabolic abnormalities," Manning Peskin continues, but "it's hard to discount the role of the psyche and the spiritual." There are, however, drugs that can ease the condition.

According to Manning Peskin, "people who witness terminal agitation often believe it is the dying person's existential response to death's approach," a physically "visceral way" in which the body "react[s] to the shattering of inertia." After all, as she puts it, "We squirm and cry out coming into the world, and sometimes we do the same leaving it" (Manning Peskin, New York Times, 6/20).

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