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Signs of Approaching Death

When someone is approaching the end of life, you are likely to see changes in physical appearance as well as less engagement with other people and the outside world. The phase leading into dying is different for each person and may occur over hours, days and even weeks.

When your physician or hospice nurse says that your family member is expected to die soon (has reached the stage of “active dying”), you may be asking: “How much time is left?” and “Who will help me?”. If hospice is involved in the care, you will turn to your hospice team for guidance. Having hospice care is a good way to get proper support. If your family member is not enrolled already, ask your physician to make a referral to hospice.

It is difficult to predict how long a person will live beyond a general time frame. Often, with the help of a hospice nurse or your physician, it is possible to understand better what is happening. When the first signs of the dying process begin, it may take weeks before the final end, or it could be only days or hours. The time frame varies, depending on the underlying illness, the general health of the individual, and other factors including personal ones that are not easy to define. Every individual has a unique experience at the end of life.

The signs of approaching death can vary in order and not all are always present. They apply to a “natural” dying process. If the individual is on a respirator or has a feeding tube, the pattern can be different. Since each individual death is unique your family member may have only some of these common signs. The information below is a general guideline.

Less Interest in Social Contact

In the final period of life, it is possible that your family member speaks less and moves less. Interest in the outside world, including close family, often decreases and he or she may sleep for long periods. Nevertheless, close to the end, it is not unusual to see an individual appear to gather a lot of strength and improve (“rally”) to talk with family and say goodbye.

What you can do:

  • Follow the lead of the person who is dying
  • Listen carefully and respond to his or her needs for conversation (for example, being silent, talking about the past or future, or asking for final good-byes)
  • Don’t be surprised or disappointed if, shortly after a lively time, all of the person’s energy seems gone
  • Regardless of how alert – or not – your loved one is, you can offer support by sitting by the bedside and holding a hand or stroking an arm

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Decreased Appetite

As the body begins to slow down in preparation for dying, most individuals lose interest in eating and drinking. Swallowing can become difficult, and eating can cause discomfort. It is best not to force feed, but only give the food and drink that is welcomed. The dying person is not feeling hunger and is not “starving.”

What you can do:

  • Offer soft foods
  • Do not force food when the person is saying no
  • Offer sips of liquid or ice chips if the person is alert enough
  • Moisten the lips and mouth with water on a sponge applicator
  • Apply lip ointment

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Changes in Bowel and Bladder Function

As your family member eats and drinks less, changes in bowel and bladder function may occur. Urine may become more concentrated with a strong odor, or it may decrease in volume and become dark in color. Constipation may occur due to decreased mobility and decreased food intake. Incontinence may occur. This is generally an expected part of the dying process and usually is not painful. Failing kidneys can also result in fluids in the body causing swollen ankles and feet.

What you can do:

  • Keep the bed clean and change bed pads often
  • Keep affected areas clean and dry to avoid rashes and sores
  • Offer support and understanding

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Confusion, Restlessness and Agitation

Confusion, restlessness, and agitation are common at the end of life, and may be caused by decreased oxygen, metabolic changes, dehydration, and medication. Although it may look distressing, these symptoms are not considered to be painful but can be controlled with medications, as needed. The dying person may pick at his or her clothing, be fidgety, or pull your hand forcefully.

What you can do:

  • Avoid startling the person by turning on lights, introducing loud sounds or abrupt movements (for example, turn off the ringer on the phone)
  • Always identify yourself, even if the person knows you well, as he or she may not recognize you at times
  • Use a gentle reassuring voice and offer support
  • Consider light hand massage or soothing music
  • Speak to the medical team about medications to relieve the agitation, as needed

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Changes in Skin Temperature and Color

During the dying process, blood pressure drops and blood flow moves away from the hands and feet toward vital organs. This may make the skin appear yellow or waxen in color and there may be abrupt changes when the dying person feels cold and then hot. You may notice a purple or pink pattern on the skin (“mottling”), and the hands and feet may feel cold while the abdomen and belly feel warm. These changes are normal during the dying process and usually do not cause discomfort.

What you can do:

  • Adjust the room temperature to suit the person’s needs
  • Apply a damp cloth to cool the forehead and back of neck or provide blankets (not electric), if the person is chilled
  • Use a fan to circulate air and cool the person

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Hallucinations and Changes in Mental State

The brain and the central nervous system begin to slow down when someone is dying. This may result in jerky movements (“twitches”) and may cause changes in sleep and wake cycles. The person who is near death may be disoriented and may hear, see, or appear to be touching things that may not be seen or heard by others in the room. These hallucinations are rarely worrying to the individual and may be comforting to them. You may notice changes in personality. This is not unusual behavior at the end of life.

What you can do:

  • Do not judge or be critical
  • Remind the patient who the other people in the room are
  • Be supportive and talk quietly and calmly
  • Do not discount the experience
  • Discuss with the medical team if the visions or hallucinations are distressing to the dying person and if medication may be helpful

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Changes in Breathing

When an individual is within hours of the end of life, the breathing pattern often changes. Several rapid breaths can be followed by periods of no breathing at all. You may observe that the breathing is shallow and quick, or slow and labored. You may hear gurgling sounds in the throat, caused by air passing through the mucus that has collected there. These changes in breathing are expected and are not believed to be uncomfortable or painful for the person.

It is not unusual that the dying person appears to be in a deep sleep. Even in this state, it is likely that he or she can hear you. You can continue to offer reassurances and support with words of love and caring. Do not ask questions and do not expect responses to your words.

What you can do:

  • Avoid showing alarm as this may cause fear in the dying person
  • Raise the head of the bed or turn the person on her side
  • Wipe the mouth with a soft and moist cloth to cleanse excess saliva
  • Ask the physician or hospice nurse about medication specifically prescribed to reduce distressing symptoms of labored breathing
  • Speak gently and offer support to the dying person

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