Bedpan Banter

Part 2 with Hospice Nurse Julie: How Honest Conversations & Science Ease The Fear Of Death

• SimpleNursing • Season 1 • Episode 7

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What if the moments that scare us most at the bedside are simply the body doing what it’s designed to do? We sit down with Hospice Nurse Julie, a New York Times bestselling author, to unpack the biology of dying in clear, compassionate terms and show how honest language can calm a room faster than any euphemism. From getting permission to “be candid” with families to explaining why IV fluids can backfire near the end, we focus on practical skills that turn fear into understanding.

We explore terminal lucidity—the rally or surge that brings a sudden burst of energy, appetite, and personality shortly before death—and lay out how to recognize it without false hope. Julie walks through the actively dying phase step by step: Chain Stokes breathing cycles, agonal respirations as brainstem reflex, and terminal secretions often called the death rattle. You’ll learn how to assess for real distress, when to use morphine to ease the work of breathing, why suction can increase saliva, and how simple repositioning and mouth care support comfort. The goal is humane, evidence‑informed care that lowers anxiety for everyone at the bedside.

We also open the door to experiences that many witness but few discuss. Julie shares a powerful shared death experience that arrived at the exact time a patient passed, and we talk about end‑of‑life “visiting,” where patients often see deceased loved ones. Whether you frame these events as spiritual, neurological, or both, acknowledging the trend validates what countless families report and helps them feel less alone. By pairing physiology with presence, and science with tenderness, we offer a guide to the last hours that is clear, grounded, and deeply human.

If this conversation helps you feel braver or more prepared, share it with a colleague or caregiver who needs it, and subscribe for more insights on the human side of healthcare. Your reviews help others find the show—leave one and tell us what you want to learn next.

To submit your stories & comments, visit: https://simplenursing.com/podcast/

Nurse Mike:

We got a code brown. Welcome to Bedpan Banter. With me, Nurse Mike, the Daddy of Nursing. Can I get a Bedpan over here? All right, continue our conversation with Nurse Julie, the hospice nurse, New York Times bestseller. Welcome back to Bedpan Banter, the official podcast of Simple Nursing, where we discuss the human side of healthcare. Welcome back, Julie.

Hospice Nurse Julie:

Thank you.

Speaker 1:

So for all of our nurses watching this, what is a lesson from your book, Nothing to Fear, that can help them provide better care even outside the hospice setting?

Speaker:

There's so many. I think to um not be afraid to say the thing you're afraid to say, or like the elephant maybe in the room. Like, be the one person who says, like, let me tell you about what you can expect with your end of life journey.

Speaker 1:

Is that how you would start it?

Speaker:

I would always word it like that.

Speaker 1:

Should they ask a question, like, do you want to know? Yes.

Speaker:

Do you want that's that's very good. Listen to him, not me. I guess because I'm always coming from like a hospice nurse perspective already, right? So we're like, they know they're dying. They already know. Right. But if they don't know, right, you can always say, like, do you want me to be a little candid with you about what what what I think is happening here? What I'm seeing. This is what, like, from my experience, that's what I always try to say. And also, if you're in a hospital setting, I would just like go rogue and just start telling all your patients, like, I think you're dying, right? But you can be the person who talks to the doctors and and says, Hey, can we have a a family meeting? I feel like the family doesn't fully get that this person might not make it. You know, they might not live. What do you think? Do you think we should start talking about that? Do you think just in in nine times out of ten, if that if that is truly what's happening, they'll say, Yeah, I think you're right.

Speaker 1:

Yeah. And this is mostly applies, I mean, it could apply to every department.

Speaker:

But also, I think too, if you want to just talk about even not just being a human being, right? Because in just really fully understanding and learning about death through the my book or watching me online or whatever other way you want to learn about it, right? I think helps you get a little more comfortable with the idea of death anyway. And then you being more comfortable somehow helps everything else proceed, right? You're suddenly more comfortable. So you're talking about it with your family, your friends. It just happens to start um and just things will unfold for you, right? I think yeah, I think it's important that people really um understand. I mean, if you're a nurse, if you're a nurse or a nursing student, to fully understand the biology of death, which is in this book. This one. Yes, is was fascinating to me. And I know as a nurse as a nursing student, I would have been like fascinated by it.

Speaker 1:

I'm fascinated right now because I'm like, geez.

Speaker:

There's like a biology, there's like a biology to death, which I I did not know that.

Speaker 1:

We need to animate this one and put it together. So speaking of the physiology of death, can you explain the rally phenomenon that happens near death?

Speaker:

Yes. So there are phenomena that happens at the end of life. So I talk a lot about like the science of end of life, the biology of it, right? And there's a whole chapter in my book, chapter six, about the phenomena that happened at the end of life. And there are certain things that are, I mean, dare I say, like medical mysteries. We don't know why they happen, but they happen all the time and they happen at end of life. And the one that happened the most is something called the rally or the surge of energy. Those are like the nicknames. The real name is called terminal lucidity.

Speaker 1:

Terminal lucidity. Yes. And this happens right before death or when? Right before death. So what like minutes?

Speaker:

Um, it depends. So the way it looks is someone looks like they're very, very sick, right? And like grandpa's gonna die, everyone comes into the room, he's gonna die. And then suddenly grandpa has, or it doesn't have to be a grandpa, it can be anyone, anyone of any age dying, um, has a burst of energy, hence the surge that they call it the surge of the rally, but burst of energy where suddenly they wake up, they're talking to normal, their like personality comes back, they're like sassy or jokey. Sometimes they walk around. Yes, yes, yes. So, and it can be as dramatic as that or something subtle where they wake up and say, like, I'm hungry, can I have my favorite cheeseburger or whatever, right? But the part that people need to know about is that they will die soon after. So it is not the rally if they don't die afterwards. So they it's like some people can like be looking very sick and then get better, and then they they prolong their life, right? The rally is sick, burst of energy, die.

Speaker 1:

Okay.

Speaker:

So they die. I mean, maybe a couple days after.

Speaker 1:

A couple days. Oh, okay.

Speaker:

I mean, sometimes it's hours. Okay, sometimes it's a day, a couple days, or at least they'll go back to where they were, right? So if they were like kind of in a coma, burst of energy, back into a coma, usually die a couple days later. And what happens is people are gonna be listening to this and they're gonna go, that happened to my aunt. So that happened to my like you just don't know what that is, right? People just think they're getting better and then they die soon after. Like my grandma, I didn't uh so my grandma died at 91. I think I was in nursing school at the time. My mom didn't know what it was, but after she heard me talk about the rally on social media, she called me being like, Oh my god, your grandma had the rally. I didn't know that's what it was, but yeah.

Speaker 1:

That's crazy. The science told us.

Speaker:

Yeah, there I mean we don't we don't know the science to what it is, but at least we know the trends.

Speaker 1:

Yes, yes, that's what I'm saying.

Speaker:

Yes, yes, there and it happens in one-third of all patients, so like one in every three.

Speaker 1:

We mainly focus our simple nursing videos on how the physiology of like what surrounds death, like the death rattle, Janey Stokes. Can you speak on those particular physiological processes?

Speaker:

Yes. So both of those things happen during the actively dying phase, which is the last phase of life. Almost everyone, if you're dying, a natural death, meaning you've your bot, your body has gotten some time to slowly progress to this phase called the actively dying phase. And your body will start doing certain things, which I'll get to, like chain stokes breathing, the death rattle. And it's very, very misunderstood. So I've had so many people write into me and say, my loved one had the most horrific death. It was so traumatizing to watch. They were gasping for air, they were, they were suffocating on their own fluids. And I think to myself, one, I don't want to take away their experience and go, hey, no, it no, that wasn't bad, right? I know if it feels very bad, it feels very scary. But what I think is, oh, they just experienced their loved one going through this very natural phase, but no one explained to them what's going on. So it looks like they're suffocating, it looks like they're drowning on their fluids. And really, it's just all physiological. So the actively dying phase is a part of life. And almost everyone looks the same. So they're gonna look, they're not not look, they're going to be unconscious. So fully unconscious, not waking up to tactile stimulation. Sometimes your eyes and mouth will be open because it takes muscles to close your eyes and to close your jaw. So sometimes they're uh high and open, their eyes will be open, maybe, and not making eye contact. So people will think their loved ones like awake, but they're not. They are they are offline, okay. Then as you're getting closer and closer, as you and I know, and a lot of nursing students and nurses know, your blood chemistry starts changing, right? So your pH is off, your CO2 is up, your oxygen's down, all these things, and it's causing you because of this metabolic change to breathe differently.

Speaker 1:

That makes sense. Yes.

Speaker:

So you start breathing differently, but they are fully unconscious, right? So then you start having these changes in breathing. And one of the changes in breathing, you can uh it's called chain stokes, and it's basically like rapid breath, long pause. And then people are looking at their loved one like, did they die? Yeah, right. And then because they're doing the they think, oh god, they're they're suffocating, they can't breathe. Yeah, then they go into agonal breathing. Agonal breathing is literally a reflex. They're probably not even getting air, they're probably actually it's like your last diet. Yes, your last. But people associate that because they don't know it's no one's fault, that that is um just a reflex of the body, right? So all of these things are naturally happening, and we know they're not causing the person distress because of how they look. So they are fully like they're relaxed, they're not flinching, they're not making this kind of face, they're not guarding when you touch them. Now, if they look like they're taking too much energy to breathe, we can we we will give morphine and stuff, and usually we'll err on the side of making sure they're comfortable and making sure they're getting they get morphine. But I think the main thing is that I like to educate is that it's normal. This is not happening because something's wrong. This is happening because this is how the body dies.

Speaker 1:

No one tells us about this.

Speaker:

No one tells us. Did you know?

Speaker 1:

I didn't know I didn't know that. I I knew a great they do a great job with with birth, and it's like Loki. Oh, you can do this and this, and like, here's like, you know, uh Patikia and the baby, and yada yada yada. And Mongolian spot, like, okay, these are all natural things. I'm like, okay, but no one tells us like here are the steps to die.

Speaker:

Like, yes, and what it's going to look like. And even in the ICU, it looks a little different because we give Ivy medication. They've been on a bunch of machines, they they don't have this long drawn-out thing. So, even um, yeah, people always think it need you need to be heavily medicated during that time. I'm okay with people being heavily medicated if they if they want, but our bodies are so magnificent that like you are they are shut up. The person is like offline, they are not. And the reason why we know that is because believe me, I have seen when patients are not offline, right? And they are and they are uncomfortable with breathing. They will look like I can't breathe. They're looking at you like I'm not okay here. Right? Yeah, it's almost like a baby. Like you can tell when a baby is um wet or fussy or teething, right? It's going to be crying a lot, restless, not sleeping. Well, it's exactly like a dying person. Like they will not just be laying there like they're asleep if they were uncomfortable.

Speaker 1:

Yeah, they're gonna be fighting it for sure.

Speaker:

Yeah, they'll be fighting it. Yeah, so the last thing that people hear is the death rattle. Such a such a such an awful name, but it gets that name because it's the last thing you hear before someone dies. So you hear this rattling noise. It's called terminal secretions. That's the real name.

Speaker 1:

Okay.

Speaker:

Um, aka the death rattle, because when you hear it, they're likely going to die soon. And all it is, so it's with every breath you hear a little gurgling noise. Okay. And a lot of people associate that with coming from their lungs. They're drowning on their fluids. Is what that's what I get that.

Speaker 1:

Yes. Okay.

Speaker:

Now, I will say in the ICU, because we do fluid overload patients who can't handle the fluid, they do get really congested in their lungs and they can kind of sound like what we would call wet. That's not what's happening here because the person is not wet. They are super dry because our body dehydrates ourselves, PS, to make us die easier.

Speaker 1:

Prepare you for death, yes.

Speaker:

Yeah, hence why you don't want to give IV fluids to a dying patient. Oh. Another little tip here. Another little tip, nurses, never give IV fluids to a dying patient.

Speaker 1:

A hospice dying patient.

Speaker:

A hospice dying patient. Well, because let's just okay, now I'm getting off topic, but this is really important.

Speaker 1:

Let's get into it.

Speaker:

If someone is really dying, then their body is like, we're done. You can put you can put all the IV fluids you want to in that body. It's not gonna stay intravascular. And we already see this ICU nurses. You you pump them full of fluid and it seeps out. It starts third spacing.

Speaker 1:

Really?

Speaker:

Yes, and then we have to intubate them because it causes respiratory distress, and then we have to diurese them. That's all we did in the ICU. And again, like we weren't doing anything really wrong. We were trying to keep them alive. But if a dying body is dying, that fluid is not gonna stay intravascular and hydrate that person. It will not, it'll seep out, cause third spacing, eventually the heart can't handle it.

Speaker 1:

Pump Are they conscious when this happens?

Speaker:

They can be conscious.

Speaker 1:

Wow. Yeah, they can be cons really want to to live, but their body says they're gonna die.

Speaker:

I mean, I see that I saw that in ICU a lot. I don't see it in hospice because hospitals, I really try to educate being like, listen, even if you did this, you're gonna cause, you're gonna cause them more pain. So what I usually say when a family's like, we're we're making them, we're dehydrating them, how can we be doing this? I say, like, what do you want for your loved one? And they say, for them to be comfortable, for for like us to help them. And then I say, that's what I want to. And if you hydrate them, it's not gonna do what you think. They're not going to perk up like you think. Sometimes they will if they're really not end of life, but I can usually tell just because I've been doing this for a while, that like this isn't gonna do anything.

Speaker 1:

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Speaker:

So the death rattle. The death rattle is we are sitting here, right, and our body's creating moisture for our mouth because our mouths being moist feels better than dry, right? And we unconsciously swallow our spit all day long. At the end of life, our body stops doing that. The brain's kind of offline, it's not really telling us to swallow spit, but our body is still like, hey, a moist mouth is a good mouth. It feels good to have a moist mouth. So it still creates the saliva, but our body is no longer telling us to swallow it. So this little bit of saliva collects in the back of the throat. And because the mouth is open, like I said, because it takes muscle to close your mouth, with each breath, that wet air going over, even that little bit of saliva will make a gurgling noise, which makes people really uncomfortable. Not the person dying, but the people around them. They're going like, oh, and in the hospital, what do we do? We suction, suction, we always suction, suction, suction. But the suction actually creates more saliva because we're introducing something to the mouth to make it get even more moist, right? It's like a foreign object. So it's like the body will start producing more saliva. So, yes, on hospice, we can order suction machine, suction machines are portable if a family really wants it. But I always try to educate, like you just you're just it's just gonna perpetuate this problem. There's medication we can give to dry up the secretions, but again, then your loved one has a dry mouth, right? So I think it's more about there are things we can do about it, but it's more about normalizing it and that it's not bothering your loved one. How do you know? That's what how do you know?

Speaker 1:

Yeah.

Speaker:

That's what everyone always says. You've never done it. How do you know? You've never died. And we know because we see when it actually does. You can tell when someone's bothered because they're not gonna lay there normally, they're gonna be agitated, they're gonna be trying to cough it up all the time. Again, if your loved one looks like they're sleeping, but you're seeing all these changes and hearing that noise, um, as long as they look okay when you touch them, they don't like jerk away from you or anything.

Speaker 1:

Totally unconscious.

Speaker:

Yeah, then then they're good. But no one knows that. So no one knows they're good. Hence the education.

Speaker 1:

Education is the key. All right, let's move into some QA's here from your followers. The question that we always get, I think every nurse always gets, is what is the craziest experience that you've had?

Speaker:

Oh man.

Speaker 1:

I knew you've heard ICU in hospice.

Speaker:

I mean, I yeah, I have so, so many. Um, the one I've been telling a lot, which I didn't for a long, long time, because you mentioned earlier how you were spiritual, right? And I and I, and as an ICU nurse, even as a hospice nurse, you're like always science-based, and like none of this is really happening. But once I became a hospice nurse, there's so there's so many crazy things that are unexplained that you can't deny it, right? You're like, what the heck is going on here? And one of these, one of the things that happened, uh, I didn't know this was called this, but I now have learned that it's called a shared death experience.

Speaker 1:

A shared death, a shared death or a near death experience.

Speaker:

Yes, not a near death, a shared death. I didn't know it was called this until I shared it once, then everyone told me about it. So one of my favorite patients, he came onto service. He was a young guy, pancreatic cancer. Oh. Didn't have a lot of friends or family, and it was young, and you know, and there's a whole hospice team. There's not just the hospice nurse. There's a social worker, there's a CNA, there's volunteers, there's a chaplain, right? This guy really needed a lot of support. He was young, he didn't have friends and family, and he had a hoarding issue. So we walk into his house to admit him into hospice, into his home, right? And his house was not safe. It was like organized mess, but it was like enough to be like, oh, you can't be here. Yeah, right. And like, we can't do it here either, you know, this is not safe. And for whatever reason, because you know, I mean, hoarding is a uh mental health issue, right? And normally people who are hoarders like have a hard time letting go of these things. But for whatever reason, this guy let us. He let us like call in distant cousins of his, and like within a weekend, they had like gutted his whole apartment.

Speaker 1:

Whoa.

Speaker:

When I came back the next week, it was like a whole new place. And he was like a whole new man.

Speaker 1:

Really?

Speaker:

Yes. And he was like, I get chills just thinking about it. And he was like, there's something about knowing I'm gonna die that I was just like able to let it all go.

unknown:

Wow.

Speaker:

And then he ended up living quite a long time for pancreatic pancreatic cancer patient and pretty well too. Like he didn't have a bunch of issues. So, like, I was just sort of visiting there, like as a nurse, obviously, but like there wasn't much to do. So he him and I would just sit and talk about all types of things, his life, what he thought about death, if he was scared. And he became close with all of us. And by the end of his life, um, he was actively dying, which is when, you know, fully unconscious, changes in breathing. I could tell he would die soon. We had a continuous care nurse in the home with him, which meant a 24-hour care nurse, making sure he was comfortable. And I, as the nurse manager or the case manager, would just go in and see him once a day. Okay. So the last day I was there, I could tell this was gonna be his last day. I could tell by how he was breathing, like, okay, this is probably he's probably gonna die today. So I said to the nurse, like, make sure you text me when he dies. Um and I kind of said my goodbyes to him in my head. And I was like walking out of his apartment and like thinking fondly of him and not really feeling sad because I felt really good. Like we really helped him die well, you know, and he had a really good last, you know, nine months or whatever it was. He was on service. And nurses know, you know, you got to keep moving, right? Like, so I'm in my car, like getting ready to go see my next patient, but I was like, no. And I stopped myself and I was like, looked at his apartment and thought of him again, and it was like, oh, I just love you so much. Like, uh thank you for being my patient mobile black, all in my head. And suddenly, this is where it gets crazy. Like, I feel embarrassed, like even talking to me.

Speaker 1:

No, I was pulling out, come on.

Speaker:

And all of a sudden, I heard his voice in my head, like clear as day. From the other side, kind of, and he goes, Oh my gosh, Julie. I know I got chills just thinking about it. And he goes, and that's it was like, oh my gosh, Julie, oh my gosh. And when I heard his voice, I kind of like had a vision of him. Uh it sounds it's so hard to articulate, but it was like he was like soaring.

Speaker 1:

Going through the light, right? Going through the light, or like soaring.

Speaker:

Oh my gosh, oh my gosh. And I'm smiling because that's how it felt. It felt like he was like, oh my gosh, Julie, oh my gosh.

Speaker 1:

It's happening.

Speaker:

Yes, if I only would have known, those were his words. If I only would have known. And he didn't fully articulate, if I only would have known, I wouldn't have been so scared, you know.

Speaker 1:

More of a static joy.

Speaker:

It was like the feeling, if I only would have known how good this is, yeah, like I wouldn't have been so scared because we had had conversations about how he was scared and he didn't know what he believed, and he didn't know what was going to happen. And he lived a life, this is where it always makes me want to cry. He lived a life that was so constricted and so small for so long because of his mental health issues. He didn't let people in. He didn't live this full life and he regretted it. And he felt so free in that moment. And I felt like he was showing me that and going, Oh my gosh, oh my gosh, I can't believe this. I can't believe this. This is actually he just kept saying, if I only would have known, if I only would have known. That's what he kept saying in my head. Oh my gosh, if I only would have known. But the feeling was like this joy and freedom. And so much so that in my car, simultaneously, while this was all happening, I'm like weeping in my car, like weeping tears of joy, like tears of joy because of the feeling I was he was giving me, right? And it probably only lasted, I don't know, 30 seconds, maybe even shorter. I don't, I don't know. Like time totally was jacked up. I don't know how long it was. He blacked out, and then all of a sudden, boom, I'm kind of like back in my car. And that's what it felt like.

unknown:

Wow.

Speaker:

I'm like back in reality. And I was like, oh, like kind of like wiping my tears, like, what the hell? And I got a beat uh a text on my phone and I looked, and the nurse inside said, so-and-so just died.

unknown:

Oh my god.

Speaker:

And I was like, I know, because I think he just showed me. I think he just showed me what it was like to die. And I didn't say that to her because I'm a nurse and I don't, you know, I'm like, I can't say this.

Speaker 1:

Did he visit anyone else or was it just you?

Speaker:

That's the thing. I didn't tell a I didn't tell anyone. I didn't tell anyone for years. I didn't tell people I worked with, I didn't tell anyone. Yeah, I was too afraid. Yeah, of course. I was too afraid. So I didn't say a word to anyone, I didn't say a word to the nurse. I didn't inside. I didn't say anything to social worker, I didn't say anything to anybody, except for my best friend Jenny. Because I trusted, I knew she wouldn't think I was crazy. But I didn't tell any anyone that for years until uh years later I was on social media and people kept asking me why I wasn't afraid to die. And then I and there were many reasons why I'm not afraid to die, but that was one really big one. And I thought, uh, screw it, I'm just gonna tell people. Oh yeah. And then I did, and that's another one said, Girl, that's a shared death experience. That's what it's called. A shared death experience. People kind of show you what it's like.

Speaker 1:

Oh my gosh. This is like science, kind of.

Speaker:

I mean, like there are there's a trend.

Speaker 1:

Yeah, there's a trend for sure. More and more people are saying this. Side note, for example, there's something called near-death experience, and I started binge watching this on YouTube over the past year. There's over a thousand cases. There's a really good book, and it's all just documenting near-death experiences.

Speaker:

Yeah.

Speaker 1:

Where people float above their body, they know what's going on in the operating room, then they go back into their body.

Speaker:

Yeah, I mean, I feel like I've already had a uh a type of spiritual belief, and then the experiences of I I've had have just helped me kind of be like, Oh yeah, okay, this all this all makes sense.

Speaker 1:

Yeah, that's really interesting. Yeah, it's amazing. Whether you call it spirituality science or whatnot, it's just observation, right? That's all we do as nurses and we document. Yep. And so this is you can't, if you have thousands of people doing this or a shared death experience and they already termed it, this is wild. Yes.

Speaker:

This is amazing. It's wild. I always just um like my whole take is that like I don't know why it's happening, right? But it's happening, but it's happening, and like it's comforting, right? Whether even even if it is just our brains making us feel comforted, it's not a wonderful thing. Yeah, how beautiful is that?

Speaker 1:

And I think it's weird that we've reached so far on the other side of the spectrum where before everything's happened in space now, right? Before, like in medieval days, like to practice medicine was like witchcraft, you know, just say it's like, what do you? But now we've reached the opposite side of the spectrum where it's like we've science the heck out of ourselves that we don't even want to realize a common trend that's happening. We want to put our head in the sand and be like, nope, doesn't exist, doesn't exist, I don't know. Yeah, it's like, dude, is this actually happening?

Speaker:

Yeah. Well, I mean, one of the major phenomena that happen at the end of life is visiting. 80% of people see dead people.

Speaker 1:

No, wait, I see dead people really.

Speaker:

Yes. Oh, I mean, it's like so common that we have to educate families about it. Yeah. Because if we don't, the families get scared because their loved one dying is saying they're talking to their dead dad. Yeah. You know, and they get scared that that's happening. Not the patient. The patient's not scared. The people watching it feel scared. It happens so much. It's hard for me to even like tell one story because that happens so often.

Speaker 1:

You need to write a second, like a you know, a whole I know. I just might be another book, a little chicken soup for the soul, like little shared experience.

Speaker:

Yeah.

Speaker 1:

Thank you so much for being on the show. Guys, nothing to fear. New York Time bestseller and the practical journal that goes along with it. Where can our listeners and viewers find you?

Speaker:

So on anywhere you get social media, YouTube, TikTok, Instagram, Facebook at Hospice Nurse Julie.

Speaker 1:

I love it. Well, thanks, guys, so much again for watching Bedpan Banter. And as always, don't let the Bed Pans bite.

unknown:

Woo!