Last Breaths – Evidence-Based Nursing Blog

This week’s blog is written by Dr Sarah Russell (@LearnPEOLC) who’s the Lead Palliative and End of Life Care Nurse at Portsmouth Hospitals University NHS Trust and can also be a @FNightingaleF Fellow.

Diagnosing dying may be difficult. Physicians have limited accuracy in predicting patient survival (Hui et al. 2011), and prognosis within the context of palliative care typically relies on clinicians’ subjective judgment (White et al. 2016). Although there could also be biomarkers that indicate a typical biological process resulting in dying (Reid et al. 2017), there may be probably no single symptom pathognomonic for dying (Kennedy et al. 2014). However, considerations of changes in respiratory (particularly Cheyne-Stokes respiratory) are often encountered within the literature on dying and the management of dyspnea at the top of life.

This blog isn’t about diagnosing dying. It’s in regards to the last breaths of life and what which may mean in how people select to make use of their last breaths.

“The silence between this breath and the subsequent,

It could also be – it isn’t yet – death.” (Wright 1955)

Over the years of working as a nurse in palliative care, I actually have been asked repeatedly “is this their last breath?” On average, an individual will take 7.5 million breaths per yr, or 600 million in a lifetime (Thorley 2021). Every day and in all places, a dying person’s respiratory could also be accompanied by family and friends, health care and social care employees. As death approaches, the ultimate days, hours and minutes of life can seem to be a continuing cycle “inhale and exhale” until that last breath.

“Last breaths, last breaths,

Quiet breaths flow gently.

Relaxed, rested face,

Death is approaching

Neither fast nor slow” (Russell 2021)

I consider that the query in regards to the last breaths is barely different from the query “How long do I have to live?” An attempt is made to diagnose dying based on a linear timeline of minutes, hours, or days; the second concerns the meaning of those moments of the last breath. Importantly, these questions will let you express your emotions and regrets “give words of sadness” (Shakespeare 1599).

Perhaps the last breaths help us understand how we come to know death (Jaworski 2014), to be present within the spaces between life and death, between certainty and uncertainty, known and unknown, present and future outside. This isn’t unknown within the evidence base. For example, Steinhauser et al. (2000), of their seminal work on the seek for a superb death, provided examples of situations through which, despite extreme shortness of breath, people use their last breaths to ascertain and maintain relationships moderately than control and alleviate respiratory difficulties.

I actually have been reminded of this previously during an assessment visit with an individual within the last weeks of their life. In the cacophony of a busy hospital ward, flashing alarms and beeping buzzers were at odds with the shortness of breath. Holding their partner’s hand tightly, they talked about “what if, what next and when” for his or her future death. Pausing for a moment, they turned to me and asked: “Did we tell you about the balloon?” I shook my head, intrigued. “We came up with this crazy idea to blow some of our breath into a balloon.”

If “words come from breath”, (Shakespeare 1599), so what else does breath represent? Raaf (2007) argues that respiratory isn’t only a conversational tool, but additionally incorporates biological material specific to a given person. Breaths represent the presence of life (Jaworski 2014) through the movement of the chest during inhalation and exhalation, gas exchange and the perfusion of cells with oxygen. Leder (2018) suggests that respiratory isn’t only the physical motion of the lungs, but additionally of the mouth, nose, face and chest. In the last moments of life, slowing down and the last breath develop into a visual, physical manifestation of the intersection of living, dying and death.

Perhaps the act of respiratory is a conscious and unconscious act, a physical, emotional, social, psychological, spiritual and non secular act. Shapiro (2019:E1) illustrates this by arguing that last breaths have religious symbolism: “the soul leaves the body with the last breath and helps the soul on its journey if those present recite the ‘Shema’ prayer as the individual takes his last breath.” Halkias (2007) and Gandevia (1970) describe the worldwide importance of breath for culture, religion and anthropology, giving examples of the connection of breath with Buddhist meditation, the breath of gods within the Judeo-Christian tradition, and the person manifestation of the immortality of the human soul through prana in Tibetan medicine.

So where does this leave us in terms of the importance of the balloon?

Holding their last breath within the balloon meant that the words of affection and a part of their physical essence would remain after death. Last breaths meant not only assessing and prescribing for shortness of breath, but additionally allowing people to speak, tell or share things that were vital to them. Their last breaths within the balloon made them a visual symbol of themselves.

Now, each time I evaluate a dying person, I feel not only in regards to the pathology, radiology, diagnosis and medications, but additionally about what those last breaths mean to them and people who look after them. Last breaths symbolize the connection between life and death, living and dying, and the way people need to use these last breaths.

“The space in between

Space behind you

Space in front,

Everything empty and full.

Last inhale, last exhale.

Now it’s gone” (Russell 2021)

What do you’re thinking that?

Bibliography:

Gandevia, B., 1970. The Breath of Life: An Essay on the Earliest History of Respiration: Part I. Australian Journal of Physiotherapy, 16(1), pp. 05-11.

Halkias, G.T., 2007. Between Breaths. IN I’m flying within the air, ANDir, art, architecture. Bakke M ACADEMY publications.

Hui, D., Kilgore, K., Nguyen, L., Hall, S., Fajardo, J., Cox-Miller, T. P., Palla, S. L., Rhondali, W., Kang, J. H., Kim, S. H. and Del Fabbro , E., 2011. Accuracy of clinicians’ probabilistic and temporal predictions of survival in patients with advanced cancer: a preliminary report. Oncologist, 16(11), p.1642.

Jaworski, K., 2014. The breath of life and death. Cultural criticism, 86pp. 65-91.

Kennedy C, Brooks-Young P, Brunton Gray C, Larkin P, Connolly M, Wilde-Larsson B, Larsson M, Smith T, Chater S. 2014., Diagnosing dying: an integrative literature review. BMJ Support Palliative Care: 4:263–270.

Leder, D., 2018. Breath as the important thing to illness and healing. Breathing atmosphere :219-231.

Raaf S., 2007. Breath cultures. I’m flying within the air, ANDir, art, architecture. Bakke M ACADEMY publications

Reid VL, McDonald R, Nwosu AC, Mason SR, Probert C, Ellershaw JE, et al. 2017., A systematically structured review of biomarkers of mortality in cancer patients within the last months of life; Exploring the biology of dying. PLoS ONE 12(4)

Russell S., 2021 The last breath within the anthology of vigil after death. Unpublished works.

Shakespeare W., circa 1599 “The Tragedy of Hamlet, Prince of Denmark”

Shapiro, M.F., 2019. Last Breath – Enriching End-of-Life Moments. JAMA Internal Medicine, 179(7): 865-866.

Steinhauser, K. E., Clipp, E. C., McNeilly, M., Christakis, N. A., McIntyre, L. M., and Tulsky, J. A., 2000. In search of a superb death: observations of patients, families, and providers. Ann Intern Med, 132: 825-832.

Thorley, J., 2021. The Breath of Life. Lancet Respiratory Medicine, 9(9), pp. 954-955.

White, N., Reid, F., Harris, A., Harries, P. and Stone, P., 2016. A scientific review of survival predictions in palliative care: how accurate are clinicians and who’re the experts?. PLOS one, 11(8),

Wright, J. 1994. Collected Poems: 1942 – 1985. Pymble, Australia: Angus and Robertson

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