Signs that help us know when death is approaching - from swallowing to strange moments
Everyone experiences death in varying ways and each and every situation is different to the next.
We will all eventually reach death ourselves and unless there is a sudden or traumatic death, there are recognisable signs that can help to guide families and loved ones to understand where the dying person is on that trajectory.
Katrina Taee, an end-of-life doula, comments on how knowing and understanding the signs of impending death can be helpful as it can inform decisions that you might make and the timings of such decisions.
Katrina wrote about some signs to look out for following her experience of her mother’s death, wanting to help others who may experience a death of a loved one.
We also spoke to some other end-of-life doulas from End of Life Doula UK to learn from their experiences of supporting those who are dying and to understand why it can often be regarded as a tranquil and peaceful experience with nothing to fear.
The following are common signs that death is on the way but are not signs taken from a textbook, rather from experience. Even medical professionals themselves have been occasionally confused by patients displaying similar signs but then improving out of the blue.
Eating and swallowing
The need for food diminishes and they will naturally eat less, sometimes refusing food altogether towards the very end. This can be distressing for families but the body knows exactly what it’s doing and realises that it simply doesn’t need the fuel like it used to.
It’s reserving its energy for vital functions such as maintaining a heart beat and taking the next breath as opposed to burning energy consuming food. Eating can actually make someone feel unwell as their digestive system has effectively shut down already.
The swallowing reflex will also slowly diminish, so another reason for not eating is the body protecting the person from not being able to swallow food.
Appearance wise, the face may be pale in complexion, white, bluish or yellow if jaundiced. Their eyes may be glassy or even ‘milky’ and may be open or shut. Sometimes pupils may be unresponsive so are fixed and staring.
Extremities may feel cold or hot to touch and sometimes nails have a bluish tinge due to poor circulation as the heart slows down.
There may also be swelling (oedema) which is usually due to fluid accumulating, and can make the skin appear to be ‘tight’. Sometimes there is a mottling of the skin and they may feel clammy or sticky, hot or cold. These symptoms can sound frightening but they are normal responses to the major organs slowing down as the end gently approaches.
Changes in breathing are common as death approaches. Changes such as heavier breathing, noisy breathing or gasping breaths. To watch this can be upsetting for families and loved ones but usually, it does not cause distress to the one who is dying.
The 'death rattle' is when some phlegm or secretions rolls backwards and forwards in their airway making a noise. This is not distressing the patient as they are often non-responsive or deeply asleep at his point.
Sometimes there can be an episode of very noisy breathing as the end gets draws closer. This is called Cheyne-Stokes breathing and it is characterised by loud breaths followed by a period of no breaths. It is difficult to listen to because families often wonder if the person has died before witnessing another breath.
Right at the end of life, the breaths generally become quieter, stiller and increasingly spaced out until eventually one breath is not followed by another. Katrina comments that this last period of time is often very gentle and peaceful.
Agitated mood and restlessness
This can present itself as a need to get out of bed, agitated behaviour or ‘knitting’ of the hands. They might reach out as if towards something or somebody.
It is natural and wholly part of the dying process, even if it's not always present. It is a temporary phase and a strong indicator that death is approaching.
Another sign that death is near is what is referred to as visioning, when a loved one may comment on subjects such as taking a trip, packing, going with someone and going home.
The diminished eating and drinking can make space for these experiences.
'The Lazarus Moment'
A phenomenon that Katrina calls 'the Lazarus Moment' describes someone who has been unresponsive or deeply asleep, suddenly waking up, sometimes sitting up, looking at those around and sometimes even talking to relatives.
This is often unexpected and sometimes shocking, but usually very welcomed by families as it might be seen as a golden last moment of normality.
Sometimes there is a burst of energy a day or two before death. The patient is more awake, talking and even eating and drinking a little. Relatives can occasionally misinterpret this as someone getting better, which it isn’t.
It can however be a happy time, one that is remembered fondly by families and is often recounted in the story of the death.
Talking of her experience with death, Emma Clare, an end-of-life doula, said: "Many ‘symptoms’ of a typical dying process are far more distressing for loved ones to witness than the person to experience, that is if they have not had someone explain what these symptoms mean.
"It is common for healthcare professionals to avoid going into detail about the dying process for fear of upsetting the person’s loved ones, however we see first-hand how having this information can reduce distress.
“Once someone has taken the time to explain to those at the bedside that these sounds (such as the death rattle) are normal and do not mean that the person is in distress – in fact they mean that the person is deeply unconscious – and that removing hydration does not mean that their loved one will “die of thirst” (something I have often heard people ask), in fact it means that the person is likely to be more comfortable as the organs which process fluids and nutrition are no longer functioning.
“This can be very difficult for families as feeding our loved ones is one of the ways we as humans show love. As Doulas we will guide people to other ways that they can do this, for example gently washing the person’s face."
Another experienced end-of-life doula, Aly Dickinson, said: "Dying is often a peaceful and gentle process. It can be the opportunity for those close to the person to spend their last tender moments with the person they love to say their goodbyes, tell them that they are beloved and wish them well for the mystery of whatever may be happening as they transition from this world to death.
“Sometimes, but not always, a person may become agitated or distressed – we do not always know why. It could be due to drug treatments; their disease or existential fear. We can be alongside the people accompanying the individual at the end of life to do the best we can to bring about an ambience of calm and peace.
"This can often be achieved by soothing with words or touch to provide reassurance and comfort. Often in the final hours the person’s anxiety will diminish as they turn their face away from this life. Like birth where the labour is hard but is followed by the joy of the baby arriving, dying can on occasions be an arduous journey for some people too.
“This can be difficult to witness but can be followed by the last moments where the person’s life is nearing completion with no anxiety, agitation or fear. These last recollections can provide solace to the bereaved.
Liz Williams, end-of-life doula, added: "We work with people who may be in their 40s, 50s, 60s who have never been with a dying person or seen a dead person. The first time they encounter death and dying may be with a parent who they are caring for. This may result in the person fearing the unknown.
"Each death is different and we can accompany the adult child to prepare them as to what dying typically looks like; what to expect; how best to support their mother or father with this final act of love; and to have the confidence needed to be an important part of this last chapter of life.
"We can give emotional and practical support required for them to be present with both the expected and unexpected."