PDF Summary:Gone from My Sight, by Barbara Karnes

Death is an inevitable part of life, yet many of us don't know what to expect when someone is dying. This lack of knowledge can leave family members and caregivers feeling anxious, unprepared, and uncertain about how to provide comfort during a loved one's final days.

In Gone from My Sight, hospice nurse Barbara Karnes describes the physical, emotional, and behavioral changes that typically occur in the final months of life. You'll learn about the signs that indicate someone is approaching death—from changes in breathing and body temperature to withdrawal and disorientation—and discover how each person's experience of dying is unique. Karnes provides practical guidance for recognizing these signs and understanding what the dying person may be experiencing, helping you provide better support during this difficult time.

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Karnes adds that breathing changes occur, with respiration either becoming faster or slower. Congestion may develop, causing a rattling noise in the upper respiratory tract. The person may cough but typically can't bring anything up. The congestion and shifts in respiration frequently occur intermittently.

The Brain’s Role in the Body’s Functions

All of these changes are the result of the brain’s inability to regulate the body’s functions. The brain controls the body’s temperature, blood pressure, and heart rate, so as the brain fails, these functions become erratic. The brain also controls movement, so as it fails, the person’s movements become aimless. The brain also controls the body’s ability to clear the airway, so as the brain fails, the person’s ability to clear the airway also fails, and secretions build up in the airway. The brain also controls the body’s ability to circulate blood, so as the brain fails, blood pools in the body, causing the skin to change color.

The person may also complain of fatigue and sluggishness. They might refuse food or fluids, and they could sweat more. Karnes adds that they might be disoriented, agitated, confused, or converse with people who aren’t there. They could sleep more but still respond to others, and they might be restless or inactive.

Additionally, their eyes may look glossy, watery, or partially open. Their knees, palms, and soles may be purplish and blotchy. Their pulse might be faint and difficult to detect. They may urinate less or have accidents in bed. Finally, they might be unable to be awakened.

(Shortform note: These symptoms occur because the body is shutting down. The blood vessels in the knees, palms, and soles are the smallest in the body, so they’re the first to stop receiving blood. This causes the purplish, blotchy appearance. The kidneys are also affected, so the person urinates less. Finally, the brain is affected, so the person can’t be awakened.)

Behavioral and Emotional Shifts

As someone nears death, they may withdraw and communicate less. Karnes notes that they might turn inward to reflect on their lives, sleep more, and lose the urge to connect with other people. Additionally, it's possible for them to become disoriented, speaking about people, locations, and occurrences that others don't recognize, and they might see and communicate with deceased loved ones.

(Shortform note: Decades before Karnes, psychiatrist Elisabeth Kübler-Ross described similar end-of-life experiences in her 1969 book On Death and Dying. Drawing on interviews with over 500 terminally ill patients, Kübler-Ross observed that many people nearing death gradually withdraw from external relationships and sometimes report seeing or conversing with already-deceased relatives. She argued that these experiences are part of how people approach death in their own way.)

Supporting the Dying Process

Let’s explore how you can support the dying person and their family and friends.

Understanding the Dying Individual's Experience

Karnes emphasizes that each person experiences dying uniquely. How they approach it depends on how they've lived and their readiness to release. Anxiety and unresolved matters can cause someone to resist death.

(Shortform note: Existential psychotherapy research supports the idea that how a person has lived and their readiness to release influence how they approach dying. When a person’s life story and current anxiety highlight unfinished roles, duties, or values, the mind clings to the need for more time to complete them.)