Hospice and Preparing for Approaching Death: Signs, Symptoms, and Changes

June 22, 2021

patient in hospital

Many physical, cognitive, emotional, and spiritual changes occur during the dying process, disturbing the dying, the families, and caregivers.

Knowing what signs and symptoms to expect and why certain things are happening can help prepare for the approaching death of a loved one.

The dying process occurs over a duration of time that is unique to each person. This guide covers the common signs and symptoms that people are most likely to share in the dying process.  


Physical Changes


Decreased Desire to Eat and Drink

As death approaches, there is a decrease or refusal to eat and drink.

The patient may be physically unable to tolerate food or fluids, becoming too tired and weak to eat or drink, leading to decreased energy levels.

First, dehydration begins, causing sleepiness that can act as a natural analgesic (pain reliever). If the person is in pain, this natural effect can be helpful in the dying process.

Increased Sleep

As the disease progresses, the person may spend an increasing amount of time sleeping, seem less talkative and withdrawn, become more difficult to awaken, and eventually become unresponsive. 

Confusion and Restlessness

Many things are happening to cause these changes. For example, electrolytes (elements in the blood) and blood sugar levels may change, which can cause confusion and restlessness. 

Kidney and liver function may decrease or even shut down, causing toxins and ammonia levels to rise, adding to the confusion, restlessness, and sleepiness.

Break Down in Skin

As the person becomes weaker, they spend more time idle in bed, causing changes in the skin, such as skin breakdown. 

Maintaining proper nutrition and hydration is key to preventing skin breakdown. However, even with the best care, the inability or refusal of the person to eat or drink makes changes in the skin nearly unavoidable.

Weight Loss

Given the lack of nutrition, weight loss usually follows, in some cases to the point where the outline of bony areas may be visible.

Witnessing your loved ones go through changes is emotionally tolling, but it’s important to remember they are natural parts of the dying process. 

Temperature and Color Changes in Skin

As the disease progresses, a person’s hands, arms, feet, and legs may feel cold. Skin color may change; there may be purple blotchiness starting on the feet and hands, then progressing up the legs and entire body.

The blood pressure often lowers, and the pulse rate may increase or decrease. In addition, the body temperature may fluctuate between warm and cold, leading to increased sweating and clamminess of the skin.

Decrease in urine and incontinence 

Because of decreased fluid intake, the person’s urine output will naturally decrease. As a result, the urine may become concentrated and “tea” colored. The person may also lose control of urine and bowel function as the muscles in that area begin to relax.

Periods of no breathing and difficulty breathing 

As terminal illnesses worsen, especially with lung cancers and chronic lung diseases, breathing can become challenging. As a result, a person can become short of breath (dyspnea), commonly referred to as ‘air hunger. 

The person’s regular breathing pattern may change. For example, breathing may become slower and irregular, or the person may experience shallow breathing. Apnea may occur, an episode of no breathing, lasting anywhere from five seconds up to sixty seconds before breathing begins again, causing a significant decrease in organ circulation. 

Rattling Breathing and Gurgling

In addition, the person may develop rattling or gurgling sounds while breathing, commonly described as ‘death rattle,’ caused by secretions (saliva, mucus, and bile) and relaxation of muscles in the throat. Although generally not painful, it can be frightening to the dying and family members witnessing it.

As the person progresses through these stages, they tend to lose the ability to cough up secretions due to their growing physical weakness; their body is now in the final stages of dying.

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Emotional, Spiritual, and Cognitive Changes


Vivid Dreams, Visions, and Hallucinations

Many people going through the dying process will often talk to people and about places or events from the past. They may see and talk with loved ones who have died before them, leading to vivid dreams, visions, and may experience hallucinations.

If it brings them happiness, it is essential not to convince them that it is not real. Attempting to correct this perception may negatively affect the emotions, upsetting the dying person and leading to arguments and withdrawal. 

As your loved one approaches death, they will begin to detach from this life and prepare for a transition.

Repetitive, Restless Tasks

They may perform repetitive and restless tasks due to unresolved issues or unfinished business preventing them from letting go. 

The most significant restlessness typically occurs at night, leading caregivers to lose sleep. The emotional and physical toll may quickly and negatively affect a caregiver, leading to increased anxiety and stress. 

Unusual Communication

Your loved one may make seemingly odd statements, gestures, or requests; commonly, this occurs when death is near. These unusual events may be testing their loved ones for reassurance that they are emotionally ready to let them pass. 

Giving Your Loved One Permission to Go

A challenging but essential action is to “give permission” for your loved ones to go, giving them peace. Permitting your loved ones to go without making them feel guilty for leaving can be an emotional, challenging, but necessary task.

Reminding Your Loved One What They Mean to You

Discuss how you feel, reminding them what they mean to you. It can be challenging for those close to finding the words to say but remember that it is better to say something than to say nothing.

As a caregiver, family member, or friend, take time to listen to your loved ones. They may be in the same situation with the desire to talk but do not know where to start.

Saying Goodbye to Your Loved One

The hospice care team will be there to prepare family members for when death is approaching. This is the time to contact family and close friends, allowing all the opportunity to gather, support each other, and say their final goodbyes. 

If your loved one is unconscious, likely they can still hear you. Let them know you’re with them. 

On many occasions, the dying person will not pass until their loved ones have left, unable to let go while their family and close friends surround them.

The greatest gift during this time is your ability to let your loved ones go when they are ready, leaving them in peace and without guilt.

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