Removing clothing near the end of life is a recognized clinical behavior often described as a symptom of terminal agitation or restlessness. This action is not a voluntary or rational decision but an involuntary physical and neurological response to profound internal distress. It is a manifestation of the body’s systems beginning to fail, leading to significant confusion and disorientation. The behavior is part of a complex state known as terminal delirium, where the patient’s altered state of mind causes them to act on a misinterpreted sensation of discomfort.
Physiological Root Causes
As the dying process advances, the body’s major organ systems slow down and lose functionality, creating a toxic internal environment. The kidneys and liver, responsible for filtering waste products from the bloodstream, become impaired. This failure leads to a buildup of metabolic toxins, such as urea and ammonia, which circulate throughout the body. These chemical waste products are a primary trigger for the physical discomfort and agitation patients experience.
Systemic failure also affects the body’s thermoregulation, causing a distorted perception of temperature. The patient may develop a fever or experience a significant internal sensation of overheating or burning, even if their external skin temperature feels cool. This discomfort is often compounded by uncontrolled pain, which manifests as intense, generalized restlessness. The patient instinctively tries to relieve this distress by removing constricting garments.
Neurological and Cognitive Disruption
The brain’s function is profoundly affected by the physiological changes occurring in the body, leading directly to the confused behavior of removing clothing. Reduced oxygen saturation (hypoxia) and the circulation of metabolic toxins impair the cognitive centers responsible for judgment, memory, and orientation. In this agitated state, the patient loses their usual inhibitions and their ability to think logically about their actions. The brain misinterprets physical discomfort—whether due to internal heat or generalized pain—as a simple, external problem that can be solved by removing clothing. Disorientation means the patient may not recognize their environment or the people around them, fueling restless attempts to escape the perceived discomfort.
Management and Comfort Measures
When a patient exhibits this behavior, the focus of care shifts to maintaining dignity, ensuring safety, and maximizing comfort. Caregivers should first check for reversible causes of agitation, such as a full bladder, constipation, or uncontrolled pain, and address them promptly. Non-pharmacological interventions are the first line of defense in managing restlessness. This includes maintaining a calm presence, speaking gently, offering reassurance, and using gentle physical touch. The environment should be simple, with reduced sensory stimulation like dim lighting and soft music, and adjusting the room temperature can help address the patient’s sensation of being too hot.
Palliative care professionals may adjust medication to manage underlying agitation and anxiety when non-pharmacological measures are insufficient. This often involves the use of anti-anxiety medications or low-dose antipsychotics to reduce the patient’s distress. The goal of medication is to gently ease the agitation, allowing the person to rest comfortably and peacefully in their final hours.