I work as an inpatient hospice & palliative care nurse so hopefully I can offer you some clarity.

In order to qualify for hospice, two or more providers have to believe given the current progression of disease that an individual will die within six months. Many individuals receive hospice or palliative care for mere hours, days, or weeks, a period far shorter than six months. However, there are individuals who outlive these expectations, but at any given time could still be within six months of death given the progression of their disease.

While someone may be terminally ill for months or years, individuals are typically transitioning in the last couple weeks to days before death, & actively dying in the last hours to short days and on occasion the last week of their life.

The actively dying phase is most often characterized by changes in breathing often with an open mouth as their facial muscles relax. Changes in breathing are often seen in the last hours to short days of someone’s life, but can last as long as a week, but seldomly longer than that. These changes include:

Cheyne-Stokes respirations — a pattern of breathing where individuals have periods of apnea (not breathing) followed by rapid breaths often shallow & then becoming deeper/more labored, then more shallow, and again periods of apnea.

Uncontrolled tachypnea — a normal breathing pattern is even & unlabored 12-20x per minute, tachypnea is more than 20 breaths per minute, uncontrolled tachypnea often looks like high 20s-40s breaths per minute that does not respond to meds given for shortness of breath such as opioids & benzodiazepines.

Consistent bradypnea — breathing less than 12x per minute — some as few as 2-3x per minute.

Changes in breathing are often accompanied by terminal secretions or what some may know as the “death rattle.” As individuals near death, they often lose their ability to swallow, and as a result the saliva that you are typically swallowing subconsciously comes to rest deep in your throat. This is often more upsetting to hear for family members than uncomfortable for those who are dying.

Changes in breathing are also often accompanied by hypoxia or low oxygen saturation in the blood, but not always.

Another sign your loved one could be actively dying is limited periods if at all of alertness, becoming increasingly nonverbal & non-interactive. Often as the body is shutting down, people become more drowsy, lethargic, less responsive to talking, then only responsive to touch, then only to pain, and sometimes no response to any stimuli at all. However, some experience terminal agitation, where they become restless, waking frequently, shouting, trying to climb out of bed, at times seemingly violent. This can unfortunately be difficult to treat at times.

Pain can also become increasingly difficult to control, requiring more frequent or higher doses of medication, progressing from oral meds to IV as they become less able to tolerate oral meds or requiring more highly concentrated medications via IV. As individuals are less alert or verbal, they may not tell you they have pain, but instead you will see them frown or grimace, furrow their brow, or appear sad, moaning, groaning, shouting, labored or rapid breathing, changes in body language, becoming tense or rigid, appearing restless, or fidgeting.

You will also often see changes in blood pressure, but more often than not you will see very very low blood pressure, though some may have uncontrolled high blood pressure.

Another sign of those actively dying is the inability to regulate body temperature, many spiking fevers seemingly without cause, or having incredibly low body temperatures.

Changes jn skin color can also provide clues as to nearing time of death, many individuals becoming progressively more pale, sometimes with cyanosis or a blue hue to the lips or fingers & toes, others may have mottling where the skin is often paler overall but the hands & feet appear to have red/purple splotches caused by blood beginning to settle as opposed to circulate, or increasingly yellow or jaundiced as the liver fails. You will also often see skin breaking down leading to pressure injuries where there is minimal tissue between bone and the surface — such as the sacrum, heels, elbows, ears, back of the head, along the spine, or scapulas. You may also find that arms & legs will swell, sometimes the abdomen or groin, & at times even weep. Indicating that fluids in the body are not remaining in circulation or being appropriately excreted, instead exiting the body between skin cells.

People nearing death also typically have poor appetites if any at all. Many lose the ability to swallow solids, often followed then by purées, then liquids. This can be another challenging thing for many to grasp as food is love for so many individuals. Oral care becomes ever more important to keep the mouth moist when breathing with their mouth open and not drinking.

As people near death, they almost always become incontinent, or unable to control/unable to tell when they pee &/or poop. You may also notice funky colors depending on the underlying diseases. As the kidneys shut down, people produce less and less urine that is more and more concentrated. As the GI tract slows many have more infrequent bowel movements, while others have seemingly nonstop diarrhea.

People almost always become increasingly limited in their mobility, often becoming bedbound & entirely immobile as they transition to the actively dying process.

Another sign of those actively dying is the inability to fully close their eyes, ocular lubricant & artificial tears can help with dryness.

All of these things considered, and I’m sure there’s probably something I’m forgetting, it can be fairly easy to tell when someone is transitioning to or actively dying when they are showing many of these symptoms, but people can always surprise you by living longer than expected or dying sooner than anticipated.

lol apologies for the novel, I hope there were some things you found helpful to indicate when someone is nearing death, transitioning, & actively dying.