How to recognise when someone is dying

The dying process usually begins well before death actually occurs, and understanding this process can sometimes help you recognize when your loved one is dying. There are changes that take place physically, behaviorally, and psychologically in the journey towards death, that are signs that the end of life may be nearing.

Death is a personal journey which each individual approaches in their own unique way. Nothing is concrete, and nothing is set in stone. There are many paths one can take on this journey but all lead to the same destination. What happens in the journey of dying, beginning one to three months prior to death, during the last two weeks before death, and during the last few days of life? In this continuum, how can you know when your loved one is dying?

The Dying Process

As a person comes close to death, the dying process begins; a journey from the known life of this world to the unknown of what lies ahead. As this process begins, a person starts on a mental path of discovery, comprehending that death will indeed occur and believing in their own mortality. The journey ultimately leads to the physical departure from the body.

There are milestones along this journey. Because everyone experiences death in their own unique way, not everyone will stop at each milestone. Some may hit only a few while another may stop at each one, taking their time along the way. Some may take months to reach their destination, others will take only days. We will discuss what has been found through research to be the journey most take, always keeping in mind that the journey is subject to the individual traveler.

The Journey Begins: One to Three Months Prior to Death

The dying process starts to be recognizable for many people in the period between a month and three months prior to death. As we discuss these changes, we may use the words 'he" or "she," but the process is fairly similar regardless of gender. There are some differences.

Behavioral and Psychological Changes: As a person begins to accept their mortality and realizes that death is approaching, they may begin to withdraw from their surroundings. They are beginning the process of separating from the world and those in it. Your loved one may decline visits from friends, neighbors, and even family members. When she does accept visitors, she may be difficult to interact and care for. This is a time when a person begins to contemplate their life and revisit old memories. In evaluating her life, she may be sorting through any regrets. She may also undertake the five tasks of dying.

Physical Changes: The dying person may experience reduced appetite and weight loss as the body begins to slow down. The body doesn't need the energy from food that it once did. The dying person may be sleeping more now and not engage in activities they once enjoyed. They no longer need food nourishment. The body does a wonderful thing during this time as altered body chemistry produces a mild sense of euphoria. They are neither hungry nor thirsty and are not suffering in any way by not eating. It is an expected part of the journey they have begun.

One to Two Weeks Prior to Death

The dying process often accelerates in the last one to two weeks of life and can be frightening for families. The mental changes, especially, can be disturbing to family members. At this point in the journey, it is not advisable to "correct" your loved one if she tells you something that doesn't make sense. Gently listen, and support her in her thoughts. If she claims to see loved ones who have died, simply let her tell you. We really don't have a way to know if these are hallucinations, or if our loved ones have seen something we cannot see. Simply love her.

Mental Changes: This is the time during the journey that one begins to sleep most of the time. Disorientation is common and altered senses of perception can be expected. One may experience delusions, such as fearing hidden enemies or feeling invincible.

The dying person may also experience hallucinations, sometimes seeing or speaking to people who aren't there. Often times these are people who have already died. Some may see this as the veil being lifted between this life and the next. The person may pick at their sheets and clothing in a state of agitation. Movements and actions may seem aimless and make no sense to others. They are moving further away from life on this earth.

Physical Changes: The body is having a more difficult time maintaining itself, and your loved one may need help with just about any form of activity. She may have trouble swallowing medications or may refuse to take the medications she has been prescribed. If she has been using pills for pain, she may need liquid morphine at this time. There are signs that the body may show during this time:

The body temperature lowers by a degree or more.
The blood pressure lowers.
The pulse becomes irregular and may slow down or speed up.
There is increased perspiration.
Skin color changes as circulation is diminished. This is often more noticeable on the lips and nail beds as they become pale and bluish.
Breathing changes occur, often becoming more rapid and labored. Congestion may also occur causing a rattling sound and cough.
Speaking decreases and eventually stops altogether.
Periods of quietness may be interrupted by sudden movements of a person's arms or legs.

Journey's End: A Couple of Days to Hours Prior to Death

The last couple of days prior to death can sometimes surprise family members. Your loved one may have a surge of energy as she gets closer to death. She may want to get out of bed, talk to loved ones, or ask for food after days of no appetite. Some loved ones take this increase in energy to be a sign the person is getting better, and it can be very painful when the energy leaves. Know that this is common, and is usually a sign that a person is moving towards death, rather than away. This surge of energy may be quite a bit less noticeable but is usually used as a dying person's final physical expression before moving on.

The surge of energy is usually short, and the previous signs become more pronounced as death approaches. Breathing becomes more irregular and often slower. Cheyne-Stokes breathing, rapid breaths followed by periods of no breathing at all, may occur. Congestion in the airway can increase causing loud, rattled breathing. Again, this change in breathing can be very uncomfortable for loved ones but does not appear to be unpleasant for the person who is dying.

Hands and feet may become blotchy and purplish (mottled). This mottling may slowly work its way up the arms and legs. Lips and nail beds are bluish or purple and lips may droop. The person usually becomes unresponsive and may have their eyes open or semi-open but not seeing their surroundings. It is widely believed that hearing is the last sense to go so it is recommended that loved ones sit with and talk to the dying loved one during this time.

Eventually, breathing will cease altogether and the heart stops. Death has occurred.