Hospice Eligibility for Dementia Patients: Part One — Disease-Specific Criteria

Dementia is common, debilitating, and heartbreaking. The many forms of this disease, including Alzheimer's dementia (or “disease”), Lewy Body dementia, and vascular dementia, all cause cognitive impairment, memory loss, impaired functioning, and varying degrees of physical (or motor) impairment. While medication may delay the progression of dementia (depending on type) – and only modestly at best -- the disease is invariably progressive, and ultimately robs its victims of the ability to recognize loved ones, talk, get out of bed, feed or take care of themselves, and eventually causes death. The course of this terminal illness is about 7 to 10 years. Dementia is increasing in prevalence as America ages; it is estimated that more than 9 million Americans aged 65 and older could be living with dementia by 2030, and nearly 12 million by 2040.

For a more detailed description of the different types of dementia, see, Understanding Dementia Progression, Hospice Eligibility, and the Importance of the FAST Score.

How to Qualify for Hospice with Dementia Under Medicare

The Connecticut Hospice can provide much needed information and help for the care of people with dementia. However, to be enrolled in hospice, a loved one with dementia must meet Medicare’s requirements for eligibility. Unsurprisingly, these are far from straightforward. Hopefully, this post will help you better understand them such that you can effectively advocate for your loved one and obtain hospice services.

Per Medicare, a physician must certify a prognosis of six months or less “if the terminal illness runs its normal course” for a patient to qualify for hospice. For people with dementia, such a prognosis can be established by two methods.

Medicare’s Disease-Specific Guidelines for Alzheimer’s and Related Dementias

One is by using Medicare’s “Disease Specific” guidelines, which establish very particular criteria as to both the type of dementia a patient must suffer and its severity.

Dementia Diagnoses That Meet Medicare Hospice Criteria

The type(s) of dementia required by Medicare are called “Alzheimer’s Disease and Related Disorders.”

Again, Medicare is very specific. Your loved one must be diagnosed with Alzheimer’s disease or have one of the several other possible causes of cognitive impairment (see below*). Most of these additional diagnoses are relatively rare. Fortunately, however, one, “senile degeneration of the brain, not elsewhere classified” – broadly defined as progressive decline in cognitive function, including memory and reasoning, associated with old age and not specifically due to Alzheimer's disease or other explicitly defined conditions -- provides a work around for hospice enrollment. That is, your loved one must either have Alzheimer’s dementia, one of the other less common causes of cognitive impairment, or “senile degeneration of the brain” to qualify for hospice.

FAST Score Requirements for Hospice Eligibility with Dementia

Next is the severity of illness. This is where the FAST score comes in. FAST, or Functional Assessment Staging Tool, is a scale used to evaluate functional decline in individuals with Alzheimer’s disease and other dementias. A FAST score of 7 or greater, ranging from “a” to “f,” is required by Medicare for hospice enrollment.

A FAST score of 7 means that dementia is advanced, and the afflicted individual is unable to walk, dress, bathe, or toilet without assistance, is occasionally (or always) incontinent of bowel and bladder, and has speech limited to six or fewer words in a single utterance. A patient with FAST 7a or b may still be able to walk with assistance and eat independently, though some hospices require a score of 7c, meaning they are no longer able to walk at all.

For those with FAST 7a, Medicare also says they “should have had” one of several medical complications in the year prior to enrollment. These complications include pneumonia, kidney infections, sepsis (bacteria in the blood), severe bedsores, recurrent fever, and reduced oral intake with a 10% weight loss in the prior six months or a serum albumin (a blood test measuring body protein) of 2.5 or less.

Other conditions that contribute to eligibility include “functional status,” including level of consciousness and ability for self-care, and “co-morbid” diseases such as hypertension, diabetes, stroke, thyroid disease, and other chronic illnesses.

Summary of Medicare Hospice Criteria for Dementia Patients

To summarize, you may seek hospice care for a loved one with dementia if he or she has an established diagnosis of Alzheimer’s disease or a “related condition,” is dependent on others for walking, dressing, bathing, and toileting, is occasionally (or always) incontinent, can only meaningfully use 6 or fewer words in a single utterance, and has suffered a complication like pneumonia in the last year, or has lost 10% or more of their body weight in the last 6 months. Eligibility is supported by increased caregiver needs, fluctuating level of consciousness, and the presence of other chronic illnesses. Some hospices may insist on a FAST score of 7c or greater (up to 7f), meaning they can no longer walk at all, in addition to the above complications.

Coming Next: Non-Disease-Specific Hospice Guidelines for Dementia

The next Connecticut Hospice blog post will explore Medicare’s “Non-Disease Specific” guidelines for enrollment in hospice, which may offer your loved one with dementia an opportunity to receive hospice care even if the disease is not quite as advanced as described in this post.

Understanding Respiratory Failure

Respiratory failure -- the inability to breathe well enough to maintain life -- is a very common consequence of a broad spectrum of medical illnesses. In fact, it is the final consequence of any illness that gets bad enough to cause death; people stop breathing and their hearts stop beating. The exception are people who suffer from a heart rhythm abnormality which causes their heart to stop prior to their losing the ability to breathe. In both cases, without further medical intervention, death ensues.

Natural Death vs. Treatable Respiratory Failure

For many, respiratory failure represents a natural death. For example, patients in hospice who are no longer benefiting from treatments directed to the management of their illnesses will get sicker until they eventually suffer respiratory failure. It is the hope of the hospice team that they will be able to enjoy the time that remains to them when while they are in hospice as much as possible before this eventuality.

For others, respiratory failure may happen while they are still experiencing and seeking treatment for a manageable or even curable illness. For example, someone with cancer may be benefiting from treatment directed towards its cure but still suffer pneumonia serious enough to cause respiratory failure. Without urgent respiratory support, that patient will die.

What Is Intubation?

This is where intubation comes in. This straightforward process involves inserting a tube called an endotracheal tube into a patient's trachea, or windpipe, fixing it into place, and attaching it to a machine called a ventilator that will do the patient’s breathing for him or her. This keeps the patient alive while doctors treat the pneumonia – or a wide variety of other problems -- and hopefully cure it, allowing the patient to breathe on their own once again. 

Alternatives to Intubation: CPAP and BiPAP

In some cases, patients may be treated with so-called noninvasive ventilation, meaning that rather than inserting an endotracheal tube -- or intubating -- a mask that covers the nose and mouth is strapped tightly on the patient and a combination of air and oxygen blown forcibly into the patient's lungs. Called CPAP or BiPAP, this procedure is a bit like driving a car at 60 miles an hour and putting your head out the window face first into the wind. Other people have partial respiratory failure. They can breathe on their own for a period of hours and then become exhausted, after which they are provided noninvasive ventilation to both keep them breathing and give them a rest.

Tracheostomies for Long-Term Ventilation

Sometimes, despite being treated for the condition that caused respiratory failure, patients are not able to breathe unassisted and doctors are unable to “extubate” them -- or remove the endotracheal tube. Many such patients are wide awake and enjoying a good quality of life and elect to remain on ventilator support. The intubation tube, however, cannot be left in long term. It has a doughnut shaped balloon at the end, which is inflated after insertion to hold it in place. This causes pressure on the delicate walls of the windpipe. Over the long term, this causes damage and scarring that can dangerously narrow the windpipe. Instead, a tracheostomy is performed. In this procedure, a hole is cut into the windpipe well below the upper trachea, where scarring is most likely, and a short J-shaped tube inserted into it to be connected to the ventilator. This tube can be taken out for cleaning and replaced, improving hygiene. It even allows the placement of a speaking valve that can return the ability to speak out loud to a patient who hasn't been able to do so for a period of days or even weeks.

Deciding on Intubation and Ventilatory Support

The decision about whether to accept intubation and ventilator support is highly personal. People who have treatable or even curable serious or life threatening illness may elect to be intubated while undergoing treatment in the hopes that, should they suffer respiratory failure from a complication like pneumonia, they will regain the ability to breathe on their own and resume treatment for their underlying illness. Others, with terminal illness where progression is inevitable may elect to decline intubation and ventilatory support and live out their lives in comfort and die a natural death at home in the company of family and friends while in hospice care. 

Breathing Support from Connecticut Hospice

Many patients receiving care at home from The Connecticut Hospice use CPAP and BiPAP, and some have used invasive ventilation with a tracheostomy at home. All three are options at our Branford inpatient unit.

Should you or someone you know be facing a decision about intubation and ventilatory support, the Connecticut Hospice Stand by Me Palliative Care program can provide additional counseling on treatment options in serious illness. We are here to help.

A Caregiver’s Guide to Crushing Medications for Hospice Patients at End of Life

When caring for a hospice patient, making sure they receive their medications safely and comfortably is essential. Sometimes, swallowing pills can be difficult for these patients due to various conditions, including trouble swallowing, weakness, or other complications. One way to help is by crushing medications, but not all pills are safe to crush. Knowing which medications can be safely crushed and which cannot is crucial to avoid any potential harm.

This guide will cover why some medications can be crushed, which types are generally safe, which are not, and how to crush medications safely.

Why Some Medications Need to Be Crushed

Many hospice patients have conditions that make swallowing pills challenging, such as:

• Dysphagia: Difficulty swallowing, which can result from neurological conditions, cancer, or muscle weakness.
• Nausea or Vomiting: Some patients may be too sick to swallow pills.
• Mental or Physical Decline: Weakness, dementia, or confusion can make taking medication by mouth difficult.

Crushing medications can help ensure the patient gets their necessary medicine without added stress or discomfort. However, not all medications can be crushed safely, so it’s important to know which ones are suitable for crushing.

Types of Medications That Can Be Crushed

While not an exhaustive list, here are some general guidelines on the types of medications that are typically safe to crush:

1. Immediate-Release Tablets
   These tablets release their active ingredient quickly and are usually safe to crush. Examples include some types of pain relievers, antihistamines, and blood pressure medications.
2. Some Chewable Tablets
   Chewable tablets are usually designed to be broken down in the mouth, so they can often be crushed and mixed with food or liquid if the patient cannot chew.
3. Uncoated Tablets
   If a tablet does not have a coating (such as enteric or extended-release), it is usually safe to crush. These coatings often serve a specific purpose, so plain, uncoated tablets are generally safe.

Medications That Should Never Be Crushed

Certain medications should never be crushed because it can change how they work, cause side effects, or even become dangerous. Here’s a list of common types that should not be crushed:

1. Extended-Release (ER, XR, XL) or Sustained-Release (SR) Tablets
   These medications are designed to release slowly over time. Crushing them can cause the entire dose to be released at once, which can be harmful. Examples include certain pain medications and heart medicines.
2. Enteric-Coated (EC) Tablets
   Enteric coatings protect the stomach from irritation or ensure the medication is released in the intestines instead. Crushing these tablets can lead to stomach upset or render the medication ineffective.
3. Capsules with Beads or Pellets Inside
   Some capsules contain tiny beads or pellets that are designed to release the medication slowly. Crushing them can destroy this timed-release mechanism.
4. Special Formulations (like sublingual or buccal tablets)
   Medications meant to dissolve under the tongue or in the cheek are designed for rapid absorption. Crushing them can interfere with this process.
5. Medications with Specific Coatings (e.g., film-coated)
   The coating is often there to protect the stomach, reduce side effects, or improve absorption. Crushing destroys this protection.

Common Examples of Medications That Cannot Be Crushed

Here are a few common medications often used in hospice care that should not be crushed:

• OxyContin (oxycodone ER): A long-acting pain reliever that should not be crushed due to the risk of overdose.
• MS Contin (morphine ER): Another long-acting pain medication that releases slowly over time.
• Effexor XR (venlafaxine): An extended-release antidepressant that can cause side effects if crushed.
• Protonix (pantoprazole): An enteric-coated medication for acid reflux that is designed to release in the intestines.
• Cardizem CD (diltiazem): A heart medication that controls release over time and should not be crushed.

How to Safely Crush Medications

When crushing medications is appropriate, it’s essential to do it safely to ensure the medication is administered correctly and comfortably. Here’s a step-by-step guide:

1. Consult with a Healthcare Provider
   Always consult with a doctor, nurse, or pharmacist to ensure the medication can be safely crushed. If a medication cannot be crushed, they may recommend an alternative form, such as a liquid or patch.
2. Use the Right Tools
   Use a pill crusher or mortar and pestle specifically designed for this purpose. Avoid using household items like spoons, which can be ineffective or unsafe.
3. Crush One Medication at a Time
   Crushing medications separately ensures there’s no interaction between drugs before they are administered.
4. Mix with Appropriate Foods or Liquids
   Mix the crushed medication with a small amount of soft food, like applesauce, yogurt, or pudding, unless otherwise directed. Avoid using hot beverages as heat can affect the medication.
5. Label Everything Clearly
   If medications are being prepared ahead of time, clearly label each one to avoid any confusion.
6. Check for Taste
   Some medications are very bitter or have an unpleasant texture when crushed. Ask the healthcare provider if it’s okay to add a small amount of sugar or flavored liquid to improve taste.

Alternatives to Crushing Medications

If a medication cannot be crushed, there are alternative options:

1. Liquid Form
   Many medications are available in liquid form, which can be easier for hospice patients to swallow.
2. Transdermal Patches
   For pain management and other conditions, patches that release medication through the skin can be a great alternative.
3. Sublingual or Buccal (Cheek) Tablets
   Medications designed to dissolve under the tongue or in the cheek can be an excellent option when swallowing is difficult.
4. Suppositories
   Suppositories may be used if the patient is unable to take medications orally due to severe nausea or vomiting.
5. Injectable Medications
   Some medications can be given as injections if swallowing is not possible. However, these are usually administered by healthcare professionals.

Final Thoughts

Caring for a hospice patient involves many special considerations, including how they take their medications. Crushing pills can be a helpful solution, but it must be done with care and the guidance of a healthcare provider. Always double-check which medications can be safely crushed and explore other options if needed. Remember, the goal is to ensure that the patient remains comfortable and receives the best possible care.

If you have any questions about medication safety for your loved one, don’t hesitate to reach out to your hospice team. They are there to support you and provide guidance every step of the way.

As we approach the end of life, our bodies undergo various transformations, both internally and externally. One of the most noticeable changes can be observed in our skin. Understanding these skin changes is crucial for caregivers, medical professionals, and loved ones to provide appropriate care and support. In this comprehensive guide, we will explore the common skin changes that occur towards the end of life, their causes, implications, and strategies for managing them effectively. Any and all of these changes are considered a normal part of the natural dying process.

Skin Changes in the Final Stages of Life:

• Pallor: As the body's circulation declines, the skin may become pale or even bluish in color due to decreased oxygenation to the skin’s surface.
• Mottling: Mottled skin appears as blotchy patches of discoloration, often seen first in the extremities. It occurs due to reduced blood flow to the skin's surface resulting in irregular patterns of pale and discolored areas. Mottling is a common occurrence in the last days or hours of life and is considered a normal part of the dying process.
• Dryness: Dehydration and decreased oil production can lead to dry, flaky skin, which may feel rough and tight to the touch.
• Bruising: Fragile skin and reduced clotting ability make individuals more susceptible to bruising, even from minor bumps or pressure. Bruises may appear more easily and take longer to heal as the body's ability to repair damaged blood vessels diminishes. Bruising is also more easily caused when patients are on blood thinners or anticoagulants. 
• Pressure Ulcers: Prolonged immobility can result in pressure ulcers, also known as bedsores, particularly in areas where bones are close to the skin, such as the heels, hips, and sacrum. These are nearly inevitable as the skin fails. 
• Skin Tears: Thin, fragile skin is prone to tearing, especially during movement or handling.

Contributing Factors to End-Life Skin Changes:

Circulatory Changes: Reduced blood flow to the skin contributes to pallor, mottling, and increased susceptibility to pressure ulcers. As the body's systems begin to shut down, blood is redirected to essential organs, leading to decreased perfusion of the skin and other peripheral tissues.

Dehydration: Diminished fluid intake or inability to process fluids properly can lead to dry, cracked skin. Dehydration is common in the end-of-life stage due to decreased oral intake, increased fluid losses, and metabolic changes.

Nutrition: Poor nutrition, common towards the end of life, can impair skin health and delay wound healing. Malnutrition, along with underlying medical conditions, can weaken the skin's structure and compromise its ability to withstand pressure and trauma.

Medications: Certain medications may affect skin integrity, moisture levels, and clotting mechanisms. For example, anticoagulants can increase the risk of bruising and bleeding, while diuretics may contribute to dehydration and electrolyte imbalances

Immobility: Limited mobility increases the risk of pressure ulcers and skin tears, as well as exacerbating circulation issues. Individuals who are bedridden or confined to a wheelchair are particularly susceptible to skin breakdown due to prolonged pressure and lack of movement.

Psychological and Emotional Impact of Skin Changes in Dying Patients

Skin changes can be distressing for both the individual nearing the end of life and their loved ones. Visible alterations in skin appearance may serve as a stark reminder of the person's declining health and mortality. Discomfort and pain associated with skin issues can also exacerbate emotional distress and affect overall well-being. It is important to discuss these changes with your medical provider and for the medical team to reassure and educate loved ones that these changes are a natural part of the dying process. Open and honest communication with the individual and their caregivers is essential to address concerns and provide reassurance. Emotional support, including validation of feelings and offering comfort, can help alleviate distress related to skin changes. Collaboration with healthcare professionals, including nurses, wound care specialists, and palliative care teams, is vital for comprehensive holistic care when it comes to managing these skin changes at end of life.

Strategies for Managing End of Life Skin Changes:

• Moisturize: Regular application of emollients or moisturizing creams can help alleviate dryness and maintain skin integrity.
• Positioning: Proper positioning, with frequent changes to relieve pressure points, can prevent some pressure ulcers.
• Gentle Handling: Handle the individual's skin with care to minimize the risk of skin tears and bruising.
• Nutrition and Hydration: Ensure adequate fluid intake and a balanced diet to support skin health and healing.
• Pain Management: Address any discomfort or pain associated with skin changes through appropriate pain management techniques. Use analgesic medications as prescribed and consider non-pharmacological interventions, such as massage or heat therapy, to alleviate pain and promote relaxation.
• Wound Care: Follow recommended wound care protocols for pressure ulcers, skin tears, and other skin injuries to promote healing and prevent infection.

Dignity and Comfort in End-of-Life Care

Providing dignified and comfortable care for individuals experiencing skin changes at the end of life is paramount. Respect for the individual's autonomy, privacy, and preferences should guide all aspects of care, including skin care routines and interventions. Encourage the individual or family members to participate in decisions regarding their care to promote a sense of control and agency.

Maintaining privacy and modesty is essential when addressing skin changes, as individuals may feel vulnerable or self-conscious about their appearance. Respectful communication and sensitivity to cultural and personal beliefs can help preserve the individual's dignity and promote a positive care experience. Additionally, incorporating rituals or practices that hold significance for the individual, such as religious ceremonies or personal grooming habits, can enhance their sense of well-being and spiritual comfort.

Skin Changes Are a Natural Part of Dying

By understanding the causes and implications of these changes and implementing appropriate strategies, caregivers and loved ones can help maintain the individual's comfort and dignity during this challenging time. Through open communication and compassionate care, we can support those nearing the end of life in their journey with grace and dignity.

Understanding Skin Changes Enhances Quality of Life

Understanding and addressing skin changes at end of life is essential for providing holistic care to individuals nearing the end of their journey. These changes, ranging from pallor and mottling to pressure ulcers and skin tears, are natural manifestations of the body's decline and require thoughtful management to maintain comfort and dignity. By recognizing the contributing factors, implementing appropriate interventions, and fostering open communication and support, caregivers, medical professionals, and loved ones can help alleviate distress and enhance quality of life for those in their care.

As we navigate the complexities of end-of-life care, it is crucial to uphold the principles of dignity, compassion, and respect for the individual's autonomy and preferences. Each person's journey is unique, and tailoring care approaches to meet their specific needs and wishes is paramount. Through this understanding, we can ensure that individuals facing skin changes at the end of life receive compassionate and comprehensive care that honors their humanity and affirms their inherent worth. Together, we can embrace the journey with empathy and grace, providing solace and support to those embarking on life's final chapter.

Connecticut Hospice recently held a ribbon-cutting ceremony to celebrate the opening of its Palliative Care Clinic. This celebration occurred shortly after the official launch of its Palliative Care Program, Stand by Me. In addition to meeting with our clinicians at their newly launched waterfront clinic, services can also be provided at skilled nursing homes and long-term care facilities.

Stand by Me Palliative Care Program

The Stand by Me palliative care service is a physician and APRN consultative program for the treatment of discomfort, symptoms, and stress caused by a serious illness. Palliative care works with primary medical practitioners to attain treatment goals, prevent or ease suffering, and improve quality of life. It gives patients a chance to live better, have better physical functioning, and decrease depression and anxiety.

What is Palliative Care?

The goal of Palliative Care is to improve the quality of life for patients being treated for serious illness. It is appropriate for all stages of treatment, starting at diagnosis. The focus is on relieving complex physical, psychological, social, and/or spiritual problems related to life-limiting or irreversible illness. It includes counseling on disease management to empower patients to better understand their illness and its treatment so they can choose the care best suited to their unique needs.

Palliative Care Symptom Management Includes:

• Pain
• Shortness of breath
• Fatigue
• Constipation
• Nausea
• Loss of Appetite
• Irregular or lack of sleep
• Side effects from treatment

Palliative Support You Can Depend On

Palliative care is available to you at anytime during the course of your illness. You can meet with a palliative specialist as little or more often as needed. Palliative care does not mean you are dying, it is about living better, healthier, and being as comfortable as possible. This all leads to a better quality of life and better engagement with loved ones. Very often, people under palliative care continue treatment of their disease and stabilize and graduate from the service. Palliative care is about living long and well!

Learn more about our Outpatient Palliative Care Services

Relief Without Delay

You should not have to endure unnecessary suffering from symptoms of disease or treatment. We respond promptly to calls for assistance, offering 24/7 support. We understand the urgency of your needs and can swiftly schedule in-person visits with our full-time Advanced Practice Registered Nurse, ensuring expert symptom management and counseling on disease management options within days, not months.

Call today to schedule an appointment: 203-315-7540

What's the difference between Palliative care and Hospice Care?

Click the links below to learn more about Palliative care vs. Hospice care.

Compassionate Care: Hospice vs. Palliative Care Insights

Palliative Care vs. Hospice Care—What You Need to Know

Mother of a Cancer Patient Authors a Guide to Palliative Care

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.