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End-of-Life Signs, Changes: What to Expect at End of Life

When a loved one is terminally ill, family caregivers often have questions and concerns about what changes will happen at the end of life. While each person is different, and many factors influence the dying process, certain  indicators are common in the weeks, days and hours leading up to death.

Knowing what to expect – and what you can do to help – can ease your worries as you navigate this difficult time. Most important: just being present with your loved is often the most valuable action you can take.

End-of-Life Signs


Each person’s end-of-life experience is unique, as it is influenced by such factors as the specific illness, medications being taken, and the person’s overall health. In some cases, these changes may occur over a period of weeks; for others, the process lasts just a few days or hours.

However, a number of end-of-life changes are fairly common, as a person’s bodily functions naturally slow and stop. The following changes are often signs of this process, though not every patient exhibits all of these end-of-life signs.

  • Less interest in eating or drinking. The person may only need enough liquid to keep their mouth from becoming too dry.

How to help: Offer, but don’t force, food, liquids, and medication. In some instances, the person may no longer feel pain they had previously felt.

[ Read more about what hospice patients can eat and drink. ]
  • Not passing fluids regularly. As bodily functions decline and the person eats and drinks less, their output of fluids will also decrease.

How to help: Do nothing. However, if the patient is not passing fluids but feels the urge to do so, contact their nurse for advice.

  • Speaking and moving less. Activity usually decreases significantly in one’s final days and hours. People may not respond to questions and show little interest in their surroundings.

How to help: Allow your loved one to rest and remain peaceful. Offer reassuring words and touches, but don’t pressure the person to interact.

“With their last breath, those we love do not say good-bye, for love is timeless.”

– Edward Hays

  • Sleeping much more than usual. It is natural to sleep more, including during the day, at the end of life.

How to help: Let your loved one sleep. At this point, it is more important to be with, rather than to do for, your relative.

  • Difficulty communicating. Vision and hearing may become impaired, and speech may be hard to understand. Lack of oxygen reaching the brain (due to decreased circulation or other causes) may contribute to these changes.

How to help: Speak clearly to the person. Ask your loved one what would make them more comfortable, such as more or less light in the room. Listen carefully when your relative speaks.

  • Gurgling with each breath; a dry, encrusted mouth. Patients often breathe through their mouth, causing secretions to collect at the back of the throat. This can cause gurgling, coughing, choking, or even vomiting. These secretions may also coat the mouth, or drain if the person is lying on their side.

How to help: Use a cool-mist vaporizer to moisten the air in the room. If this does not help, contact the hospice nurse for advice. Then clean the patient’s mouth, using a swab dipped in mineral oil, glycerin, or water. Give small amounts of water through a straw: place a straw in a glass of water, then seal the top end of the straw with your finger. Gently place the bottom end of the straw in the patient’s mouth, then remove your finger from the top to release the water. This may help prevent dryness in the mouth.

  • Breathing that stops and starts. Breathing may become irregular or seem difficult, with periods of no breathing lasting 20 to 30 seconds. (This is called Cheyne-Stokes breathing.) The person may moan with each breath. This sound is typically caused by air passing over very relaxed vocal cords, and not due to pain or distress. As death nears, breathing may become more regular, but shallower and more mechanical.

How to help: Raise the head of the bed to make breathing easier. To help reduce the sound of noisy breathing, you can turn the person onto their side.

  • Restlessness or combativeness. Your loved one may pull on bed linens or clothing, hallucinate, or even try to get out of bed, due to less oxygen reaching their brain. Repetitive, restless movements may also indicate something is unresolved or unfinished in the person’s mind.

“Facing a loved one’s final moments is scary. But if you know what end-of-life changes to expect, you’ll feel less anxious, and be better prepared to help the person.”

— Donna Fahey, MFA, MSN, RN, CNL, HNB-BC, Manager, The Samaritan Center at Voorhees

How to help: Play soft music, talk in a calm voice, or read to you loved one. Help them recall a favorite place or experience. Try giving a back rub to relax them. If your loved one tries to get out of bed, provide support to avoid a fall. Reassure the person that you are there for them, and that it’s OK to let go.

  • Being more confused or hallucinating. End-of-life changes to the brain can cause misperceptions of reality. Patients may have illusions, which are misunderstandings of something that is actually there. For instance, your relative might hear rain falling, but think someone is knocking at the door. They might see a lamp, but think it’s a person.Your loved one may also have hallucinations, which are perceptions of things that are not there. For example, the person may hear, see, or feel things – such as voices or visions — that others don’t perceive. Many patients speak about the presence of deceased loved ones.

Similarly, some people who are dying think others are trying to harm them (this is called “delusions of persecution”). Some think they are much stronger than they are, and that they can do things that are not possible (this is called “delusions of grandeur”).

How to help: Affirm your loved one and be reassuring. Don’t try to correct them. If your relative is frightened, let them know they are safe and that their experience is normal and natural. You can also try to shift their attention to a different topic or activity. In general, keep conversations light. Talk about the day, the time, where you are, or about someone present in a casual way, to put your loved one at ease.

  • Becoming very cold, then hot; developing a bluish skin tone. As the end draws near, the body loses its ability to control its temperature. In addition, blood pressure gradually falls, and less blood flows to the hands and feet. Arms and legs become cold and bluish in color as circulation slows. The underside of the body may darken, and it may become impossible to find a pulse at the wrist.

How to help: Provide blankets to warm, and cool, wet washcloths to cool your loved one when needed. Change linens and clothing as needed to keep your relative comfortable.

  • Skin of the knees, feet, and hands turn purplish, pale, gray, and blotchy. This end-of-life change usually signals that death will occur within hours to days.

How to help: Be aware that death may come soon, and share that information with other relatives as appropriate.

  • Becoming unresponsive or lapsing into a coma. Dying affects the central nervous system, so your relative may sometimes be fully awake, and at other times be unresponsive. Before death, people will often slip into a coma – a deep state of unconsciousness. Even in a coma, though, your loved one may be able to hear sounds and feel something painful.

How to help: Always act as if the dying person is aware of what’s going on, and can hear what you’re saying and feel you touching them.

  • Loss of bodily functions. This may occur around the moment of death, or sooner in patients with incontinence.

How to help: Place disposable, waterproof pads (known as “chux”) under the patient, and cover the mattress with plastic. This will protect both your loved one and the bed.

Emotional and spiritual end-of-life changes

In addition to physical differences, many people go through emotional and spiritual changes near the end of life. These can include:

  • Giving away belongings and planning their funeral. Some people want to play an active role in distributing their property or making decisions about their final arrangements.

How to help: Though it may be emotionally difficult for you, let your loved one control these decisions if they want to. All people – including those who are dying — want their choices honored.

  • Withdrawing. The person may seem detached, unresponsive, or comatose. However, they can usually still hear you and be aware of your presence.

How to help: Identify yourself when you arrive. Speak in your normal voice. Hold your loved one’s hand. Say what you need to say to them. This will help them – and you — let go.

  • Making uncharacteristic statements. Your loved one may say things that seem out of character, or even rude. They may be testing whether you’re ready to let them go. They may only want to be with one person or a select few.

“It can be helpful to discuss with your family what you will do as these end-of-life signs occur, and at the moment of your loved one’s death.”

— Kim Rumaker, MSS, LCSW, Manager, Samaritan Social Work, Spiritual Support & Center for Grief Support


How to help: Understand that, if your loved one excludes you, it doesn’t mean they don’t love you or that you’re not important. It simply means your task with them is fulfilled. And if they want you at their side, it may mean they need your affirmation, support, and permission to let go. Let your relative know you will be OK. Say any words of love and support you need to tell them. Give them permission to let go.

  • Saying goodbye. This is your loved one’s final gift to you.

How to help: Listen. Hold them. Say anything you need to say. You may want to recall favorite memories, apologize for something, thank the person, or simply say “I love you.” Don’t hide your tears; crying expresses your love and helps you let go.

Changes at the time of death

People sometimes think that the moment of death will be dramatic, difficult or painful. That is not usually the case, especially when a person dies while receiving hospice care. Hospice providers work to alleviate patients’ pain and discomfort.

[ Read more: What is hospice care? ]

In fact, the signs of death are often subtle. It may take a few minutes to realize the person has died, rather than just being asleep or unresponsive.

When someone dies, you many notice the following end-of-life changes:

  • Breathing ceases.
  • The heart stops beating.
  • The person cannot be roused.
  • Their eyelids may be partially open, with their eyes in a fixed stare.
  • Their mouth may fall open slightly, as the jaw relaxes.
  • Their body may release any waste matter in their bladder or rectum.
  • The skin turns pale and waxen as the blood settles.

What to do when death occurs:

If the patient is receiving hospice care at home, call the hospice organization. Do not call 911 or any other local emergency number. The hospice nurse will help you with any calls to the physician and funeral home of your choice.

If the patient is receiving care at an inpatient hospice center or other facility, notify a staff member.

To learn more about end-of-life signs and about caring for your loved one who is terminally ill, call Samaritan Healthcare & Hospice at (800) 229-8183.