During the final stage of life, each person goes through a unique set of physical and psychological changes. As their body begins shutting down, their thoughts gradually turn inward while they come to terms with their mortality. Signs death is near can appear as early as three months, but often occur much closer to the end. Regardless, understanding the process enables families to support their loved ones as they approach the final moments of life.
Loss of appetite is one of the earliest signs death is near. As their metabolism slows and their energy requirements fall off, patients gradually stop eating. This is a natural part of dying but upsetting for families. They frequently ask about supplementation or intravenous feeding, but neither are effective at this stage. The digestive system is shutting down and forcing nutrition into the body will not slow the process, though it may lead to complications.
Caregivers can help by offering small meals throughout the day. Patients may show interest in simple foods: puddings, milkshakes, and soups, for example. Nausea medication may revive their appetite, but only for a short time. Eventually, their body will be too weak to swallow and digest food at all. In fact, eating and drinking might even be painful.
When this happens, the only thing left to do is make the person comfortable. Brushing and flossing is still important, to prevent harmful bacteria from building up on their teeth. If they can tolerate them, ice chips and hard candies will help keep their mouth from becoming overly dry. Otherwise, try moistening their lips with a damp cloth.
Along with lack of appetite comes lack of energy and more need to sleep. Patients will spend more time in bed, sometimes only rousing themselves for a few hours a day. It might be possible for them to participate in some normal activities, but only for short periods. Visits will tire them quickly, so ask friends and family to keep them short. However, sitting quietly or holding their hand will still be a comfort to them while they sleep.
In the last few days of life, patients may suddenly become agitated, hostile, or aggressive. They might toss and turn, pulling at their clothes, bedding, or IV. In some cases, they might also make angry accusations or call for help. Conversely, the person may collapse into lethargy, become anxious over a missing item, then forget about it once it is brought to them.
Terminal restlessness is brought on by many factors. Partially it is the result of the body’s natural deterioration. For example, failure of the liver and kidneys can lead to hormonal and neurochemical imbalances that affect behavior. However, these symptoms may have more immediate causes that can be treated, such as:
When terminal restlessness occurs, families should do their best to calm the patient and contact their hospice team for help. In the meantime, stay close, play soothing music, talk about happy memories, and do your best to keep them safe.
As circulatory and pulmonary systems begin to fail, red and purple blotches will appear on the skin. They generally start on the extremities and move up towards the torso. The patients’ hands and feet will also become cold to the touch. Mottling is one of the last signs death is near, usually occurring in the final week of life. It is not painful but giving the patient an extra blanket may help keep them warm.
Weakened muscles prevent patients from clearing secretions that build up in the back of their throat. As a result, each breath is accompanied by a gurgling sound, sometimes called the death rattle. It is not painful. Patients can still breathe, but it may upset family members. Hospice workers can help by drying up the secretions with medication. Rolling the patient onto their side may help as well but ask your hospice team first to prevent any problems.
Families might notice other irregularities as well. Breathing generally starts to fluctuate between apnea and hyperventilation, meaning patients stop breathing momentarily then gasp for air. Neck and abdominal muscles become more active to help compensate for weakness elsewhere. This is one of the last signs of death. Once patients have trouble drawing breath, it is a good time for family members to start preparing their final words.
Beyond making them comfortable, the best way to support your loved one is to remain close. Patients may not be alert, but they will be able to sense your presence, which will be more valuable than anything. Dying alone is one of people’s most common fears. Likewise, physical touch (holding their hand, patting their shoulder, etc.) will help console them. Remain close even if your loved one slips into unconsciousness. Although they cannot respond, patients can still hear you, so talk to them as much as you can to let them know you are still there.
Though not one of the common signs death is near, people may hallucinate before they pass away. Many times, they claim to see loved ones who are not there or have died. If these visions are not distressing, then simply acknowledge them. On the other hand, if they are distressing, do your best to distract the patient with a story or memory.
Death is often a painful process, especially if it comes at the end of a long disease. Besides their illness, muscle tissue is breaking down, so even if the patient is not experiencing major symptoms, they might still be distressed. Because an anguished death is not dignified, families need to work closely with the hospice team to make sure pain is kept under control.
Dying is difficult for families, as well as patients. Once they start seeing signs death is near, many people understandably forget about their needs and focus on their loved one. However, taking care of yourself is just as important. Patients do not like seeing their families upset; it makes them feel like a burden. So do not feel ashamed about setting aside time for your own needs. Ask a friend, relative, or chaplain to sit with your loved one while you step away. In the long run, it will be the best way to ensure your presence remains a comfort.
Jose Escobar is the Hospice Executive for Parentis Health. He works with patients and families across Southern California, providing support and education, in order to alleviate the pain and suffering of chronic and terminal illness.