When a loved one is nearing the end of life, it can be an emotional and difficult time for families. Hospice care provides comfort care and support for patients with terminal illnesses and their families. One of the responsibilities of the hospice care team is to help provide an idea of how much time a patient may have left. This is called providing a “prognosis”. Prognoses are difficult to make exactly, but hospices use various signs and symptoms to determine when a patient’s death may be imminent, or close at hand.
What does “imminent” mean?
When hospice says a patient’s death is imminent, they generally mean death is expected within days to weeks. Some key signs hospices look for when making this determination include:
- The patient is mostly bedbound and sleeping the majority of the time
- The patient is very difficult to wake or rouse
- The patient is unable to take foods or liquids by mouth
- The patient is showing signs of kidney failure, such as little to no urine output
- Breathing patterns are irregular, with periods of apnea (stopped breathing)
The presence of these signs indicate the patient is transitioning and death is likely to occur in the near future.
Why does hospice provide a prognosis?
Hospice provides families with information about when death may happen for a few key reasons:
- To help families prepare emotionally and practically for the death of their loved one
- To assist families in making any end-of-life arrangements and decisions
- To alert families that the patient’s condition is declining and death is close at hand
- To ensure families have adequate support from hospice staff during this difficult time
Having a general idea of when death may occur, even if not exact, can help families provide comfort care to the dying patient and gain closure.
What are the signs death is imminent?
Hospices look for several physical, psychological, and behavioral signs and symptoms to determine when a patient’s death is likely imminent. Here are some of the key signs:
Physical signs
- Breathing changes – Breathing may become rapid, shallow, irregular, with periods of apnea (stopped breathing). Congestion and rattling breathing sounds may occur.
- Decreased urine output and intake – The patient produces little or no urine. Food and fluid intake decreases.
- Eyes glassy or tearing – The patient’s eyes may tear or appear glossy.
- Skin changes – Skin may become mottled, pale, or take on a bluish hue. The underside of body (arms, legs etc.) may turn purplish. Extremities feel cool to the touch.
- Restlessness – Patient seems agitated or restless. May pick at clothing or have sudden body jerking movements.
Mental/emotional signs
- Confusion and delirium – The dying person may become confused about time, place, and identity of people around them.
- Withdrawal – The patient becomes less responsive and communicative. They appear to withdraw into themselves and close their eyes.
- Vision-like experiences – The patient may state they see deceased loved ones, angels, or other visions.
- Decreased need for food/drink – The patient loses interest in eating, drinking, or taking medications.
Whole body changes
- Incontinence – Loss of bladder and bowel control may occur as the muscles relax.
- Congestion – Fluids pool in the body, causing gurgling sounds in the lungs and throat.
- Darkening of extremities – Hands, arms, feet and legs may turn a purple or dark color.
- Difficulty swallowing – Weakened muscles make swallowing difficult. The patient can’t take oral medications or food/liquids.
- Fever – The patient runs a low-grade fever or has a slight temperature elevation.
As death nears, the patient falls into a deep sleep state and becomes unarousable. The combination of these physical, mental, and whole-body changes indicate death is imminent.
How long can imminent last?
Once hospice has determined death is imminent, families often wonder how long their loved one may still have to live. Unfortunately, there is no precise way to predict exactly when death will occur. However, here are some general guidelines:
| If hospice says death is… | Timeframe |
|---|---|
| Imminent | Hours to 3 days |
| Very close / Anytime | Within hours to 2 weeks |
| Close / Soon | Within days to weeks |
| Will occur relatively / somewhat soon | Within weeks |
The key is that once death has been determined as imminent, it signifies the patient is actively dying and has hours to days left. However, some patients progress faster than others. Hospice nurses will continue monitoring the patient closely and updating families as death draws nearer.
Why predictions can vary
No one can predict the exact moment death will occur. Estimates of how long a patient has when death is said to be “imminent” can vary for several reasons:
- Each patient dies in their own time and way
- The dying process does not follow a precise scientific timeline
- Some patients progress through the final symptoms faster than others
- Families may interpret hospice statements in their own way
- Illnesses and medical conditions affect dying differently
Hospice teams provide their best judgment based on experience, but emphasize that predictions are just estimates. Families should be prepared that death could occur faster or slower than indicated.
Providing comfort when death is near
The timeframe between when death is said to be imminent and when it occurs can be a sacred, intimate time for families. Here are some ways to provide comfort and make the most of this final period:
Be present
- Spend time at the bedside letting your loved one know you are near
- Hold your loved one’s hand, speak to them reassuringly, or provide gentle touch
- Convey that you will be okay and they have your blessing to go
- Have children and other loved ones visit to say goodbye
- Read aloud, play music, or engage in important faith rituals
Even when your loved one is unresponsive, it’s believed hearing continues in dying. Your presence supports them.
Attend to personal care
- Keep lips and mouth moistened with a moist cloth
- Apply lotions or oils to keep skin hydrated and comfortable
- Change soiled bedding or clothing promptly
- Reposition them gently every two hours for comfort
- Keep room at a comfortable temperature and dim lights when sleeping
Caring for physical needs provides comfort. Work with hospice nurses to provide personal care.
Provide emotional support
- Give reassurance it’s okay to go when ready
- Allow them to express fears, concerns or say goodbyes
- Grant forgiveness or ask for forgiveness if needed
- Share memories, stories, expressions of gratitude
Addressing relational and emotional needs can help bring closure. Your support eases their transition.
Honor faith traditions
- Have important religious or spiritual texts read aloud
- Play spiritual music or light ceremonial candles
- Invite faith leaders to visit and perform important rituals
- Pray, meditate, or solemnize the space as desired
Observing important faith traditions offers comfort. Work with their spiritual community and hospice chaplains to meet needs.
Signs death has occurred
When a loved one’s death occurs, you may wonder how to confirm it. Here are some of the physical signs that indicate death has definitively happened:
- No heartbeat or pulse
- No breathing
- Eyes are fixed in one direction
- Eyelids may be open or half-open
- No response to calling their name or shaking shoulders
- Skin color changes to a waxen pallor or grey tone
- Loss of control of bowel and bladder with release of contents
- Relaxation of muscles with closing of the mouth and eyelids
Check for a pulse, breath, and eye response to confirm death. Hospice nurses will assist you in determining and documenting time of death.
Steps to take after death occurs
After your loved one passes:
- There is no rush. Take time for grief, presence, rituals. The hospice nurse can guide you.
- Notify hospice staff of the death. They will offer assistance.
- Make calls to close family and friends. Share wishes for calls/visits.
- Decide if you want assistance from hospice with after-death care of the body.
- Move slowly with post-death arrangements. Seek support as needed.
Hospice staff will continue providing bereavement services for you and your family after your loved one’s death to support you during grief and mourning.
Conclusion
Knowing when death is imminent allows families to provide comfort to dying loved ones, gain closure, and start the transition to grief. While hospice staff do their best to indicate when death is close, the dying process varies for each patient. Imminent can mean hours to days. Focus on being present in the final moments and honoring what is meaningful to your loved one. Hospice teams provide guidance every step of the way to make the end-of-life time one of honor, care, and love for your family member.