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

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 significantly 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 (apnea). This is known as Cheyne-Stokes breathing—named for the person who first described it. Coughing and noisy breathing are common as the body’s fluids accumulate in the throat. This breathing is often distressing to caregivers but it does not indicate pain or suffering. The secretion that cause this sound can often be dried up with the use of certain medicines, such as atropine or scopolamine. Sometimes a vaporizer can ease breathing. Also reposition the patient on his or her side can help diminish the sound of noisy breathing.
 
As death approaches the skin of the knees, feet, and hands may become purplish, pale, grey, and blotchy. These changes usually herald death within hours to days. When death does occur, the skin turns to a waxen pallor as the blood settles. 

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).

April 19, 2017: "Signs of Approaching Death" has been revised in part for clarity by Hank Willner, MD, Hospice Foundation of America's Medical Adviser. 

About William Lamers: William Lamers, MD, died in 2012 at the age of 80. Dr. Lamers was a long-time consultant to HFA, where he answered questions from families and patients as part of the organization's "Ask HFA" service. A pioneer in U.S. hospice care, Dr. Lamers founded Hospice of Marin (now Hospice by the Bay) in Northern California. Dr. Lamers was a frequent panelist on HFA's Living with Grief ® programs and contributor to its Living with Grief ® books.

About Hank Willner: Hank Willner, MD, is Medical Adviser to Hospice Foundation of America, Chief Medical Director at Holy Cross Home Care and Hospice, and Palliative Care Consultant at Holy Cross Hospital in Silver Spring, Maryland. Certified in both Hospice and Palliative Medicine and in Family Practice, Dr. Willner is a Clinical Assistant Professor of Family Practice at Georgetown University Medical School and is a member of the Maryland State Advisory Council on Quality Care at the End of Life.