End-Of-Life Signs, Symptoms & Timeline
This guide serves as an essential resource for family caregivers, offering a detailed exploration of the signs, symptoms, and timeline associated with the end-of-life process. These symptoms can be distressing for both the individual experiencing it and their loved ones. By better understanding how and when these physical, emotional, and spiritual end-of-life changes take place, patients and their loved ones are better prepared to navigate this challenging time.
Physical end-of-life signs.
The following describes the physical symptoms you may observe by patients approaching death. By understanding these physical changes, caregivers are better equipped to offer comfort, maintain dignity, and provide love and support during this transition.
1. Coolness.
The symptom of “coolness” refers to a noticeable decrease in the body temperature of a person approaching death. This drop in temperature often manifests as a cool sensation in the extremities, such as the hands, arms, feet, and legs. Additionally, the color of the skin may change and become mottled. The cooling of the body is a natural part of the dying process, and occurs as the body’s circulation slows down and vital organs begin to shut down.
How you can help: Keep the person warm with comfortable, soft blankets and keep the room temperature warm and cozy.
2. Confusion.
Confusion during the end of life involves the patient experiencing disorientation and difficulty recognizing time, place, and people around them. They may appear unaware of their surroundings and struggle to identify familiar faces or understand current events. This symptom can cause feelings of fear, frustration, and anxiety for both the patient and their loved ones.
How you can help: Identify yourself by name before you speak. Speak normally, clearly, and truthfully. Explain routine activities in a calm and reassuring manner such as, “It’s time to take your medicine now” with reasoning like, “So you won’t start to hurt.” Create a familiar and soothing environment, such as playing familiar music or displaying personal mementos, to help ground the patient and reduce confusion.
3. Increased sleeping.
An increasing amount of time may be spent sleeping. The person may become unresponsive, uncommunicative, and difficult to arouse. This may be stressful for both the individual and their caregivers, as it may signal the approach of death and limit opportunities for communication and interaction.
How you can help: Sleeping more frequently is normal. You can sit quietly with them. Speak in a normal voice. Hold their hand. Assume they can hear everything you say. They probably can.
4. Incontinence
Incontinence during end of life involves the loss of control over urinary and/or bowel functions. This is a common end-of-life change that can occur during the process of passing on, but can compromise the person’s comfort and dignity.
How you can help: Keep your loved one clean and comfortable. This may involve regularly changing soiled clothing and bedding, using protective pads or undergarments, and ensuring proper hygiene to prevent skin irritation or infection. Your hospice nurse can provide personalized advice and assistance tailored to their needs and preferences.
5. Restlessness.
The person may make repetitive motions such as pulling at the bed linen or clothing. This can be attributed, in part, to a decrease in oxygen levels and other physiological changes that occur as the body approaches death. Terminal restlessness can be concerning for the individual and loved ones, as it may come across as discomfort or agitation.
How you can help: Do not interfere with these movements or try to restrain them, as this can increase their agitation and distress. Instead, speak in a quiet and natural manner, offering gentle reassurance. Provide comforting touch such as lightly massaging their forehead. Engaging them in calming activities such as reading to them or playing soothing music can help distract from feelings of restlessness and promote relaxation. Also ensure that their physical comfort needs are met by adjusting their position or providing pain relief as needed.
6. Congestion.
Congestion during the end of life may involve gurgling sounds inside the chest, often referred to as a "Death Rattle." These sounds may be loud and can be distressing. It’s important to note that congestion or the Death Rattle does not indicate the onset of severe pain. It’s caused by the accumulation of secretions in the airways and may contribute to difficulty breathing and discomfort.
How you can help: Gently turn their head to the side to drain secretions. Gently wipe their mouth with a moist cloth and offer lip balm to keep them comfortable and hygienic. While this may be distressing to witness, it’s important to remember that it is a natural part of the dying process and does not typically cause severe pain to the individual.
7. Urine decrease.
This symptom involves a reduction in urine output, accompanied by changes in color, often appearing tea-colored or darker than usual. This is common as the body’s system begins to shut down. It may be attributed to decreased fluid intake, changes in kidney function, and overall decline in bodily functions.
How you can help: Consult your hospice nurse. These professionals can provide guidance and support tailored to the individual’s specific needs and circumstances. They may offer recommendations for managing hydration, adjusting medications, or addressing any underlying medical concerns.
8. Fluid and food decrease.
Your loved one may want little or no food or fluid. This decrease in appetite and thirst is a common occurrence as the body’s systems begin to shut down in preparation for the dying process. The body naturally conserves energy as it approaches the end of life, redirecting resources away from activities such as eating and drinking, and can result in weight loss. This is not only normal but also serves a purpose in conserving the individual’s energy for the task ahead.
How you can help: Do not force them to eat or drink if they don’t want to. It only makes them more uncomfortable. Small chips of ice or frozen juice chips might be refreshing and provide hydration without requiring significant effort. A cool, moist cloth on their forehead might help alleviate any discomfort.
9. Change in breathing.
Breathing patterns before death commonly change. This symptom involves alterations in the pattern and rhythm of breathing as the body approaches the final stages of life. Changes may include Cheyne-Stokes breathing or shallow breaths with periods of no breathing for a few seconds to a minute, as well as rapid, shallow panting. These patterns are common and indicate a decrease in circulation as the body shuts down.
How you can help: Elevating the person’s head or turning them on their side may bring comfort and ease breathing. Holding their hand speaking to them gently can offer reassurance and emotional support.
10. Fever.
An increase in temperature is common. Fever during end of life can occur because of various factors, including underlying infections, inflammation, or metabolic changes. It does not necessarily indicate severe illness or discomfort.
How you can help: Caregivers can offer a cool, moist cloth on their forehead to help reduce their body temperature and provide relief from discomfort associated with fever. Consult your hospice nurse for guidance and support since they can provide personalized advice tailored to the patient’s specific needs. A benefit of hospice care is that you can consult a hospice nurse instead of calling 911 when you have medical concerns.
Emotional and spiritual end-of-life signs.
As end-of-life physical changes occur, your loved one is completing important work on another level. The following describes the emotional and spiritual changes patients who are near death may experience. Understanding these symptoms helps caregivers navigate this transition with greater compassion, acceptance, and connection, ultimately promoting a more peaceful and meaningful end-of-life experience for everyone involved.
1. Giving away belongings and making funeral plans.
Individuals may take active steps to make final decisions about their possessions and funeral arrangements. This symptom often arises from a desire to maintain a sense of control over their life and to ensure their wishes are honored after they pass. This can provide a sense of comfort and peace to the individual, but can be emotionally hard for families.
How you can help: It’s important to respect and support the individual’s autonomy and decision-making process at this time. Everyone, especially the dying, appreciate having their choices honored. Caregivers can offer emotional support and encouragement, and provide a safe and supportive environment for open communication to help facilitate this process.
2. Withdrawal.
The person may seem unresponsive, withdrawn, in a comatose-like state. This withdrawal is often characterized by a sense of detachment as the person begins to disengage from their surroundings and prepare for the end-of-life transition. It may be a way for the person to conserve energy and focus inwardly. It is a typical end-of-life symptom.
How you can help: While it may be challenging to witness this withdrawal, caregivers can offer gentle interventions to provide comfort and connection. Despite appearing unresponsive, know that hearing remains. It’s important to continue speaking to them in a normal voice and identifying yourself. Hold their hand. Say what you need to say. This helps them let go.
3. Vision-like experiences.
People nearing death may report encounters with people who are already deceased, or describe having been places or seen things not visible to others. These experiences, often referred to as visions or hallucinations, are not typically a drug reaction or mental illness. It is a common symptom of the end-of-life process, and may even provide comfort, reassurance, or a sense of connection to the spiritual realm.
How you can help: While it may be challenging for caregivers and loved ones to understand or validate these experiences, it’s important to approach them with empathy, openness, and respect. Do not contradict, explain away, or discount this experience. Instead, affirm them and acknowledge their significant to provide reassurance. If the experience frightens your loved one, reassure them it is common and natural: “Yes, these things happen.”
5. Communication and permission.
Your loved one may make statements or requests that seem out of character. These communications may include expressing preferences for specific people to be present, making requests for certain arrangements or rituals, or seeking affirmation and permissions to let go. This can serve various purposes including testing the readiness of loved ones to let go, expressing specific desires or needs, or seeking reassurance and support during the dying process.
How you can help: It may be challenging for loved ones to understand or respond to these communications. They may want to be with a few select people or only want one person. If you are not included, it does not mean you are not important or loved, it just means your task with the person is fulfilled. If you are selected, it may mean the person needs your affirmation, support, and permission to let go. Let your loved one know you will be alright. Say whatever words of love and support you need to say. Give them permission.
Saying goodbye.
This is their final gift.
How you can help: Listen. Hold them. Say whatever you need to say. It may be just, “I love you,” or recounting favorite memories you have shared. It may be an apology, or saying, “Thank you.” There is no need to hide your tears. Tears express your love and help you let go.
Timeline for end-of-life changes:
Since the end-of-life journey is a unique experience for everyone, patients may move this end-of-life timeline at a different pace than expected. It’s possible that the timeline for end-of-life changes below does not exactly match what you or your loved one is experiencing. But it’s useful as a guide to know what commonly occurs during these times, so caregivers can better support their loved ones during their final days.
One to Three Months Before Death
- Decreased desire for food
- Increased desire for sleep
- Withdrawal from people and the environment
One to Two Weeks Before Death
- Even more sleep
- Confusion
- Restlessness
- Vision-like experiences
- Change in temperature, respiration, pulse, and blood pressure
- Congestion
- Not eating
Days or Hours Before Death
- Surge of energy
- Decreased blood pressure
- Glassy, teary eyes
- Half-opened eyes
- Irregular breathing
- Increased restlessness
- Cold, purple, blotchy feet and hands
- Weak pulse
- Decreased urine output
Minutes Before Death
- Gasping breathing
- No awakening
Dying may take hours or days. No one can predict the time of death, even if the person is exhibiting typical end-of-life signs and symptoms. This can sometimes cause fatigue and confusion; and although you may be prepared for the dying process, you may not be prepared for the actual death moment. It may be helpful for you and your family to discuss just what you would do at that moment.
Contact Us to Learn more about End-of-Life Signs & Changes
Whether you need advice from one of our caregivers regarding end-of-life symptoms and signs, or just want an opportunity to talk, Crossroads Hospice & Palliative Care can help. Family caregivers can give us a call at 855-327-4677 to speak with someone anytime, or choose one of the options in the blue help bar above. You can also view our hospice service areas to find a Crossroads in your area. A trained professional will come to the patient.
It is very important to seek out and engage a hospice organization at this time.
End-of-life signs by disease.
Learn about the specific end-of-life signs of common diseases and illnesses: