A factual guide to common physical changes as death approaches

Important: There is no medically fixed number of stages. Every person and illness is different. For clear teaching, the natural dying process can be organized into four general stages. The stages may overlap, occur in a different order, or not all appear.

1. Early decline — months to weeks
   • Increasing weakness and fatigue
   • Sleeping and resting more
   • Reduced appetite and fluid intake
   • Weight loss
   • Needing more help with bathing, dressing or walking
   • Less interest in activities or social visits
   • More quiet reflection or withdrawal

2. Approaching death — weeks to days
   • Sleeping for most of the day
   • Becoming mostly bedbound
   • Very little interest in food or fluids
   • Difficulty swallowing food, fluids or medication
   • Less urine, which may become darker
   • Speaking less or having difficulty concentrating
   • Confusion, restlessness or increased quietness
   • Changes in pain, breathing or other symptoms

3. Active dying — days to hours
   • Becoming difficult or impossible to wake
   • Stopping food and fluid intake
   • Being unable to swallow medication safely
   • Producing very little or no urine
   • Cool hands and feet
   • Blotchy or purplish skin, often on the feet, knees or hands
   • A weaker or irregular pulse
   • Irregular or shallow breathing with longer pauses
   • Rattling or gurgling breathing caused by pooled secretions
   • Restlessness, confusion or reaching movements
   • Eyes partly open without focusing

4. Final moments and death
   • Breathing becomes slower and more irregular, with increasingly long pauses
   • Breathing stops
   • The heartbeat stops
   • The person does not respond
   • The pupils become fixed
   • The jaw may relax and the mouth may remain open
   • Skin colour may become pale, grey or waxy

Understanding timing
When changes occur from day to day, death may be days away. When changes occur from hour to hour, death may be hours away. This is only a general guide, not an exact prediction.

Comfort and safety
These physical changes do not automatically mean the person is suffering. Noisy breathing, for example, may sound distressing to family members without causing distress to the dying person.

Do not force food, fluids or medication when swallowing is unsafe. Ask the healthcare team about mouth care and alternate medication routes.

Report new or uncontrolled pain, severe agitation, obvious breathing distress, bleeding, a fall, or any sudden unexpected change to the nurse, physician or palliative-care team promptly.

Scope note
This page provides general education. It cannot determine exactly how long a person has to live and does not replace assessment or advice from the person’s healthcare or palliative-care team.

Sources
Canadian Virtual Hospice — Final weeks and days: What to expect
National Health Service — Changes in the last hours and days of life
U.S. National Cancer Institute — Last Days of Life, Patient Version