Stages of Imminent Death

Most patients in their last moments usually go through the same patterns. Understanding these patterns will help you understand what is to come and be better prepared for yourself and your loved one. Hospice practitioners refer to this actively dying process as “transitioning.” Identification of this transition and these patterns allows providers to intervene and provide adequate patient comfort and also allows for loved ones to be supported.

Early (Days to Weeks)

Patients start to show decline in their usual activities during this stage. They become bed bound. They start to lose interest in eating and drinking as physiologic changes occur in the brain. Patient’s lose the feelings of hunger and thirst, and no longer are interested in drinking or eating anything. They start to get more confused and tired and spend more time sleeping and when awake more confused. The body shows signs of muscle atrophy (breakdown) and families are able to notice significant weight loss.

Identifying this stage and allowing hospice to intervene provides the patient with medical interventions to help ease this transition.

Mid Stage (Days to Hours)

Patients continue to show further decline. Patients become lethargic and obtunded which is characterized by diminished responsiveness to physical and verbal stimuli. Patients become slow to arouse and only have periods of wakefulness. They remain sleeping and difficult to arouse.

Identifying this stage and allowing hospice to intervene provides the patient with medical interventions to help ease this transition.

Late Stage (Days to Hours)

In this last stage, patients become comatosed. They are no longer interacting with family and staff. Patient’s body’s start to shut down. They have periods of apnea (stop breathing for periods of time) or breathing becomes irregular. They develop fevers as the immune system starts to slow down. Patients may demonstrated bluish hands and feet or blue lips as the heart starts to shut down. Patients lose their ability to clear secretions from their throat due to loss of swallowing reflex and develop the death rattle. This term is used to describe the distinctive gurgling or rattling sound that occurs as secretions pool at the back of the throat. The body during this stage is shutting down and is clearly evident to those who are around the patient.

Identifying this stage and allowing hospice to intervene provides the patient with medical interventions to help ease this transition. Hospice has medications to help with the transition to make things as painless as possible. Having someone around who knows what to do during this time for caregivers and family provides much needed support.

Time Frame

The time for a patient to transition through these stages can take anywhere from a few hours to up to 2-3 weeks. When patients stop eating and drinking, the time frame is usually 10-14 days. Patients who enter these stages nutritionally intact with no infections or without other serious etiology (heart attack, stroke, trauma, etc.) will usually take the full 2-3 weeks to complete these stages.

Treatment during these stages does not change the course of the patient’s trajectory and can actually worsen the patient’s condition. IV fluids, tube feeds, antibiotics, finger sticks, etc. only will increase patient suffering at this point as the patient has transitioned to a point where modern medicine no longer is effective. Focusing on keeping the patient comfortable and providing loved ones support should be the top priority.

Frequently Asked Questions:

  • Are they in pain? – No. There are things that can happen which may cause discomfort and the hospice staff is trained to look for signs of discomfort. Patient can be given low doses of pain medications if there is concern to keep them comfortable.
  • Are we not starving them? – No. The body is shutting down and as a result the gut is no longer working. The brain is also shutting down and patients are no longer feeling hungry or thirsty. Force feeding during this time or starting IV hydration can lead to dramatic fluid shifts leading to fluid in the lungs, swelling of the face, hands, feet which all worsen patient suffering. IV fluids and forced feedings during this time are not a good idea and are not recommended.
  • How long will this take? See the timing section above. No one knows for sure, but depending on the patient’s condition prior to entering this stage will determine how fast the patient progresses through the stages.
  • Can my loved one hear me? Physically speaking, the brain is shutting down and as a result it is unlikely that the patient can hear and understand what is being said. However, we are all spiritual beings, and one should assume that your loved one’s soul can hear you. Taking about death and dying should not scare you nor should you be afraid to speak of it in front of your loved one. Life ends with death for all of us, and this is a journey we must all endure. Talk through it, and let them know you are there, and you will miss them and we will eventually all join them.