Death Becomes Her: Writing About Death
by Out of the Darkness
One of the hardest things to write about for a lot of writers is death scenes. This is understandable, because it’s an uncomfortable topic in life and not one that most people deal with up close and personal. However, if you write fiction, your characters are going to encounter it. The death of a loved one, be it on the battlefield or at home, is a great motivation for your character to act. The act of caring for a dying family member or friend is hard and pushes characters to examine who they are. So for those of you who aren’t often on the front lines, this post is to help you know what your character will experience a bit better.
The first thing to understand is that death on the battlefield or of a quick illness (like an aneurism bursting) is sudden, and the movement around the character may prevent an immediate response. This can lead to delayed grieving, survivor’s guilt, second guessing their response, and the feeling that the person who died is merely missing for a bit and will return soon. In real life, bereavement counseling is extremely helpful. On the other hand, lingering or overwhelming grief may be just the type of torture- I mean character development- that you need to push things along.
For long term illnesses, it’s a totally different experience. When death is near, there are a number of sights, sounds, smells, and experiences that your character will be aware of on some level. If your character is some kind of supernatural critter with extra sharp senses, they are probably more aware of them than normal. So the rest of this post will be devoted to breaking things down along that line.
What is it like to take care of someone with a terminal illness?
More often than not, it’s exhausting. People lose control of bowel and bladder, and they have to be changed or else they get bedsores and/or infections. They have to be bathed and dressed. Often times people have a harder time swallowing food and you have to find soft food to feed them or put meals into a blender to make them soft enough to swallow easily. They need meds, and you’re probably going to have to crush up medications and put them in pudding or apple sauce. They have pain and anxiety at odd hours and you have to get up to take care of them. They have changes happening in their body and maybe their mind, and you are desperately seeking out information and wondering when they’re going to die. You’re tired, so tired, and grieving while trying not to let your grief get in the way of doing what has to be done. You’re hoping that they’re going to die soon, if only so they stop suffering, and then you’re feeling guilty for hoping that they die.
There are often family issues to deal with, and people in the family who refuse to accept that death is coming and want to “do everything to save them” and that just adds to the exhaustion. Maybe you have hospice care to help with some of this. Maybe you don’t. Being the primary caregiver for a terminally ill person is like being on the front lines of a battle, constantly, for an undetermined period of time that could be years or days depending on what is causing the death and the will of the dying person to live.
What does it look like when people are about to die?
This section covers what you might see. In the days before most deaths, the person’s skin changes. They become pale, even when very dark skinned, and the skin takes on a waxy tone. They’re probably running a fever and not sweating much because they’re too dehydrated to sweat. As blood flow starts to move away from the arms and legs, fingers and toes start to turn darker in dark-skinned people and a purplish-blue in pale people. This discoloration looks like bruising and can come and go almost at random in the days before death but quickly becomes very permanent as death approaches. It can move up the arms and legs, but happens sooner in the legs for most people. It’s not uncommon for it to move up to the knees and into the thighs. If the person is dying of liver failure, their skin will have a yellowish tint that will first be noticed in the eyes. After death, gravity takes over pretty quickly and blood pools on whichever side of the body is facing the ground. The rest of the skin looks translucent in light-skinned people and ashen in dark-skinned people.
Breathing also changes. At first, people breathe more rapidly. They look short of breath. This can be helped with oxygen, if the person will tolerate it. A lot of people won’t. They’ll pull at the tubing and try to get it off. This is usually caused by anxiety, which can be helped with medication. In the hours before death, people start breathing fully through their mouths. Their chest heaves and their abdomen seems to be doing most of the work. This is called accessory muscle breathing, and it happens because the diaphragm muscles are failing. This will continue until breathing stops.
The person will urinate less and less until they stop urinating at all. They will have more trouble having bowel movements due to lack of strength to push the stool out. Often at the time of death, as the muscles relax the person will release stool and/or urine. They should be cleaned up in accordance with whatever your religious standards are. Many religions have special requirements for this, and you should look into this if your character is a different religion than you are.
What Will I Hear?
A lot of people have heard of the death rattle, but don’t have a realistic idea of what it actually sounds like. It’s a wet, raspy sound. If you have one of the fountains for your cats and have ever let it get really low on water, that’s pretty close. Another way to describe it is a moist crackling or popping sound. It can be heard without a stethoscope and pretty much anywhere in earshot of the person. You can hear it on every exhalation. It sounds like it’s coming from the lungs and throat at the same time, and that’s because it is. There is medication that can help (Atropine most commonly), but it’s as much for the family’s peace of mind as for the dying person. Secretions can also be suctioned out of the mouth and that helps a bit too.
The open mouth breathing sounds very raspy and loud even without the death rattle. There’s a definite wheeze there. The person is struggling to get enough air in because as they are dying, the body is moving blood flow to the core organs and away from the arms and legs, which leaves all that sacrificed tissue telling the brain that it’s not getting oxygen. It sounds like a fight to get air in, and it kind of is.
If your character is a medical type, they will use a stethoscope to listen to the bowel sounds, which are noted during the death process by being slow at first and then absent as the body shunts blood away from the bowels and they stop moving at all. Absent bowel sounds are most common within 24-48 hours of death.
If the person is on an oxygen concentrator or other equipment, there will also be the sounds of the machines running in the background. They’re fairly loud depending on the model and their maintenance level, but they quickly become background noise.
What Will I Smell?
By and large, there isn’t a lot of smell involved until the very end unless the person has wounds. Infected wounds or especially tumors that have grown outside the skin are one of the worst smells on the face of the planet. The smell of exposed tumors is rancid and acrid, and extremely strong. You can smell it anywhere in the room. Infected wounds are best described as a rotting meat smell that sometimes has notes of bitterness or sweetness to it depending on what kind of infection we’re talking about. There will also be the smell of urine and/or fecal matter if the person isn’t kept very clean.
The smell of impending death is something else altogether. It is the result of the liver and kidneys shutting down, and it’s most noticeable within 24-48 hours of death, especially when one is changing the briefs of the dying person. It’s a smell like an old cider press, sweet in the same way that rotting apples are and just as cloying. This is because the smell is actually ketones and ammonia in the urine, but the smell is unmistakable once you know it. Animals and humans alike respond to it on an instinctive level. Even if you’ve never smelled it before, you are repelled by it. Families will ask caregivers to wash the person over and over again, but nothing gets rid of it. For anyone who has ever cared for the dying, when someone says, “It smells like death,” that cloying smell is what comes into your head.
During the process of active death, several changes in vital signs are pretty good indicators that the time is coming. Blood pressure measured on an extremity (usually the arm) gets lower and lower until you can’t read it at all. Oxygen saturation (measured with a pulse oximeter on the finger) gets lower and lower until the hands are too cold to get a reading at all. The heart rate goes wildly high and then starts to drop off until the heart is hardly beating at all before it stops forever. Most people will breathe very rapidly at first (I’ve seen as high as 42 breaths/minute), and this will eventually slow down with longer and longer pauses (periods of apnea) between breaths. In the last moments, it’s very easy to think that they’ve stopped breathing altogether only to have them take another breath 45 seconds or a minute later. This is a huge source of anxiety for families, because they wonder whether the person is actually dead or not.
Keep in mind that this is NOT a comprehensive list, only a general outline for the purpose of helping you write with a more authentic touch. It is NOT a substitute for medical advice. It is also a generalized overview, because the process of death is incredibly unique. Some people just die all at once and some people drag on for weeks. A lot of it depends on individual temperament and the person’s level of acceptance of their own death. I will also note that this doesn’t always happen in a straight line. Some people seem to get better for a day or two and then decline rapidly. Some people do that several times. This causes a lot of confusion because family members will think that their loved one is getting better and will breathe a huge sigh of relief just in time for the person to plunge back into the decline.
Terminal lucidity is also remarkably common. This is a phenomenon in which a person who was unresponsive due to coma, advanced dementia, or massive personality shift becomes responsive again for a brief period of time before death. Sometimes for a few moments, occasionally as long as a couple of days. This is a great time for family members to say goodbye or enjoy some last sweet memories before the loss of a loved one. It’s common enough that those who deal with the dying start circling the wagons as soon as it’s noticed because they know that the time is coming and soon. If they’re on hospice, they get bereavement ready and the number of visits will go up or they might bring in round the clock nursing care. If they’re in a hospital and the person doesn’t have a DNR on file, they get the crash cart ready. It’s a remarkably telling sign, but it’s also a gift to the dying person and their families that medical types try to respect by encouraging them to spend the time together.
Death is a universal experience and nearly every good book has at least one. Hopefully this post has given you a better idea of what it looks like so that you can write your death scenes with more accuracy and better detail. If you need a reference for dealing with grief in your characters, I wrote a post on According to Hoyt in January that you may find helpful: https://accordingtohoyt.com/2018/01/31/the-right-way-to-grieve-and-support-the-grieving-by-out-of-the-darkness/
Now go forth and write!