Signs of Death

Hospice Patients Alliance: Consumer Advocacy


When confronted with approaching death, many of us wonder when exactly will death occur. Many of us ask the question, “How much time is left?” This can often be a difficult question to answer. The dying do not always cooperate with the predictions of the doctors, nurses or others who tell family members or patients how much time is left.

Hospice staff have frequently observed that even the predictions by physicians about the length of time from the original diagnosis till death is often inaccurate. Many families report that “the doctor told us he [the patient] only had so much time left, and he’s lived much longer than that.” … or a similar story. Statistical averages do not tell us exactly how long a particular patient has to live; they can only serve as a general guideline or point of reference.

Although statistical averages do not help much in an individual case, there are specific signs of approaching death which may be observed, and which do indicate that death is approaching nearer. Each individual patient is different. Not all individuals will show all of these signs, nor are all of the signs of approaching death always present in every case.

Depending on the type of terminal illness and the metabolic condition of the patient, different signs and symptoms arise. An experienced physician or hospice nurse can often explain these signs and symptoms to you. If you have questions about changes in your loved one’s condition, ask your hospice nurse for an explanation, that is one of the reasons she is serving you.

There are two phases which arise prior to the actual time of death: the “pre-active phase of dying,” and the “active phase of dying.

On average, the preactive phase of dying may last approximately two weeks, while on average, the active phase of dying lasts about three days.

We say “on average” because there are often exceptions to the rule. Some patients have exhibited signs of the preactive phase of dying for a month or longer, while some patients exhibit signs of the active phase of dying for two weeks. Many hospice staff have been fooled into thinking that death was about to occur, when the patient had unusually low blood pressure or longer periods of pausing in the breathing rhythym. However, some patients with these symptoms can suddenly recover and live a week, a month or even longer. Low blood pressure alone or long periods of pausing in the breathing (apnea) are not reliable indicators of imminent death in all cases. God alone knows for sure when death will occur.

Signs of the preactive phase of dying:

increased restlessness, confusion, agitation, inability to stay content in one position and insisting on changing positions frequently (exhausting family and caregivers)

withdrawal from active participation in social activities

increased periods of sleep, lethargy

decreased intake of food and liquids

beginning to show periods of pausing in the breathing (apnea) whether awake or sleeping

patient reports seeing persons who had already died

patient states that he or she is dying

patient requests family visit to settle “unfinished business” and tie up “loose ends”

inability to heal or recover from wounds or infections

increased swelling (edema) of either the extremities or the entire body

Signs of the Active Phase of Dying

inability to arouse patient at all (coma) or, ability to only arouse patient with great effort but patient quickly returns to severely unresponsive state (semi-coma)

severe agitation in patient, hallucinations, acting “crazy” and not in patient’s normal manner or personality

much longer periods of pausing in the breathing (apnea)

dramatic changes in the breathing pattern including apnea, but also including very rapid breathing or cyclic changes in the patterns of breathing (such as slow progressing to very fast and then slow again, or shallow progressing to very deep breathing while also changing rate of breathing to very fast and then slow)

other very abnormal breathing patterns

severely increased respiratory congestion or fluid buildup in lungs

inability to swallow any fluids at all (not taking any food by mouth voluntarily as well)

patient states that he or she is going to die

patient breathing through wide open mouth continuously and no longer can speak even if awake

urinary or bowel incontinence in a patient who was not incontinent before

marked decrease in urine output and darkening color of urine or very abnormal colors (such as red or brown)

blood pressure dropping dramatically from patient’s normal blood pressure range (more than a 20 or 30 point drop)

systolic blood pressure below 70, diastolic blood pressure below 50

patient’s extremities (such as hands, arms, feet and legs) feel very cold to touch

patient complains that his or her legs/feet are numb and cannot be felt at all

cyanosis, or a bluish or purple coloring to the patients arms and legs, especially the feet and hands)

patient’s body is held in rigid unchanging position

jaw drop; the patient’s jaw is no longer held straight and may drop to the side their head is lying towards


Although all patients do not show all of these signs, many of these signs will be seen in some patients. The reason for the tradition of “keeping a vigil” when someone is dying is that we really don’t know exactly when death will occur until it is obviously happening. If you wish to “be there” with your loved one when death occurs, keeping a vigil at the bedside is part of the process.

Always remember that your loved one can often hear you even up till the very end, even though he or she cannot respond by speaking. Your loving presence at the bedside can be a great expression of your love for your loved one and help him to feel calmer and more at peace at the time of death.

If you have questions about any of the changing signs or symptoms appearing in your loved one, ask your hospice nurse to explain them to you.


Signs of 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).

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