This article will include all of the following section:
- Definition of Mottling and Gurgling
- Mottling and Gurgling in the Dying Stages
- Mottling and Gurgling Symptoms
- The Stages Before and After Mottling and Gurgling
- Treatment for Symptoms of Mottling and Gurgling
- Telling family members that their loved one is close to death
- Hospice and Mottling and Gurgling
- Prognosis for Mottling and Gurgling
- Learning to Cope with Grief and Death
- Last Preventative Measures That Can Be Taken
- Final Thoughts on Mottling, Gurgling and Dying
Mottling and Gurgling at End of Life:
The end of life is a stage with which we all must come to terms. We are frequently reminded of this aspect through our media and other entertainment outlets. Watching a loved one slowly slip away is one of the hardest things a person can go through and, understandably, the processes of dying can be difficult and scary. Many people worry that doctors and others in the medical field do not communicate well enough to let them understand some of the key stages of the dying process. In this article, we will outline two of the more common prior to dying symptoms, mottling and gurgling, and we will sum up the other stages of dying while offering ways one can go about preparing for passsing.
Mottling is a condition of spotting with patches of color. The medical term for mottled skin is dyschromia or livedo reticularis. It is usually the result of cutaneous ischemia, or a lowering of blood flow to the surface of the skin. Mottling, commonly though not always, occurs when someone is near the end of their life.
Gurgling, also known as the death rattle, is the gurgling or rattling sometimes made in the throat of a dying person. It is due to the loss of the coughing reflex and passage of breath through a collection of mucous.
Mottling and gurgling commonly occur during the one to four-week period of the final stages of life, although there have been cases of those two conditions clearing up and not leading to the end of life. The first signs of mottling consist of body temperature highs and lows that leave the skin pale, cool, warm and moist, often with a mottled color in the outer extremities. Gurgling on the other hand consisted of congested breathing due to the buildup ofmucous in the back of the throat.
Mottling usually occurs in the lower members first (i.e. legs and feet). It then advances to the upper extremities as cardiac functions decline and circulation throughout the body becomes poor. Gurgling occurs in the back of the throat and lungs.
The pathophysiology of mottling usually involves:
- A quick change in body temperature
- Certain blood disorders causing mottled skin
- People taking anticoagulants
- Advanced age
- Excessive exposure to the sun
- Low platelet count
- Some medical conditions like lupus, rheumatoid arthritis
The pathophysiology of Gurgling
“Death rattles” are usually sounds caused by saliva and bronchial secretions accumulating at the back of the throat and in the lungs. These are caused by an interference with the swallowing reflex, likely the result of brain injury or dying.
- Hands, feet and arms feel cool to the touch
- The lowering of blood pressure and heart rate is erratic, at times fast or slow and labored, though weak
- Fingers earlobes and nail beds may look bluish or grey
- Because the body doesn’t need much energy in the final stages, the digestive system slows, and the desire for food lessens
- As eating and drinking slow down, the body gets dehydrated, which makes patients more tired and sleepy and often also less aware of pain or discomfort, something that is normal in the dying process
- Fever may occur as death approaches
- Fluids get thicker and build up in the throat and lungs
- Breathing sounds of rattling or gurgling may come and go through the process. This is not usually too discomforting
- Changes in breathing will occur, i.e. changes in the rate, depth,rhythm, and depth; also periods of not breathing for 5-30 seconds, or perhaps a slow and shallow pattern of breathing, speeding up, and then slowing down again
- Since the kidneys and bowels stop working, there’s a smaller amount of urine, which may be darker and the smell stronger
- Bowel movements become less frequent, thus causing a slight discomfort or constipation, after 3 or 4 days of not using the bathroom
- Vision may become blurry
- It is practical to assume that the patient can hear you even when they cannot respond
- Restlessness and irritation are typically the result of lack of oxygen to the brain -or physical pain
- Intermittent bewilderment may be prompted by interruptions in daily routines, illness or simply old age
- Being alert or aware may vary on occasion and depending on the individual
- Exhaustion is typical as well as having moments of alertness.
Treatments for mottling don’t always work. Here are a few options:
- Topical medications, such as retinoids, tretinoin and tazarotene are commonly prescribed
- Surgeries may also be warranted
- Chemical peels that come in different levels: deep peels (the phenol peel), medium peels (the 30% trichloroacetic acid peel), and lastly the superficial peel (the alpha hydroxyl and salicylic acid peel.); it should also be noted that people of a darker complexion should opt out of using the deep peel since they have been known to cause severe scarring and bleaching
- Photo rejuvenation is a skin treatment that uses lasers, i.e. intense pulsating lighting that helps to treat certain skin conditions. Doctors however warn that in most cases, there is no cure unless the underlying cause of the condition is reversed
According to many in the medical field, the best ways to treat gurgling include:
- Managing the condition physically through repositioning of the body and clearing the upper airways with a mechanical sucker (though suction is not always recommended)
- Wiping the outer mouth of excess saliva and mucous
- Managing the condition with medications, specifically with anticholinergic drugs (drugs used to block parasympathetic nerve impulses or involuntary muscle movements to the lungs and other parts of the body); it has to be noted however that these can produce side effects such as agitation, dry mouth, mental confusion in those 65 and older, hallucinations, and potentially other side effects, making it important for the patient to be closely monitored
- Be clear when speaking with the family memeber
- Be sure that the family member understands what is going on
- Address any questions that they may have
- Keep in mind that it is common for the family to be uneasy and not verbalize concerns
- Coaching the family so as to build a mutual understanding and trust, essential for good communication
- Assist the family in nurturing the dying loved one (i.e. help feeding and hydrating the loved one with ice chips or light foods like yogurt, and dabbing their parched lips); it should nevertheless be said that one should never force the ill person to eat or drink, for while their digestive system is shutting down, they may simply not have any appetite
- Explain to the family that hearing and feeling are the last senses to go; offer them support and advice on communicating with their dying loved one, with the following tips:
- Follow the ill person’s lead. If they are not feeling well, be sure to inform their doctor or care team. Also, listen to cues pointing to the patient being ready to discuss the end of life, e.g. they are exhausted and tired of being sick, or they want it to be over. Be sure to listen and ask questions to make sure you understand what is being said.
- Make sure to deal with regrets. Talk to the person about the issues of the past and making amends. Whatever their response, you will know at least have done what you could to address the past.
- Remind the loved one that you care for them. Say I love you often, and make sure when you leave to tell them goodbye in a way that is not regretful. Be sure to evoke that they will be important after they are gone.
- When words are no longer necessary or possible, a soft touch speaks immensely. Placing your hand on the loved one says that you are there for them during this toughest of transitions.
Hospice bring in the care and philosophy that focus on the palliation of terminally ill patients’ pain and other symptoms, providing emotional and spiritual support. When is the appropriate time to talk about bringing in hospice? When the ill person has reached a point that there are no viable medical options, hospice is often the route that is chosen. Common worries family members may have include the fact that that they are worried their loved one is going to suffer, although the goal of the palliative care team is to ensure that the end is as peaceful as possible. They also offer options like emotional and religious counseling to the ill person.
A prognosis is an estimate of the probable path and outcome of a disease or, alternatively, the probability of a full recovery from a disease. Many people think that doctors know how long a person is going to live but are withholding the information from them, when in truth, no one knows when the ill person will die.
Families of loved ones should abstain from pressuring medical personnel to give fateful predictions because of the variation in the length of time in which someone can live with a disease. In some cases, the sick person can live for months or even years, while others may die in days or weeks. If a dying person wants a specific person with them at their dying time, they may have to make indefinite allowances for that wish. There are times however when predicting a person’s time of death may be necessary. Hospice in particular may require a doctor’s projection of death within six months or less.
Rather than asking the doctor questions like, “How much time do they have?” or “their likelihood to die within six months,” it may be better to ask for a typical range of survival, i.e. the shortest and longest reasonable time one is likely to live. Doctors have to take a lot into consideration when trying to help predict a time of passing. They must consider a person’s illness and if it is expected to get worse. If the ill person is sick enough for the doctor to say that they would not be surprised if the person were to die within a year, you can then prepare for the possibility of diminishing health and the likelihood of death, and thereby also plan for their life to be as full and as comfortable as possible.
Some doctors may offer hope by speaking of rare recoveries patients have made, without mentioning the high probability they have of dying from a serious illness more quickly. Seriously ill people and their families often find this “hope” to have been misleading or disparaging. Patients and families are entitled to the most realistic information and prognosis viable, but it is important to clearly express their preference for realistic rather than a more optimistic prognosis.
It is common at end of life stages to feel anxious or experience feelings of hopelessness, and getting help during those tough times is important to your mental and emotional well-being.
It is common to go through the 5 stages of grief (denial, anger, bargaining, depression, and acceptance), although these need not occur in any order. Denial is often a temporary response to immense fears of loss of control, an uncertain future, pain and suffering considerations, and detachment from loved ones. Speaking with a doctor or health care practitioner can provide some clarity in realizing that you do still have control.
Anger may be expressed as a sense of injustice: “Why me?” Bargaining can be a sign of reasoning with death or desire for more time, but when people realize that it isn’t working, depression may develop. Acceptance, sometimes described as facing the inevitable, may come after patients speak with their family, friends and care providers.
The same can be said about the family members. They too go through the 5 stages of grief, although these may be experienced at different stages of the the dying process. Often times when it is more evident the loved one is going to die, they may have feelings of anxiousness, regret, and fear. Receiving some type of counseling, be it from a therapist, doctor, family members, or religious leaders, may offer help and ease you through this process.
Talking to the loved one and asking them how they are feeling as well as what they may want also helps. Understanding and getting affairs and desires in order before they pass may seem like a daunting task, but you’ll often find that asking about this gives the ill person a sense of relief because they may have felt anxiety from bringing it up with you.
Simply being there for the ill person and lending a hand or an ear can be a way to cope and give you the understanding you need to best prepare you.
While there may be no way to prevent mottling and gurgling in a dying person, there are ways of treating these conditions:
- Turning the patient every two to three hours to help the sick person drain their mouths and keep them from choking on their own saliva and secretions
- Ensuring that they aren’t significantly dehydrated, although some patients may need an IV if they can no longer swallow on their own
- Assuring that the patient is comfortable by supporting the extremities with soft pillows
- Using a fan or opening a window to circulate the air for the loved one if they are too warm
- Cover them in blankets to ensure their warmth if they are cold
- Keep in mind that palliative care, essential for the comfort and quality of life of the loved one, focuses on providing people with relief from pain, physical stress, and the mental distress that accompanies an imminent prognosis of death
Mottling and gurgling are some the most common indicators that an individual is in the final stages of life. Understanding these symptoms and how they work are particularly important in determining what is to be done next. In addition, communication with doctors and family members who are involved in the proceedings is necessary. Coaching from the doctors on how to help alleviate some of the patient’s strain, such as touching and loving words, can offer you and the patient a sense of ease and stress-relief. The last stages of the dying process can seem distressing to all concerned, but with the proper information, you will be better prepared to deal with life’s most important stage.