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Knowledge Point Articles   

June 2006

Stages, Signs and Symptoms of Approaching Death

Although death is a uniquely individual experience, there are some common stages, signs and symptoms that are important to explore and understand. Usually one to three months before patients die, they will begin to withdraw from the world around them. Your patients may “live inside” themselves where they internalize their thoughts and evaluate their life. This internalizing and evaluating process is commonly done with their eyes closed.

You will notice your patients beginning to sleep more; in fact, they are more than likely spending more hours asleep than they are awake. As withdrawing increases, the need to communicate with others decreases. You may notice that touch becomes increasingly more important. It is okay to be silent and hold your patient’s hand. Silence combined with touch is a powerful communication tool.

Also in this time period, as your patient prepares for death, it is natural for the appetite and desire for food to diminish or even stop. This is a hard reality for family members to deal with. We need to help family members understand it’s okay for their loved ones to not eat—in fact it is the patient’s choice. For your patient, a different kind of energy is needed now. It’s more of a spiritual need rather than a physical need.

As death draws closer (one-two weeks prior to death) your patient is now sleeping most of the time and finding it extremely difficult to keep his or her eyes open. We often see the patient becoming more confused, talking about people, places and events that are unfamiliar to the support system. Or, a patient may talk of seeing and having conversations with loved ones who have died before them. Agitation can begin and he or she may become increasingly restless.

At one to two weeks prior to death, some physical changes occur that signal the body is shutting down and preparing for death. Those physical changes are:

• Blood pressure begins to drop
• Heart rate often is between 80 and 200 beats/minute or slowing down
  to zero 
• Body temperature fluctuates between feverish and cold, with an increase in perspiration
• Skin color may change
• Nail beds, hands and feet are often pale and bluish due to poor circulation
• Breathing can be very rapid or very slow, occasionally stopping and starting
• Gurgling and rattling in your patient’s throat

Now that the patient has reached imminent death, (anywhere from an hour to a couple days away) you will often see a “burst of energy”. Your patient may be alert and oriented and may eat a regular meal, which probably hasn’t been done in weeks. This is the body preparing for its final journey. After this latent burst of energy, the patient once again becomes increasingly restless, breathing is irregular and congestion may be very loud. The eyes are open, but he or she has lost the ability to see. Often your patient’s eyes look as though they are coated with glass. The extremities may become purplish. The knees, ankles and elbows may start to look blotchy, as well as the arms, legs, back and buttocks.

Hospice caregivers are entrusted with the monumental task of helping a patient through the final journey. Our role requires knowledge, understanding, skill and compassion. Understanding these stages, signs and symptoms of approaching death will enable us to give our best by providing compassionate care.

Cyndi Rohret RN, BSN, CHPN
Clinical Consultant, Briggs Corporation

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