In the two weeks before death, a person typically experiences pronounced physical and mental changes as the body slows down, including extreme fatigue and sleepiness, loss of appetite/thirst, confusion, restlessness (terminal agitation), irregular breathing (with potential rattling sounds from congestion), skin changes (coolness, mottling), decreased urine/stool, and sometimes vivid hallucinations or final moments of clarity (terminal lucidity). These signs, part of the natural dying process, focus care on comfort, not emergencies.
Tiredness and lack of energy
It is normal to have less energy as you approach the end of your life. You may find you need help to do things you usually do for yourself. You may also need to rest more. Tiredness and weakness can make it harder for you to focus or take part in what is going on around you.
Physical signs of dying
They might close their eyes frequently or they might be half-open. Facial muscles may relax and the jaw can drop. Skin can become very pale. Breathing can alternate between loud rasping breaths and quiet breathing.
Three common signs that death is near include significant changes in breathing (like long pauses or irregular patterns), decreased responsiveness and increased sleep, and physical changes such as cool, mottled skin and reduced intake of food/drink, signaling the body is shutting down. These signs vary but focus on diminished bodily functions, increased withdrawal, and altered breathing/circulation as the body prepares for the end.
As people get closer to dying, they may sleep more, become drowsy or be difficult to wake. They may fall asleep while talking. A person may slowly lose consciousness in the days or hours before death. When visiting someone with advanced cancer, be aware that visiting may be tiring and difficult for the dying person.
➢ Apnea. ➢ Absence of palpable pulses at carotid, radial, and femoral sites. ➢ Unresponsive pupils. ➢ Absence of heart sounds.
Poor diet, smoking, physical inactivity, and obesity are consistently among the biggest predictors of early death, often combined with high blood pressure, with some studies highlighting physical activity as the single strongest predictor for all-cause mortality, while smoking remains a top cause of preventable death, notes the Star Tribune, National Institutes of Health, and Centers for Disease Control and Prevention https://www.ncbi.nlm.nih.gov/books/NBK279981/, https://www.startribune.com/move-or-die-new-study-shows-activity-is-top-predictor-of-when-you-might-die/601200361,. Other significant factors include insufficient sleep, high salt intake, and high LDL cholesterol, with social factors like inequality also playing a role.
Before death, people often experience comforting visions, seeing deceased loved ones, religious figures, or pets, or having vivid dreams about journeys, which are usually peaceful and can provide a sense of connection, though sometimes these can be distressing hallucinations from metabolic changes or medication. These "deathbed visions" (DBVs) are common, often happen weeks before death, and can involve reliving life moments, feeling peace, and preparing for a journey, distinct from delirium.
Eating less and loss of appetite in the last weeks of life
Wanting to eat less is natural in the last weeks of life, as the body uses less energy. The person's tastes might change and they will not always need to eat at the same times every day. They might have difficulty swallowing, a sore or dry mouth, or feel sick.
Terminal lucidity (also known as rallying, terminal rally, the rally, end-of-life-experience, energy surge, the surge, or pre-mortem surge) is an unexpected return of consciousness, mental clarity, or memory shortly before death in individuals with severe psychiatric or neurological disorders.
You can simply sit with the person and perhaps hold their hand. Hearing is said to be the last sense to go, so you may want to talk to the person or even have a conversation among the people in the room so that the person knows they are not alone. You could read aloud, sing or hum or play some of their favourite music.
Changes in the last hours and days of life
One is 'terminal agitation' or restlessness. This often appears as a need to get out of bed, agitated behaviour or commonly plucking of the sheets or 'knitting' of the hands. They might reach out as if towards something or somebody.
Five highly specific signs are loss of radial pulse; mandibular movement during breathing; anuria; Cheyne-Stokes breathing; and the “death rattle” from excessive oral secretions (see Fast Fact # 109) (6).
Fatigue (feeling very tired) is one of the most common symptoms in the last days of life. A person's fatigue may become worse every day during this time. Drowsiness, weakness, and sleep problems may occur. Drugs that increase brain activity, alertness, and energy may be helpful.
Made famous by her pioneering work in near-death studies, Kübler-Ross conceptualized five common emotional stages experienced by her clients facing terminal illness: denial, anger, bargaining, depression, and acceptance (DABDA).
How long is the active stage of dying? The dying process can last roughly three days, though this can vary depending on the individual and their condition. This stage follows the pre-active stage of death, which lasts for about three weeks.
The 5 stages of death, developed by Elisabeth Kübler-Ross, describe common emotional responses to terminal illness or loss, and are Denial, Anger, Bargaining, Depression, and Acceptance (DABDA). While often depicted as a linear progression, these stages are not fixed; people experience them differently, out of order, or not at all, and they apply to various forms of significant loss, not just death.
Some people's breathing slows down and becomes irregular. It might stop and then start again or there might be long pauses or stops between breaths. Some people's hands, feet, arms and legs may feel colder. Some people's skin looks slightly blue.
Angry patients frequently try to blame someone for their disposition: “You missed my cancer diagnosis.”14 They succeed when they transfer ownership for their emotional state to someone else. Psychiatrists call this coping style projection. Patients who project their anger are difficult to engage.