Being in the presence of the dead - Terminally ill patients frequently see or talk to someone who has already died.

Preparing to travel or change - Communications about going home, standing in line, or going on a trip may be references to the patient's desire to complete the dying process. Sometimes those who are dying want family members to give them permission to leave.

Seeing another place - Many dying patients have glimpses of "another world" or have feelings of being in "another place".  This may happen several weeks before death.  Usually the dreams or feeling are comforting, but sometimes they create anxieties about mental dysfunction.   We need to provide reassurance that such experiences are normal.

Choosing when to die - Sometimes the dying wait to die until after they've had a chance to visit with a special family member.  On other occasions they may wait until a loved one has left the room.  Very private people may actually prefer to die alone.

Knowing the time of death - On most occasions terminally ill patients seem to know when they are going to die, even when no one else sees any signs of rapidly approaching death.  Patients may call a loved one in the morning to say good-bye, knowing death will have occurred before the next visit.

Pflaum and Kelley remind us communication with our patients continues throughout the dying process.  As our patients are dying we need to let them know we are still listening.

1. Respond in an accepting way to whatever they see or hear
2. Ask gently questions about what they are seeing
3. Ask them to repeat statements we don't understand
4. Support them in their leaving by acknowledging the difficulty of "letting go"
5. Be aware when they don't want to talk and remain in silence