Signs of Approaching Death

By William Lamers, M.D.
former Medical Consultant, Hospice Foundation of America

Donate to HFANote: This is a general picture. It will vary greatly according to the cause of death, the person's general health, medications and any other significant factors.

All dying experiences are unique and influenced by many factors, such as the particular illness and the types of medications being taken, but there are some physical changes that are fairly common. For some, this process may take weeks; for others, only a few days or hours.

For most dying persons, activity decreases significcantly in the final days and hours of life. They speak and move less and may not respond to questions or show little interest in their surroundings. They have little, if any, desire to eat or drink.

As you hold their hand, you may notice that they feel cold. When a person is dying, his or her body temperature can go down by a degree or more. Blood pressure will also gradually lower and blood flow to the hands and feet will decrease.

When a person is just hours from death, breathing often changes from a normal rate and rhythm to a new pattern of several rapid breaths followed by a period of no breathing. This is known as “Cheyne-Stokes” breathing—named for the person who first described it. Coughing can also be common as the body’s fluids begin to build up in the lungs. Fluid that accumulates in the lungs also causes “rales” and “rattles.” This breathing sound is often distressing to caregivers but it is not an indication of pain or suffering. The secretions that cause these sounds can be dried up with a medication called atropine delivered via injection, scopolamine (oral or transdermal), or a small dose of liquid morphine. The oral administration of a small amount of a common eye drop solution usually prescribed to reduce the amount of tears can also help reduce the amount of lung fluid. On the other hand, when lung secretions are thick or dry, running a vaporizer in the room can ease breathing.

As death approaches, skin color is likely to change from the normal pinkish tone to a duller, darker, grayish hue. The fingernail beds may also become bluish rather than the normal pink.

Because the central nervous system is directly impacted by the dying process, your loved one may sometimes be fully awake and other times not responsive. Often before death, people will lapse into a coma. A coma is a deep state of unconsciousness in which a person cannot be aroused. Persons in a coma may still hear what is said even when they no longer respond. They may also feel something that could cause pain, but not respond outwardly. Caregivers, family, and physicians should always act as if the dying person is aware of what is going on and is able to hear and understand voices. In fact, hearing is one of the last senses to lapse before death.

It is not unusual for dying persons to experience sensory changes. Sometimes they misperceive a sound or get confused about some physical object in the room. They might hear the wind blow but think someone is crying or see the lamp in the corner and think someone is standing there. These types of misperceptions are called illusions. They are misunderstandings about something that is actually in their surroundings.

Another type of misperception is hallucination. Dying persons may hear voices that you cannot hear, see things that you cannot see, or feel things that you are unable to touch or feel.

Some dying persons confuse reality and might think that others are trying to hurt them or cause them harm. Or, they can come to believe that they are much more powerful than they really are and think that they can accomplish things that are not possible. These types of misconceptions are called delusions of persecution and delusions of grandeur.

If you want more information about the sequence of events leading up to the moment of death, we suggest the book How We Die by Sherwin Nuland, M.D. (New York: Knopf, 1993).