Practical Hospice Care

By: Birgitt Bahlmann

Thanks to the growing hospice movement and changing health care policies, many seriously ill and dying people are again being cared for in the home. This is an act of great responsibility, love and courage. It is also a deeply enriching time, when medicines are less important than simple humanity.

The first step is planning for a part-time nurse or relative to share in the extra work so that it does not become unmanageable over time.

Terminal illness is often accompanied by weight lost and weakness. Digestion and elimination becomes difficult. At the same time sense perception is heightened—a wide-open door, to unspoken soul gestures or moods. The caregivers should clarify their own relationship to illness, death, and to the patient. It is not necessary to have an answer for everything; just to be aware of one's intentions and feelings. Needs must be intuited through sensitive observation.

Bed Care
As life forces ebb there is always the danger of an additional acute illness. Preventive measures should be undertaken, but always in an observing, loving way and not against the patient's resistance. Excessive routine is avoided. Positioning the patient is extremely important. Each individual is different. How can they be made comfortable? How can we creatively enhance the room?

Body Care
Aromas should be on the light side, and the caregiver should find out which ones are tolerated. Almond oil or a light rose essence may be preferred.

Lavender in every form is often welcome, especially Aurum Lavandulae Ointment around the heart region. Aurum is gold, the metal related to the sun, which is related to the heart and to courage. It is important to address the heart/breathing region during the dying process to help alleviate fears and difficulty.

Weleda Citrus Deodorant or a light cologne are refreshing and Lavender Water has a harmonizing effect. However patients should be "forewarned" with a touch of the substance on wrist or neck so they are not startled.

Lightly massaging the hair near the scalp in small circular motions with lavender oil can also be very comforting.

External Stimuli
Avoid noise. The patient is working hard and needs an appropriate setting. When speaking, a low voice is tolerated better than a high one.

Whispering is not recom­mended either. Even though patients may appear withdrawn and less communicative, their hearing is sensitive and they need information as to what is going on. Whispering makes them insecure. Any discussion not for their ears should be conducted elsewhere.

Let honesty and candor, combined with tact and hope prevail. In their deepest souls, patients know very well how it stands with them.

Radio or television, if used at all should be kept to a minimum. On the other hand occasional original music can nourish and facilitate the harmonious dying process.

Bright lights are to be avoided but daylight should enter the room.

Fresh air is welcome as long as it is not too cold or too hot.

Often patients will have no desire or will to eat, and the caregiver has to ascertain what kind of nourishment can be assimilated. What is the "will of the organs" and does the patient have the will to live or not. The problem becomes acute when the patient can no longer respond. The caregiver's duty is not to let anyone starve or dehydrate, but it is a question whether induced feedings can still be handled by the organism. Signs such as weight, stools, the existence of electrolytes can reveal this. Quality and simplicity is important. Quality addresses the heightened sensitivity, simplicity reduces irritation.

Delicate seasoning is best, even for someone who previously loved spices. Many patients are grateful for fruit juice, especially if freshly pressed, warmed or frozen into small ice cubes to freshen the mouth. Herb teas and uncarbonated mineral water are usually well tolerated. Flaxseed is helpful for sensitive digestion cook 1 teaspoon flax seeds in 500 ml spring water; allow to steep for 20 minutes and then strain. A teaspoon of almond paste and lactose can be added). For someone who is dose to departing, a small teaspoon of weak herb tea can be administered.

Even with minimum food intake bowel movements are necessary. Homeopathy and anthroposophical medicine offer gentle remedies, to be discussed with the physician. A massage with Melissa 10% Oil in the morning over the thighs and stomach supports the bowels. After the massage, wrap a flannel cloth over the stomach for warmth.

Altogether warmth is often unstable during the dying process, varying between sweating and freezing. Warmth should be kept regulated at all costs.

If there is fever or perspiration, a quick wash with Weleda Citrus Bath is recommended, just as long as it doesn't cool down too much.

Sage tea in the washing water has a regulatory effect.

For comforting warmth rub Wala Solum Uliginosum Oil (warmed in the hands) into the skin, then cover with a light bunker, wool fleece or a flat hot water bottle wrapped in terry cloth.

Rosemary is an ancient remedy for the dying. Cold limbs and feet are helped by a rub with Rosemary ointment.

The Soul
Support for the soul might take the form of a fairy tale or myth during the transition from day to night. These ancient stories often contain wisdom and allegories of life's turning points which a dying person can understand just as a small child does.

Any favorite literature or poetry will be gratefully received, and perhaps a prayer or song. With careful observation the caregiver will know when to choose the right moment.

Interest in what is happening around should always be encouraged even if there is initial resistance: whether living or dying we are in the service of life. At a seminar on death and dying Michaela Gloeckler, M.D. of the Medical Section in Dornach has been heard to say, "I have had to deal with death and dying so much during my life, I don't want anything to do with it when I die."

The Will
If the dying person becomes restless it may be that there are still affairs to be regulated. Here one can feel one's way in, and experience the patient's gratitude. S/he can express a wish for a last will, a visit from a rabbi or minister, the writing of a letter, or destroying private papers. This all helps to clear the way.

There is another kind of restlessness before death. It might be described as the meeting with one's own double. The patient may become aggressive or abusive. It is crucial that the caregiver doesn't take this personally but rather stays with the patient, trying a prayer or meditation to "drive away" the double experience. Where this is possible it is a real help to the dying one.

At the Moment of Death
When death nears it can be recognized by certain signs. Breathing often becomes loud, which may be hard to bear for the caregiver. However the patient probably does not suffer as long as mouth and nose are free.

The facial expression is watched, to see whether medical or other care is needed.

In the last phase, breathing becomes less frequent and deeper, with many pauses between. Blood vessels shimmer through the skin; the ear lobes become bluish; and feet and hands are like marble.

Frequently, body fluids are lost. There may be restlessness and previous high fever might abate.

Each death is as individual as the life that has been lived.

And then comes the magical moment when peace enters, and a vibrant unusual quiet. There is no need for activity other than to take note of the moment of death, and then a quiet, contemplative observation of the event.


Birgitt Bahlmann is a practical nurse and care instructor in Germany. She has many years experience with the dying. Currently she is employed by Weleda, AG.

This article was translated from the Weleda, Germany publication "Advisor" (Ratgeber "Haeusliche Gesundheits and Krankenpflege), Issue 2000. Most of the remedies, unless otherwise noted, are available from Weleda.