How do hospice workers know when death is near?

Hospice workers rely on a variety of signs and symptoms to determine when a patient’s death may be approaching. This allows them to provide appropriate care and support to the patient and their family during this difficult time. Some of the main things hospice workers look for include:

Changes in vital signs

As death nears, there are often changes in vital signs like pulse, blood pressure, and breathing patterns. An irregular or weak pulse, low blood pressure, and changes in breathing such as shallow, irregular, or rattling breathing can all signal that death is approaching within hours or days.

Changes in consciousness

Patients often become less responsive and start sleeping more as death gets closer. They may become difficult to rouse or unable to communicate. Confusion, restlessness, and disorientation are also common.

Changes in appearance

The patient’s appearance may change noticeably as death nears. Their skin can become pale, cool to the touch, and mottled. Their extremities may turn blue or purple. They may develop dark circles under their eyes. Their eyes may appear sunken or half-open when sleeping.

Changes in metabolism

The patient may lose their appetite and stop eating and drinking in the days before death. Nausea, vomiting, and constipation are common. The patient may also develop swelling in their limbs from fluid retention.


New or worsening pain can signal that death is approaching. This may occur even while on pain medication. Bone pain from metastasized cancers is common. Patients may also develop muscle cramps or twitching.

Changes in secretions

The patient may develop liquid secretions in their airways as death nears. This can lead to gurgling or rattling breathing sounds. Secretions and mucus can also collect in the back of the throat, which is usually cleared by coughing. As consciousness decreases, the patient is less able to clear these secretions.

Social withdrawal

It’s common for patients to start withdrawing from social interactions, become less interested in their surroundings, and sleep more as death approaches. They may refrain from speaking even when awake.

Saying goodbye

Patients may start saying goodbye to loved ones and making amends. Some become restless and pick at their blankets. These can be signs that the patient senses death approaching.

Decreased urine output

Kidney function often slows down near the end of life. The patient may urinate less frequently and have darker urine. Dehydration can also lead to decreased urination.

Skin breakdown

Bedridden patients are prone to developing pressure sores in areas like the lower back, hips, and heels as circulation decreases. Skin can appear thin or translucent. Purplish blotches may also develop on skin as blood circulation slows.


As blood circulation drops off, patients often feel cool to the touch, especially in the arms and legs. Low blood pressure reduces circulation to the extremities. The person may also report feeling cold.

Behavioral changes

Restlessness, agitation, anxiety, sleep disturbances, and even hallucinations can occur. The person may pick at their blankets or clothing. Changes in breathing patterns are also common.

Loss of interest

The person often loses interest in food, drink, and physical activity as death approaches. They tend to sleep more and communicate less. Little things that used to bring them joy no longer do so.

Swallowing difficulties

Weakness and loss of coordination can make swallowing difficult. The gag reflex may also diminish. These issues increase the risk of aspiration when eating or drinking.

Moaning or groaning

Vocalizations like moaning, groaning, or short repeated cries can occur. This may indicate pain, shortness of breath, or anxiety. Medications can help relieve these symptoms.


The facial expression may appear strained, anxious, or painful. This grimacing is not under the person’s control and not necessarily reflective of their mental state.

Withdrawal from loved ones

As death nears, the person may seem withdrawn and uninterested in relating even to close family members. This is usually due to slowly decreasing consciousness, not indifference.

Vision-like experiences

Nearing death, some people report seeing or speaking with loved ones who have died. Others have vision-like experiences that comfort them. These are normal and not signs of mental illness.

Surge of energy

Occasionally, someone may experience a temporary surge of energy within days of death. They may want to get out of bed, talk to loved ones, or ask for food after losing interest. This usually lasts less than a day.

Decreased need for medication

Many hospice patients experience decreased pain and anxiety as death approaches, so need less pain medication and sedation. However, medication should not be withdrawn prematurely.

Breathing changes

Breathing can change markedly as death approaches. It may become very shallow, irregular, or stop temporarily. Congestion can cause loud, rattling sounds. The pause between breaths may lengthen.


Mottling refers to purple blotchy spots that develop on the hands, feet, knees, and other areas as circulation slows. Gravity causes blood to pool in the extremities.

Putting it All Together

Hospice workers don’t rely on any one sign that death is approaching. They understand that every patient experiences the end of life differently. However, by watching for a combination of the different signs above, they can generally recognize when death is likely within days to hours. The most common sequence is:

  1. Withdrawal from social interaction
  2. Increased time sleeping and difficulty waking the patient
  3. Patient stating they “feel sick” or “something feels wrong”
  4. Loss of appetite and decreased fluid intake
  5. Coolness and mottling of extremities
  6. Changes in breathing patterns, congestion, and respiratory secretions
  7. Decreased urine output and dark urine
  8. Delirium, restlessness, and agitation as consciousness decreases

However, the timeline varies considerably between patients. A hospice nurse or doctor makes frequent assessments to identify when a patient’s condition starts changing more rapidly so that care can be modified appropriately. They rely on their experience and the aggregated signs rather than a fixed timeline. With attentive care focused on comfort, most patients are able to pass peacefully once the dying process begins.

Providing Comfort and Support

Once it becomes clear that death is likely within days, the focus of care shifts to maximizing comfort. The patient’s bed is kept clean and dry, they are positioned for comfort, and gentle massages can help ease muscle cramping or twitching. Medications are used judiciously to control pain, nausea, anxiety, delirium, and noisy respiratory secretions without sedating the patient excessively. Gentle care like pet therapy, aromatherapy, and spiritual support provides comfort. The patient’s wishes for medical interventions and resuscitation are reviewed and family members are counseled about what to expect. Hospice staff explain signs like mottling and decreased oral intake so family members understand these are normal. As the patient nears death, vigilant observation helps ensure they pass peacefully and without distress. While losing a loved one is always difficult, this quality of hospice care helps provide reassurance and meaning at the end of life.

Signs That Death Has Occurred

Once breathing and heartbeat cease, there are several additional signs that confirm death has occurred:

  • No response to verbal or physical stimulus
  • Eyelids slightly open
  • Pupils fixed and dilated
  • Loss of bladder and bowel sphincter control
  • No movement, reflexes, or muscle tone
  • Jaw relaxed and mouth slightly open

The patient’s eyes will typically remain at least partially open after death. The body will then gradually begin to cool and rigor mortis will set in, with stiffening beginning within a couple hours of death. Livor mortis causes settling of blood and a purplish discoloration in the lower (dependent) parts of the body. Pallor mortis describes the paleness that occurs as blood circulation ceases. Within 4-6 hours of death, algor mortis results in a decline in body temperature to match ambient temperature. While difficult for loved ones, acceptance of these unmistakable signs can help transition to the grieving process. With dignity and care, hospice workers help guide families through this difficult time.


Hospice professionals draw on their experience, intuition, and aggregated subtle signs rather than a fixed timeline when determining that death is likely approaching for a patient. There are some common patterns like withdrawal from normal activity, changes in breathing, decreased oral intake, and mottling of the skin that signal death is generally close at hand. However, attentive observation of each patient and their unique end-of-life trajectory guides quality, dignified care. Hospice workers take the time to explain normal signs to expect and provide around-the-clock support as death nears. Their focus remains on comfort and quality of life all the way to a peaceful, dignified death. While losing a loved one is always difficult, hospice care provides reassurance and meaning that helps families through this transition.

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