Understanding changes in the last few days of life

The dying process is unique to each person, but there are often common changes, whatever the underlying illness.

During the last few days or hours of life, there may be physical changes and symptoms that indicate the person is close to death. Even though these changes and symptoms are normal, they can be difficult, emotional, and upsetting for both the person and those around them.

Being prepared for what may happen can make the situation a little easier to cope with, reducing stress and anxiety. 

This leaflet describes the typical features of the dying process, which can be short, gradual or may last for several days, and even weeks.

Common symptoms

Reduced need for food and drink 

People naturally start to lose interest in eating and drinking as they approach the end of life. They can experience taste changes, problems with swallowing, a sore or dry mouth and feelings of sickness.

You may wish to support them to eat and drink tiny amounts of soft food and sips of fluid. If they struggle to chew, they may prefer soft high-calorie food (yoghurt and Ice cream).

In the last days or hours of someone’s life they will stop eating and drinking completely. This is normal. It can be hard to accept, because it is a physical sign that they are not going to get better.

A person will not require fluids at this stage of their lives and may experience related problems (increased chest secretions etc.) If the person still feels thirsty and has trouble swallowing, they may be able to take sips of fluid from a teaspoon, a mouth sponge or ice chips. Your District Nurses (DNs) will be able to advise you.

Changes in breathing

Relatives often worry that their loved one cannot breathe, and patients also fear breathlessness. However, as someone approaches the end of life, their body becomes less active, and they need less oxygen.

Their pattern of breathing may change and become more laboured. It is common for breathing to become shallower, and there may be long pauses between breaths. You may see their abdominal muscles (tummy) take over the work. (Their abdomen will rise and fall, instead of their chest.)

At times there can be a noisy rattle to their breathing. This is sometimes referred to as a 'death rattle', and it can be upsetting to family and carers. However, evidence shows that this sound is not distressing to the dying person.

It is due to a build-up of mucus in the chest when the person is no longer able to clear their chest or cough. Changing their position and using pillows may help reduce respiratory (breathing) secretions. DNs can also administer medications to help with this.

Withdrawing from the world

The person is likely to lose interest in the things around them, and spend more time asleep. Eventually they may lapse into unconsciousness and stay like this for hours. When they wake, they may not realise they were asleep and can appear quite drowsy. They may fall asleep again soon afterwards.

Spending time with the person can provide comfort. You can share memories, hold hands, and play music. You can also involve them in the general chatter and gossip of family life. Although they can be deeply asleep, it is likely they can hear and recognise familiar voices.

Physical changes

Skin changes

The person's skin may start to change, becoming pale, moist and slightly cool to touch.

If they are being cared for at home, they are likely to need a hospital bed and a pressure relieving mattress to prevent the risk of pressure damage (pressure sores). This can also help carers administer personal care to them.

Mouth care

Mouth care will provide comfort and help to keep the person's mouth and lips clean and moist. You may want to help with this. Even if the person is sleepy, it is important to give them mouth care.

You can use a soft baby’s toothbrush with patients who have a painful mouth. Dip the toothbrush in water or other favourite flavours (tea, wine, fruit juice etc). 

You can apply gel to their lips to keep them moist, but do not use Vaseline if the person is on oxygen.

You can also consider using ice chips, saliva replacement, or oral gel/spray. You can discuss these options with your District Nurse.

Bowel and bladder function

Bowel movements may become less frequent because the person is no longer eating.

Your nursing team will check for constipation and may need to administer suppositories Suppositories are used to administer medicine in the person's back passage (anus).

The person will need to pass urine (wee) less often because they are drinking less. Their urine is likely to become darker in colour.

It may become difficult for the person to reach their commode and your medical team may suggest urine pads or decide to administer a catheter. A catheter is a flexible tube used to empty the bladder and collect urine in a drainage bag. Catheters are inserted by the district nursing team.

Anticipatory (just-in-case) medications 

Your medical/nursing team may prescribe anticipatory medications as the person approaches the end of their life. These will help relieve symptoms, or can be used if they are no longer able to take oral (by mouth) medications. 

Anticipatory medications are given via injection just under the person's skin. They are administered by District Nurses when needed.

Sometimes the DNs will insert an SC line (a small, soft tube just under the skin). This is often done when the person needs several injections. 

The DNs may also need to start a syringe pump, so that non-stop medication can be given over a 24-hour period. The DN will change the syringe pump every day.

Your DN or hospice nurse will discuss this with you.

Anticipatory medications may be prescribed to relieve:

• pain 
• respiratory (breathing) problems
• agitation and restlessness  
• nausea and vomiting.

For guidance on the basic steps to follow after an expected death at home, see More information, below.

More information

Hospice UK has more information and advice on what to expect as someone dies.

Kingston Hospital information on the practical steps that happen when someone dies in the community (at home).