The last hours and days of a person’s life can vary greatly depending on the cause of death and other factors. However, there are some common symptoms and experiences that often occur during the active dying process, when a person is transitioning from life to death.
When Death is Near
Doctors and hospice care providers often speak of “active dying” to describe the final phase of life when a person’s body begins shutting down. There are changes that happen physically, psychologically and socially that indicate death is imminent within hours or days. These include:
- Loss of appetite and thirst
- Extreme fatigue and weakness
- Disorientation and confusion
- Restlessness or agitation
- Difficulty breathing
- Slurred speech or inability to speak
- Changes in skin color, such as pale or bluish skin
- Cooler hands and feet
Some experts describe these as the “active dying phase” and state they generally begin about two weeks before death, though the timeframe can vary widely.
Social Changes
As a person declines in their final days, they often feel the need to have important conversations and connect emotionally with loved ones. They may want to reminisce about fond memories, accomplish unfinished goals, or express love and gratitude. It’s important that family and friends make themselves emotionally available and have meaningful interactions to provide comfort.
It’s also common for dying individuals to become detached from their immediate environments. They may speak to deceased loved ones as if they are present in the room. While this can be disturbing for family members, it is generally a normal part of the dying process and not a cause for alarm.
Physical Changes
There are several physical changes that indicate death will occur within days or hours:
- Breathing changes – Irregular, shallow or rattling breaths are common as breathing slows down. Periods of no breathing for up to 45 seconds may occur.
- Decreased urination – Lower blood circulation results in less urine production.
- Incontinence – Loss of bladder and bowel control occurs as muscles relax.
- Congestion – Fluid buildup in the lungs and inability to cough causes gurgling sounds with breathing.
- Skin breakdown – The skin becomes cool and may turn bluish in color. Pressure sores and skin tears appear.
- Swallowing difficulties – Weak throat muscles make swallowing tough, resulting in buildup of saliva and mucus.
These signs indicate the person is unlikely to live longer than a week without medical intervention. However, variation exists from person to person depending on health status.
Pain
Pain management is an important priority for end-of-life care. People in the dying process may experience pain from pressure sores, infections, swelling, circulatory impairment, nerve damage or musculoskeletal issues. Medications can provide relief in the final hours and days. If discomfort persists, immediate pain control should be requested from hospice staff or healthcare providers.
Medication Changes
As the end nears, healthcare providers may discontinue medications for chronic conditions like diabetes and high blood pressure. The focus shifts entirely to comfort. IV fluids and tube feedings may also be stopped, along with supplemental oxygen. Medications for anxiety, nausea, excessive secretions and shortness of breath may be prescribed instead.
Nutrition Changes
In the final days, the dying person lacks interest in food or drink. The body’s organs begin shutting down, making digestion difficult. Mouth care is still important to prevent thick secretions and aspiration pneumonia.
Small chips of ice, frozen Gatorade, popsicles or moist swabs may provide relief. Do not force food or water on someone actively dying, as this increases discomfort. IV fluids may also cause fluid buildup in the lungs at this point.
Psychological Symptoms
There are various psychological symptoms that indicate death is near:
- Confusion – The person may seem unsure about time, place and identity of people around them.
- Restlessness – Anxiety and agitation are common as death approaches.
- Vision-like experiences – The dying often speak of seeing deceased loved ones welcoming them.
- Withdrawal – Decreasing interaction with the environment and unresponsiveness is common.
- Fatigue – The person has very little energy, keeps eyes closed and sleeps more.
Delirium and hallucinations may also occur. Talk calmly, use gentle touch for comfort, keep lighting soft and reduce noise and distractions in the room to help ease any distress.
Saying Goodbye
Knowing death is imminent allows loved ones the opportunity to say goodbye. This can provide a sense of closure. Many find it helpful to say the things they feel they need to say, reminisce about fond memories, express how much the person means to them, convey forgiveness, or simply sit quietly while holding the dying person’s hands or stroking their arms and face.
Even when someone is unresponsive, hearing is believed to be the last sense to go, so it’s recommended to continue talking in a soothing tone. Avoid saying things you don’t want the person’s last memories to be. Be calm and reassuring to help ease any fear.
Signs Death has Occurred
There are certain unmistakable signs that indicate when death has occurred. These include:
- No breathing or heartbeat
- No response to stimuli
- Eyelids slightly open
- Eyes fixed in one direction
- Mouth slightly open
- Bowel and bladder incontinence as muscles fully relax
- Cooling of the body’s extremities and skin discoloration
There may also be some involuntary muscle movements or gasping following the moment of death, but these are reflexes and don’t indicate life.
Providing Comfort
It’s important that family and caregivers provide comfort during the dying process. In addition to pain management, this includes:
- Moistening the lips, eyes and mouth
- Applying unscented lotion to prevent dry skin
- Changing soiled bedding and clothing
- Turning or repositioning every 2 hours for pressure relief
- Elevating the head if breathing is difficult
- Playing soothing music if desired
- Limiting noise and room traffic to create a peaceful setting
Simple comfort measures can help maintain dignity and quality of life in the final hours.
Moment of Death
The exact moment of death is when the person’s breathing and heartbeat cease. There is an official medical standard for determining when death occurs:
| Criteria | Description |
|---|---|
| Breathing | No breathing for 5-10 minutes |
| Heartbeat | No heartbeat for 5-10 minutes |
| Reflexes | No response to stimuli like pain |
Doctors may listen for heart sounds, check for a pulse, watch for breathing, and examine the eyes for responsiveness. Time of death is recorded when these signs are absent for the designated duration.
What Happens to the Body After Death?
For the first few hours after death, the following changes occur:
- Pupils become fixed and dilated
- Body releases remaining air in the lungs
- Residues like urine and stool may be released
- Blood pools at the lowest parts of the body
- Facial muscles relax and the jaw may fall open
- Body temperature begins dropping (algor mortis)
- Limb muscles stiffen through rigor mortis
Over the next few days, the body enters decomposition. The rate depends on factors like temperature, air exposure, and body fat percentage. This process includes:
- Greenish discoloration visible on the abdomen
- Skin blistering
- Facial distention with gas accumulation
- Marbling appearance from blood vessel breakage
- Strong odor from released bodily gases
- Leaking of body fluids
For this reason, bodies are typically refrigerated if burial arrangements exceed two days. Chemical preservation may also be used.
What is Palliative Care?
Palliative care provides comfort and pain relief when someone is seriously ill or dying. The goals are to:
- Relieve pain and other distressing symptoms
- Support the psychological and spiritual needs of the person and family
- Improve quality of life as much as possible
- Ensure the patient’s final wishes are honored
- Provide bereavement support for family after death
Palliative care can be provided at any stage of illness alongside curative treatments. Hospice care is palliative care given when life expectancy is 6 months or less.
Palliative Care Services
An interdisciplinary team provides medical, emotional and practical support. Services may include:
- Medications, oxygen, medical equipment
- Physical, speech or occupational therapy
- Nutritional counseling
- Social work and counseling
- Chaplain services
- Bereavement counseling
- Volunteer assistance
This comprehensive approach focuses on the highest quality of life possible for whatever time remains.
Hospice Care
Hospice provides palliative care and pain management for terminal patients with less than 6 months left. Services include:
- Visits by nurses, aides, social workers, chaplains
- Medical equipment like hospital beds
- Medications for symptom control
- 24/7 on-call support
- Bereavement services for family
Hospice staff are specially trained to provide physical comfort, emotional support, and help coping with death. The aim is to allow a natural death with dignity.
Location of Hospice Care
Hospice care can be given in several settings:
- At home
- In a hospice facility
- In a hospital
- In a nursing home
Most hospice patients prefer to remain at home surrounded by loved ones. Some benefits of home hospice include:
- Comfort of familiar surroundings
- Family can stay together
- Flexible visiting hours
- Lower cost than hospitalization
Paying for Hospice
Hospice care is covered by Medicare, Medicaid and most private insurances. This includes drugs, medical equipment, therapies and other services needed for pain relief and comfort. Bereavement services for the family after death are also covered for about a year.
If insurance does not cover hospice costs, some programs provide care on a sliding fee scale. Many hospice organizations are also charitable non-profits that rely on community donations.
Comforting the Dying
While nothing can eliminate the sadness of losing a loved one, there are ways to provide solace and meaning during the last hours of life:
- Offer sincere words of love, gratitude, and respect
- Share positive memories and reminisce
- Read aloud comforting poems or religious passages
- Play soothing music
- Hold the person’s hands or gently massage their arms and forehead
- Keep the room peaceful with soft lighting and limited noise
Gentle words of reassurance may also help ease any fear. Validating the dying person’s feelings provides comfort. Simply being present can mean a great deal.
Conclusion
The final hours and days of life have a range of common physical, psychological and social symptoms indicating death is near. Understanding these changes and providing comfort care helps ease distress. While saying goodbye to a loved one is painful, this time can also be meaningful. Hospice and palliative care aim to support a natural death with dignity, surrounded by loved ones.