What Happens in the Last Hours of Life?

How will I know that death may be very close?

It is not always possible to know exactly when someone has entered the final hours of life. However, you may notice that changes which have been developing over the previous days become more pronounced.

The person may:

Not everyone will experience all of these changes. Some people may have them for several hours, while others may experience them for longer. Even when death appears to be very close, it is not possible to give an exact time.

The person may become deeply unconscious

During the final hours, someone may spend most or all of their time unconscious. This can look like a very deep sleep but they may not respond when you speak to them or touch them. Although they cannot respond, it is possible that they may still hear your voice or feel your touch. You can continue to talk to them. There is no need to keep talking constantly but a quiet, familiar voice may be comforting.

Their breathing may change significantly

Breathing can look very different during the final hours.

It may become:

• slower
• shallower
• irregular
• deeper for a short period
• interrupted by increasingly long pauses

Sometimes there may be several breaths close together, followed by a noticeable pause before breathing starts again. This is known as Cheyne Stokes breathing. This type of breathing pattern can be alarming to watch but it is usually a natural part of the dying process.

What is the death rattle?

You may hear a wet, rattling or gurgling sound when the person breathes. This is sometimes called the death rattle. It happens when saliva and other secretions collect in the throat or upper airways because the person is no longer able to swallow or clear them effectively.

The sound can be extremely upsetting for family members, however, it does not usually mean that the person is choking or experiencing the same distress that you may feel when you hear it. If you are worried that the person is uncomfortable, tell the healthcare team. They can assess them and advise whether anything needs to be done.

Their breathing may eventually become very shallow

As death gets closer, the person’s breaths may become increasingly shallow. There may be longer and longer pauses between breaths. Sometimes it can appear as though they have stopped breathing altogether before another breath begins. This can be frightening if you don’t know what to expect.

Try to remember that these changes are generally part of the body’s natural process of dying.

They may no longer be able to swallow

During the final hours, swallowing may become very difficult or stop altogether. This means that the person may no longer be able to take food, drink or medicines by mouth safely.

Do not try to force food or drink.

If someone cannot swallow safely, they may choke or aspirate fluids into their lungs. Instead, the healthcare team can advise about mouth care and alternative ways of giving medication where necessary.

You may be able to:

• moisten their lips
• provide mouth care as you have been shown
• keep their mouth comfortable
• use lip balm if appropriate

Ask the nurse or other healthcare professional caring for the person to show you what is suitable.

Their body may become colder

During the final hours, circulation slows further. The person’s hands, feet, arms and legs may become cold and their skin may also become pale, bluish or mottled. On darker skin tones, changes in colour can be more difficult to see. Blue colouring may be easier to notice on areas such as the lips, tongue, inside of the mouth, nose or ears. Mottling may appear darker than usual, purple or brownish.

These changes are a normal part of the body slowing down.

You can use blankets or socks if they seem to make the person more comfortable, but avoid overheating them. Follow their cues where possible.

They may stop passing urine

As the body’s circulation and kidney function slow down, the person may produce very little urine or stop passing urine altogether. They may also become incontinent of urine and/or faeces. This is a normal part of the dying process in someone who is known to be approaching death. If the person appears uncomfortable or you are concerned, tell the healthcare team.

Their face and body may look and smell different

As the body relaxes, you may notice changes in the person’s appearance.

• Their face may become more relaxed.
• Their mouth may fall slightly open.
• Their eyelids may remain partly open.
• Their skin may become paler or develop a waxy appearance.
• You may notice a slightly sweet smell

These changes can be surprising if you have never seen them before.

What if they make sounds or movements?

Sometimes a dying person may make sounds, move their arms or legs, twitch or appear restless. This does not automatically mean that they are in pain. However, if the person appears distressed, agitated or uncomfortable, tell the healthcare team.

There can be several possible causes of distress, including pain, breathlessness, medication effects, infection or other problems. Healthcare professionals can assess what is happening and provide appropriate treatment or comfort measures.

What if the person becomes restless or distressed?

Sometimes a person becomes restless, agitated or confused towards the end of life and this can be upsetting to witness. Try to create a calm environment and avoid unnecessary noise or activity. Speak gently and reassure them.

However, don’t assume that restlessness is simply “part of dying”. There can be different causes, including pain, infection, medication effects, difficulty passing urine or other problems. Tell the healthcare team if someone becomes newly restless, agitated or distressed so that they can assess what may be causing it and provide appropriate care.

What can I do when someone is dying?

There may be very little that you need to do. Your presence can be enough.

You can:

• sit beside them
• talk quietly
• hold their hand if appropriate
• stroke their arm or forehead gently
• play familiar music
• keep the room calm
• dim bright lights if they seem uncomfortable
• help with mouth care if you have been shown how
• reassure them that they are not alone

You don’t need to keep checking whether they are still breathing or fill every silence. Even if the person cannot respond, they may still be able to hear or feel you.

Should I tell them that they are dying?

There is no single right answer. If the person is conscious and wants to talk about dying, it can be helpful to allow them to do so.

You could say: “I’m here with you.”, “You are safe.”, “Is there anything you want me to know?”, “Is there anyone you’d like me to call?”

If they don’t want to talk, you don’t need to force a conversation.

What if I am not there when they die?

You may feel that you have to be beside someone for their final breath. You don’t and very often people will appear to wait until they are alone before dying.

If you need to go to the bathroom, make a cup of tea, speak to another family member or simply take a few minutes away, it does not mean that you have failed them.

If you are caring for someone at home, ask someone else to sit with them if that would make you feel more comfortable and if you cannot be there at all, that does not diminish the love or care you have given them.

What does the moment of death look like?

There is not always a clearly recognisable moment. The person’s breathing may gradually become slower and further apart until there is a final breath. Sometimes the final breath is a gentle breath in followed by an exhalation. There may then be no further breath.

The person may look peaceful. Their face may relax and their mouth may fall open. It can sometimes take a little time to realise that they have died. You do not need to panic or rush.

If the death was expected, follow the instructions you have been given by the healthcare team about who to contact. A doctor or other appropriately trained healthcare professional will confirm the death according to the circumstances.

Do I need to do anything immediately after death?

If the death was expected, you generally do not need to rush. You can take some time to sit with the person and I often suggest having a cup of tea and taking some time to acknowledge what has happened.

You might want to:

• hold their hand
• talk to them
• open a window
• play music
• say a prayer or other words
• invite close family members to come
• simply sit quietly

There is no requirement to immediately leave the person or rush to make funeral arrangements. The exact procedure after an expected death depends on the circumstances and where the person was being cared for.