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End-of-life timeline: clinical signs by stage.

By Joseph Shega , MD , Chief Medical Officer , VITAS Healthcare

Dying is a natural process accompanied by decrements in neurocognitive, cardiovascular, respiratory, and muscular function.

The dying process is highly variable and can last up to several weeks in some instances. The expression of clinical end-of-life signs varies substantially among patients, but a greater number of clinical signs present in an individual increases the likelihood of death.

End-of-Life Stages Timeline

Here is a breakdown of the different stages of the end-of-life journey:

Months Before Death

Weeks before death, 4-6 days before death, 2-3 days before death, less than 2 days before death.

Identifying the transition to imminent death is crucial for educating patients and families about the natural dying process. This information enables effective, compassionate decision-making and allows families to prepare for the passing of their loved one.

It's important to update the care plan to reflect the patient's changing status, including any required clinical visits. A higher level of care may be necessary in moments of crisis or when symptoms are uncontrolled.

The tables below provide a general overview of each stage of death.

During this phase, which occurs one to three months before death, patients may experience decreased appetite, increased sleepiness, ambivalence toward their surroundings, heightened pain and nausea, and visible weight loss. Emotional changes may lead to increased withdrawal, reduced activity, decreased communication, and introspection.

As the end of life nears, extreme fatigue, confusion, and social withdrawal become more pronounced. Patients may engage in life review and focus on funeral planning, revealing their emotional state.

This stage occurs four to six days before death. It is characterized by intensifying emotional and physical symptoms.

As the end approaches in two to three days, the active stage of dying begins. Common symptoms include unresponsiveness and a significant drop in blood pressure, indicating impending death.

In the final hours, patients exhibit specific clinical signs that indicate the approach of death.

Clinical signs are based on studies of cancer patients but are generalizable to other causes of death (e.g., heart disease, advanced lung disease, sepsis and dementia). This list is not exhaustive but includes some of the most common end-of-life symptoms.

Link Between Clinical Signs of Dying and Impending Death

A direct relationship exists between the number of clinical signs of dying and death:

• Persons with two clinical signs of dying had a 40% chance of dying in the next three days
• Persons with eight clinical signs of dying had more than an 80% chance of dying in the next three days

The likelihood of dying in the next three days death increases with the number of present end-of-life signs. Physicians should make a care plan update as end-of-life signs escalate.

How Long Does the Active Stage of Dying Last?

The active stage of dying generally spans about three days following a roughly three-week pre-active dying stage.

Typical symptoms include unresponsiveness and a significant drop in blood pressure.

What Is the Difference Between Transitioning and Active Dying?

Transitioning and active dying are distinct stages at the end of life.

Transitioning is the initial phase in which a patient's decline becomes evident. During this time, they may exhibit noticeable changes in physical and cognitive function, as well as emotional withdrawal.

Active dying is the stage that directly precedes death and is characterized by a significant decline in the patient's overall condition, often accompanied by symptoms like unresponsiveness and a drop in blood pressure.

This differentiation helps caregivers and medical professionals understand and respond appropriately to the evolving needs of patients during this delicate period.

What Are the Emotional Signs of Death?

Clinical indicators and symptoms are not the only signs of impending death. Analyzing emotional signs can also shed light on a patient’s end-of-life status. Some of these signs include:

• A prolonged state of excessive fatigue, sleep, appearing catatonic
• Confusion and/or disorientation; hearing or seeing people and events not visible or not present to you
• Social withdrawal and detachment
• The desire to conduct a life review or settle something unresolved
• The desire to focus on funeral planning

Hospice Team Involvement During Stages of Dying

When clinical signs of dying emerge, the hospice interdisciplinary care team initiates a care plan update that includes:

• Revisions to necessary interdisciplinary visits
• Education on the dying process
• Medication adjustments
• Assurance that appropriate HME is in place to assist your patient and their family

The hospice team provides support in a variety of ways specific to each team member's discipline.

A nurse, nurse practitioner, and/or physician may:

• Discuss the discontinuation of non-beneficial or burdensome treatments
• Ensure symptom medications and necessary equipment are available
• Educate family on use of medications to manage symptoms and/or pain, and describe physiological changes associated with the dying process

The social worker and chaplain:

• Help patients and families explore their feelings and relationships
• Participate in life review, including the search for meaning and contributions
• Conduct life closure, including forgiving and facing regrets, saying goodbye, and coming to terms with the acceptance of ongoing losses and death

Hospice aides:

• Recognize the clinical signs of dying and communicate them to the other team members, as well as support the patient and family through the dying process.

How to Help Families Cope After a Loved One Has Died

Family members need time to process their feelings  after a patient dies. They should not be subjected to additional stress with the logistics of legal forms or removal of the body. Be empathetic.

Medical professionals and care teams should keep in mind that the time, setting, and specific events surrounding a loved one’s death shape lasting memories for their family members—solemn moments that deserve to be respected and honored.

To support families as they begin the grieving process:

• Give private time alone with their loved one after a death to say their goodbyes and share memories
• Answer family members’ questions factually, calmly, and with empathy
• Explain clearly and compassionately what will happen in the next several hours or days

Honor rituals

• Honor families’ needs for specific rituals at the time of or shortly after death, such as bathing of the body, recitation of prayers, or dressing of their loved one in special clothing or garments.
• Make sure the immediate environment—whether the patient’s home, hospital room, nursing home/care facility room, inpatient hospice room, etc.—is as uncluttered, clean, and orderly as possible, with no offensive odors

Encourage a healthy grieving process

• Remind family members and caregivers that each person’s grief is unique and will ebb and flow over the following days, weeks, months, and years. If the patient was on hospice care, Medicare-certified hospices provide up to a year of grief and loss counseling  for their family following the patient’s death.
• Invite family members and friends to stay in touch and rely on each other as they move through their grief.

References:

• Hui D, dos Santos R, Chisholm G. et al. Bedside Clinical Signs Associated With Impending Death in Patients With Advanced Cancer: Preliminary Findings of a Prospective, Longitudinal Cohort Study. Cancer 2015;121:960-967.
• Hui D, dos Santos R, Chisolm G, et al. Clinical Signs in Cancer Patients. The Oncologist 2014;19:681–687

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End of Life Care

• Planning at the End of Life
• Talking with People as You Near the End of Life
• Coping with Emotions as You Near the End of Life
• What Is Hospice Care?
• Where Is Hospice Care Provided and How Is It Paid For?
• Finding a Hospice Program
• What to Expect When a Person with Cancer Is Nearing Death
• Saying goodbye
• Grief and Bereavement
• Seeking Help and Support for Grief and Loss

What to Expect When a Person With Cancer is Nearing Death

The end of life is different for everyone. No one can predict how long the final stage of life will last or when death will happen. Sometimes death comes quickly. Other times the dying process takes longer and the person may linger.

Changes in body function

Possible changes in consciousness, changes in appetite, possible changes in metabolism, possible changes in secretions, possible changes in circulation and temperature, possible changes in senses and perception, possible changes in breathing, possible changes in elimination, signs that your loved one has died.

• What to do when you think your loved one has died

It's hard to know exactly what will happen in the final stage of life and especially near death. There are some common symptoms that most often happen in people with cancer who are dying. All might not happen, but it may help you to know about them.

• Extreme weakness. May have trouble moving around in the bed and might not be able to get out of bed.
• May not be able to do much for themselves. They may need help bathing, brushing their teeth, and dressing. They may need to use a bedpan or bedside toilet, if they can get up.
• Less interest in food, often eating or drinking very little
• Trouble swallowing pills and medicines
• Lips may appear to droop
• Might not be able to focus on what’s going on around them
• Might not be able to help with their own care
• Sudden movement of any muscle, jerking of hands, arms, legs, or face

What caregivers can do

• Help the patient turn and change positions every 1 to 2 hours. It's best to time any position changes to about 30 minutes after pain medicine is given.
• Speak in a calm, quiet voice and avoid sudden noises or movements to reduce the chances of startling the patient.
• If the patient has trouble swallowing pills, ask about getting liquid pain medicines or a pain patch.
• If the patient is having trouble swallowing, do not give them solid foods. Try ice chips or sips of liquid.
• Do not force them to drink. Near the end of life, some dehydration is normal.
• Apply cool, moist washcloths to head, face, and body for comfort.
• More sleeping during the day
• Hard to wake from sleep
• Confusion about what time it is, where they are or who the people around them are
• Restless, might pick or pull at bed linen
• May talk about things unrelated to the events or people present
• May be more anxious, restless, afraid, and lonely at night.
• After a period of sleepiness and confusion, may have a short time when they are mentally clear before going back to sleep
• Plan to be with them when they are most alert or during the night when your presence may be comforting.
• Remind them who you are and what day and time it is.
• Continue pain medicines up to your loved one’s death.
• If your loved one is very restless, try to find out if they are having pain. If it appears they are, give breakthrough pain medicines as prescribed, or check with the doctor or nurse if needed.
• If your loved one is confused, use calm, confident,gentle tones so you don’t startle or frighten them.
• Gentle touching, caressing, holding, and rocking are usually helpful and comforting.

In the last stage of life, many people lose their desire to eat or drink. This is not unusual. People also don’t need to eat and drink as much. Loss of appetite can be caused by changes in the body happening now. Try not to get upset when they don’t feel like eating or aren’t eating as much as they used to.  

• Avoid family food battles
• Let them eat what and when they feel like it
• Try to keep their favorite foods and drinks around, but know their tastes can change day to day.
• If the smell of food bothers them, offer foods that are cold or at room temperature.
• If they have nausea or pain, help them take medicines given to them as directed
• Try not to get upset when they don’t feel like eating or aren’t eating as much as they used to  
• Let them know that your efforts to get them to eat more are because you love them
• Ask how you can best support them and spend time together in ways that don’t involve eating
• Mouth may dry out
• Might no longer need some of their medicines ( such as vitamins, replacement hormones, blood pressure medicines, and diuretics), unless they help make them more comfortable.
• Put lip balm, lubricant, or petroleum jelly (Vaseline®) on your loved one’s lips.
• Try giving ice chips from a spoon, or sips of water or juice from a straw.
• Check with the doctor to see which medicines may be stopped. Medicines for pain, nausea, fever, seizures, or anxiety should be continued to keep your loved one comfortable.
• Mucus may collect in the back of the throat. This may cause a rattling sound with breathing that’s very distressing to hear. But know that this isn’t usually uncomfortable for your loved one.
• Secretions may thicken and build up due to less fluid intake and because your loved one can’t cough
• If mouth secretions increase, keep them loose by adding humidity to the room with a cool mist humidifier.
• If your loved one can swallow, give them ice chips or sips of liquid through a straw. This may help thin secretions.
• Change your loved one’s position – turning them to the side may help secretions drain from the mouth. Continue to clean your loved one’s teeth and mouth with water and a soft toothbrush or foam mouth swabs.
• Certain medicines may help. Ask your doctor or nurse about them.
• Arms and legs may feel cool to the touch as circulation slows down
• Skin on arms, legs, hands, and feet may darken and look blue or mottled (blotchy)
• Other areas of the body may become either darker or paler
• Skin may feel cold and either dry or damp
• Heart rate may become fast, faint, or irregular
• Blood pressure may get lower and become hard to hear
• Keep your loved one warm with blankets or light bed coverings.
• Don’t use electric blankets, heating pads, etc.
• Vision may become blurry or dim
• Pupils may not change size
• May have trouble closing eyelids
• Hearing may decrease, but most people can hear you even after they can no longer speak.
• Leave indirect lights on as vision decreases.
• Always assume your loved one can hear you.
• Continue to speak with and touch your loved one to reassure them of your presence. Your words of affection and support are likely to be understood.
• Breathing may speed up then slow down
• Your loved one may grunt while breathing
• Neck muscles may look tight to help breathe
• Mucus in the back of the throat may cause rattling or gurgling with each breath
• Your loved one may have periods up to 30 seconds when they don’t breathe, then start breathing again
• Put them on their back, or slightly to one side.
• Raising your loved one's head may give some relief.
• Use pillows to prop your loved one’s head and chest up or raise the head of the bed.
• Any position that seems to make breathing easier is OK, including sitting up with good support. If your loved one is a small person, they may be more comfortable in your arms.
• Urine may become darker and decrease in amount
• Your loved one may lose control of their urine and stool
• Pad the bed beneath your loved one with layers of disposable waterproof pads.
• If your loved one has a catheter to collect urine, the nurse will teach you to care for it.
• Bathe your loved one as they can tolerate it - this could be a sponge bath or simply washing certain parts of the body.
• Breathing stops
• Blood pressure cannot be heard
• Pulse stops
• Eyes stop moving and may stay open
• Pupils of the eyes stay large, even in bright light
• May lose control of their bowels or bladder

What to do when you think your loved one has died  

Try to have a plan for what to do just following your loved one’s death. This can help caregivers and other people who are with the loved one when they die. If your loved one is in hospice, the hospice nurse and social worker can help you. If your loved one is not in hospice, talk with the doctor so that you will know exactly what to do at the time of death. 

If your loved one dies at home and is not under hospice care, caregivers are responsible for calling the right people. Regulations or laws about who must be notified and how the body should be moved differ from one community to another. Your doctor or nurse can get this information for you.

If a hospice or home care agency is involved, call them first. If you’ve completed funeral arrangements, calling the funeral director and doctor are usually all that you have to do.

It’s all right if you want to sit with your loved one for a while. There’s no rush to get anything done right away. Many families find this is an important time to pray,  talk together, and share their love for each other and for the person who has passed away.

The American Cancer Society medical and editorial content team

Our team is made up of doctors and oncology certified nurses with deep knowledge of cancer care as well as editors and translators with extensive experience in medical writing.

Ijaopo EO, Zaw KM, Ijaopo RO, Khawand-Azoulai M. A Review of Clinical Signs and Symptoms of Imminent End-of-Life in Individuals With Advanced Illness. Gerontol Geriatr Med. 2023;9:23337214231183243. Published 2023 Jun 26.

Jolley C. Palliative care. In: Eggert JA, Byar KL & Parks LS, ed. Cancer Basics. Oncology Nursing Society; 2022: 263-276.

National Cancer Institute. End-of-life Care for People Who Have Cancer. cancer.gov. Accessed at https://www.cancer.gov/about-cancer/advanced-cancer/care-choices/care-fact-sheet on September 11, 2023.

National Institute on Aging. Providing Care and Comfort at the End of Life. Nia.nih.gov. Accessed at https://www.nia.nih.gov/health/providing-comfort-end-life on September 11, 2023.

UpToDate. Palliative Care: The Last Hours and Days of Life. Accessed at uptodate.com on September 11, 2023. 

Last Revised: June 5, 2024

American Cancer Society medical information is copyrighted material. For reprint requests, please see our Content Usage Policy .

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Palliative care - what the final days are like

If a loved one is dying, you may have a lot of questions about what to expect. Every person's end of life journey is different. Some people linger, while others pass quickly. However, there are some common signs that the end is near. It can be helpful to know that these signs are a normal part of dying.

• Palliative Care

Palliative care is a holistic approach to care that focuses on treating pain and symptoms and improving quality of life in people with serious illnesses.

Hospice care helps people with illnesses that cannot be cured and who are nearing death. The goal is to give comfort and peace instead of a cure. Hospice care is usually free to Medicare recipients and covered by most commercial insurance plans. Hospice care provides:

• Support for the person and the family
• Relief of the person's pain and symptoms
• Help for family members and loved ones who want to stay close to the dying person

Most hospice patients are in their last 6 months of life.

The Final Days of Life

For a while, signs that death is near may come and go. Family and friends may need help understanding the signs that mean a person is close to death.

What you Might see

As a person gets closer to death, you will see signs that their body is shutting down. This may last anywhere from a few days to a couple of weeks. Some people go through the process quietly, while others may be more agitated.

The person might:

• Have less pain
• Have trouble swallowing
• Have blurry vision
• Have trouble hearing
• Not be able to think or remember clearly
• Eat or drink less
• Lose control of urine or stool
• Hear or see something and think it is something else, or experience misunderstandings
• Talk to people who are not in the room or who are no longer living
• Talk about going on a trip or leaving
• Have cool hands, arms, feet, or legs
• Have a blue or gray nose, mouth, fingers, or toes
• Have breathing that sounds wet, maybe with bubbling sounds
• Have breathing changes: breathing may stop for a bit, then continue as several quick, deep breaths
• Stop responding to touch or sounds, or go into a coma

What you can do

You can help make loved one's final days more comfortable both physically and emotionally. Your efforts will help to ease your loved one's final journey. Here are ways to help.

• If you do not understand what you see, ask a hospice team member.
• If you think the person would want to see other family and friends, let them visit, even children, a few at a time. Try to plan for times when the person is more alert.
• Help the person get into a comfortable position.
• Give medicine as directed to treat symptoms or relieve pain.
• If the person is not drinking, wet their mouth with ice chips or a sponge. Apply lip balm to ease dry lips.
• Pay attention to signs that the person is too hot or cold. If the person is hot, put a cool, wet cloth on their forehead. If the person is cold, use blankets to warm them. Don't use electric pads or blankets, which could cause burns.
• Apply lotion to soothe dry skin.
• Create a soothing environment. Keep a soft light on, but not too bright. If the person has blurry vision, darkness can be scary. Play soft music that the person likes.
• Touch the person. Hold hands.
• Talk calmly to the person. Even if you get no response, they can probably still hear you.
• Write down what the person says. This may help comfort you later.
• Let the person sleep.

When to Call the Doctor

Contact a member of the hospice team if your loved one shows signs of pain or anxiety.

Alternative Names

End of life - final days; Hospice - final days

Arnold RM, Kutner JS. Palliative care. In: Goldman L, Cooney KA, eds. Goldman-Cecil Medicine . 27th ed. Philadelphia, PA: Elsevier; 2024:chap 3.

Colvin LA, Fallon M. Pain and palliative care. In: Penman ID, Ralston SH, Strachan MWJ, Hobson RP, eds. Davidson's Principles and Practice of Medicine . 24th ed. Philadelphia, PA: Elsevier; 2023:chap 8.

Shah AC, Donovan AI, Gebauer S. Palliative medicine. In: Gropper MA, ed. Miller's Anesthesia . 9th ed. Philadelphia, PA: Elsevier; 2020:chap 52.

Review Date 3/11/2024

Updated by: Frank D. Brodkey, MD, FCCM, Associate Professor, Section of Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Related MedlinePlus Health Topics

• End of Life Issues

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• Providing care and comfort at the end of life. National Institute on Aging. https://www.nia.nih.gov/health/providing-comfort-end-life. Accessed April 4, 2023.
• Perng A, et al. Identifying and treating complicated grief in older adults. The Journal for Nurse Practitioners. 2018; doi:10.1016/j.nurpra.2017.12.001.
• What is hospice care? American Cancer Society. https://www.cancer.org/treatment/end-of-life-care/hospice-care/what-is-hospice-care.html. Accessed April 4, 2023.
• Advance care planning: Advance directives for health care. National Institute on Aging. https://www.nia.nih.gov/health/advance-care-planning-advance-directives-health-care. Accessed April 4, 2023.
• Ross V, et al. Exploring the support needs of people bereaved by suicide: A qualitative study. Journal of Death and Dying. 2021; doi:10.1177/0030222819825775.
• Making decisions for someone at the end of life. National Institute on Aging. https://www.nia.nih.gov/health/making-decisions-someone-end-life. Accessed April 10, 2023.

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What end of life care involves

End of life care is support for people who are in the last months or years of their life.

End of life care should help you to live as well as possible until you die and to die with dignity. The people providing your care should ask you about your wishes and preferences and take these into account as they work with you to plan your care.

They should also support your family, carers or other people who are important to you.

You have the right to express your wishes about where you would like to receive care and where you want to die. You can receive end of life care at home , in a care home , hospice or be cared for in hospital , depending on your needs and preference.

People who are approaching the end of their life are entitled to high-quality care, wherever they're being cared for. Find out what to expect from end of life care .

Who provides end of life care?

Different health and social care professionals may be involved in your end of life care, depending on your needs. For example, hospital doctors and nurses, your GP, community nurses, hospice staff and counsellors may all be involved, as well as social care staff, chaplains (of all faiths or none), physiotherapists, occupational therapists or complementary therapists.

If you are being cared for at home or in a care home, your GP has overall responsibility for your care. Community nurses usually visit you at home and family and friends may be closely involved in caring for you too.

What is palliative care?

If you have an illness that cannot be cured, palliative care makes you as comfortable as possible by managing your pain and other distressing symptoms . It also involves psychological, social and spiritual support for you and your family or carers. This is called a holistic approach, because it deals with you as a "whole" person, not just your illness or symptoms.

Palliative care is available when you first learn you have a life-limiting (terminal) illness. You might be able to receive palliative care while you are still receiving other therapies to treat your condition.

End of life care is a form of palliative care you receive when you're close to the end of life.

Who provides palliative care?

Many healthcare professionals provide palliative care as part of their jobs. An example is the care you get from your GP or community nurses.

Some people need additional specialist palliative care. This may be provided by consultants trained in palliative medicine, specialist palliative care nurses, or specialist occupational therapists or physiotherapists.

Palliative care teams are made up of different healthcare professionals and can co-ordinate the care of people with an incurable illness. As specialists, they also advise other professionals on palliative care.

When does end of life care begin?

End of life care should begin when you need it and may last a few days or months, or sometimes more than a year.

People in lots of different situations can benefit from end of life care. Some of them may be expected to die within the next few hours or days. Others receive end of life care over many months.

People are considered to be approaching the end of life when they are likely to die within the next 12 months, although this is not always possible to predict. This includes people whose death is imminent, as well as people who:

• have an advanced incurable illness, such as cancer, dementia or motor neurone disease
• are generally frail and have co-existing conditions that mean they are expected to die within 12 months
• have existing conditions if they are at risk of dying from a sudden crisis in their condition
• have a life-threatening acute condition caused by a sudden catastrophic event, such as an accident or stroke

The National Institute for Health and Care Excellence (NICE) has published guidance on the care of dying adults in the last days of life . This guidance covers how to manage common symptoms, as well as dignity and respect for the dying person, their relatives and carers.

How do I find out about end of life care services in my area?

If you are approaching the end of life, or caring for someone who is, and you want to find out about the care and support available, your first step is to speak to your GP or to call the number your healthcare professionals have given you.

Part of their job is to help you understand which services are available locally. You can ask about all sorts of help – for instance, there may be particular night-time services they can tell you about. You can also search for care services that provide palliative care near you .

Planning ahead

The guide about end of life care also covers legal issues to help you plan ahead for your future care. These include creating a lasting power of attorney , so the person or people of your choice can make decisions about your care if you are no longer able to do so yourself.

Video: Getting the most from palliative care

In this video Lucy, who has a life-limiting condition, shares what she's learned about palliative care.

Getting the best out of palliative care - Joe and Melita's story

In this video, Melita and her husband Joe discuss how they turned to palliative care to make life more comfortable.

Page last reviewed: 6 April 2022 Next review due: 6 April 2025

Understanding End-of-Life Visions

When reading about signs and symptoms of end of life , there are many clinical descriptions: changes in breathing, mottling , decreased intake of fluid and food . One sign often stands out as being decidedly not clinical: visions before death . Yet, if you ask anyone working in end-of-life care about this, they’ll assure you that it is a common occurrence. 

Experiencing end-of-life visions. 

“ I’ve been with many patients who see loved ones ,” Crossroads Hospice & Palliative Care Chaplain Ann O’Shea shares. “Recently, a patient sat up and said ‘hello’ to someone I couldn’t see and began talking to them.”

Many nurses, hospice aides, and family caregivers providing end-of-life care to patients and family members share similar experiences of visions before death.

“Sometimes patients don’t see a loved one, but they say they see spirits they don’t know popping in to visit. Sometimes, it is many people. They’ll say the room is crowded,” Crossroads Nurse Carolyn Quach-Huynh adds. “It’s also not always a vision. It can be a deceased spouse or parent appearing in dreams. Or a familiar smell – like cigars or a certain perfume.”

The terminally ill patient may also share that they are getting ready to go on a journey or that they recently visited places with a deceased parent or spouse.

All of these situations are very common, not just in the final hours of person’s life, but often in the days and weeks leading up to it.

What to do if your loved one is experiencing visions at end of life. 

These visions are not hallucinations or a reaction to medication. The most important thing to do if your loved one is seeing visions or having visitation dreams is to acknowledge and support them. Do not argue with your loved one about the experience, correct them, or try to explain the vision. Do not panic as that can upset your loved one. Instead, take them at their word and encourage them to share the experience with you.

“As a caregiver, it is not our job to prove, disprove, or do experiments,” says Carolyn. “We are there to provide support and comfort.

In most cases, these end-of-life visions are indeed a source of great comfort to the person experiencing them.  

If this is not the case and your loved one is becoming agitated by the visions or nightmares, talk through what the source of their fear is. Are they afraid of dying? Are they afraid of the person in the vision because of past bad acts? Let your hospice care team know about your loved one’s agitation. Chaplains and other trained hospice staff can help alleviate many concerns.

“This is the beauty of Crossroads Hospice & Palliative Care,” says Carolyn. “We are available to support families 24 hours a day, 7 days a week, and we can come out at any time if the patient or their family needs extra assistance.”

While it can be very hard to accept that the end is near for someone you love, these visions before death often signal to your loved one that their time has come. A vision of a parent or other loved one waiting for them can provide a feeling of peace about the experience, bringing comfort to both the patient and those around them.

If you know someone who could use the support of hospice or has been diagnosed with six months or less to live, please call us a 1-888-564-3405 to arrange for a hospice evaluation.

Recommended Reading:

A Guide to Understanding End-of-Life Signs & Symptoms

Is Dying Easier for the Faithful?

After Death: What Happens Next?

If you found this information helpful, please share it with your network and community. Copyright © 2017 Crossroads Hospice & Palliative Care. All rights reserved.

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12 Signs That Someone Is Near Death

Pain, Shortness of Breath, Bowel Changes, Fatigue, and More

If a person is near death , they will go through certain changes as the organs of their body start to shut down. This will lead to common symptoms like anxiety, fatigue, constipation, and changes in bowel movement before progressing to end-of-life symptoms such as delirium and characteristic breathing sounds known as the "death rattle."

This article will discuss 12 signs that a person is nearing the end of their life. It also suggests ways to help your loved one manage through the final stages of life.

Thomas Odulate / Getty Images

Pain is a common symptom experienced near the end of life, although it can vary from person to person. Pain is not only determined by medical conditions that cause pain, like cancer or lung disease, but also by factors like emotional distress, interpersonal conflicts, and the non-acceptance of one’s own death.

Pain control near the end of death should involve addressing all of these factors as part of hospice or palliative care . If medications are needed for severe pain, opioid analgesics like morphine are typically the first-line option.

Shortness of Breath

Shortness of breath, also known as dyspnea , is one of the most common end-of-life symptoms. Even if a person doesn't have lung disease, dyspnea can occur because the organ systems of the body are interconnected.

For example, if your heart is slowing down due to heart failure and less oxygen is being delivered to the body, you can become breathless with minimal physical activity.

Deep breathing exercises and relaxation techniques can help in the early stages. As the condition progresses, medications and oxygen therapy may be needed.

Igor Novakovic / Getty Images

Anxiety is normal at the end of life as a person contemplates their own death or struggles through the stages of dying. This is commonly expressed as agitation, worrying, sweating, stomach upset, nausea, sleeping problems, shortness of breath, and heart palpitations .

Counseling and therapy can go a long way toward easing anxiety. Medications like antidepressants , anxiolytics , and benzodiazepines can also be prescribed.

Decreased Appetite and Thirst

As a body starts to shut down, it no longer needs as many calories and nutrition to function at such lowered levels. Although it is normal for people to refuse food and drink near the end of life—either because they have no desire for it or find the effort of eating or drinking to be too much—it can still be upsetting for families.

The important thing to remember is that when someone is dying from a terminal illness , a disinterest in food is natural and does not really speed up the process of death.

Nausea or Vomiting

There are many reasons a person may be nauseous near the end of life. It may be due to constipation , having a reduced appetite, or certain medicines they are taking. It could also be caused by emotional distress.

Anti-nausea medications may help, but it's important to pinpoint the underlying cause to help make your loved one more comfortable. Getting fresh air, eating smaller meals, sipping ginger tea , and avoiding off-putting smells from foods like cabbage or fish can also help.

Constipation

Alvis Upitis / Getty Images

Medications used to treat pain and shortness of breath can cause constipation . Other causes include a lack of physical activity, dehydration, decreased fiber intake, and the progression of the underlying terminal illness.

Changes in diet, increased fluid intake, and simply taking short walks can help. The use of stimulant laxatives as well as a low enema can provide relatively fast relief.

If constipation caused by opioid painkillers is severe, an injection of a drug called methylnaltrexone  can help.

mediaphotos / Getty Images 

Fatigue near the end of life is not a surprising symptom for most people to grasp but one that can be increasingly worrisome when watching a loved one spend more and more time in bed.

As much as illness, medications, and sleep problems can cause fatigue, so can emotional issues such as depression. To this end, it is important to not only ask your loved one what they are feeling but how they are feeling emotionally.

Providing a loved one with sunlight and fresh air, and keeping their living space cheerful and clean can help lift fatigue to a certain degree.

It is equally important to accept fatigue as a natural part of the dying process. You shouldn't force your loved one to do things that may only add to their tiredness.

Isolation and Drifting Away

Ariel Skelley / Getty Images

As someone nears death, they naturally start to focus inward and may separate from the world around them, including friends and family. While this may be a reasonable response, it can be of concern if it amplifies feelings of anxiety or depression.

It is important to remember that any and all emotions are normal when someone is dying. This doesn't mean that you should back away.

By just being there, you may find that certain feelings are causing your loved one to drift away. There may be unspoken regrets or worries. Or, they may simply be emotionally worn out.

While you may not be able to help them sort out these feelings, studies show that being there almost invariably makes end-of-life care less complicated and taxing on your loved one.

Incontinence

krisanapong detraphiphat / Getty Images

Both urinary incontinence (loss of bladder control) and fecal incontinence (loss of bowel control) are common near the end of life.

Incontinence can be a result of surgery or illness, or because the person is simply too weak to go to the bathroom. At the very end, when the urinary and bowel muscles relax entirely, the person will have no control over these functions.

If a loved one soils or pees on themselves, it is important to clean them immediately to prevent irritation, sores, and infections that cause pain.

Skin Changes

Emilija Manevska / Getty Images

Hands and feet may become colder and the skin may look blotchy, purplish, and mottled as a person nears. These changes happen because the heart is no longer able to pump blood as effectively to the limbs.

Over time, the mottling may work its way up the arms and legs, while the lips and nails may turn bluish due to the lack of oxygen (referred to as cyanosis ). The swelling of the legs and ankles ( peripheral edema ) is also common.

Oxygen therapy may help ease cyanosis, while compression socks may help reduce edema and possibly pain as well.

ImagesBazaar / Getty Images

Confusion, agitation, and restlessness are common near the end of life. Delirium (sudden confusion and disorientation) can be caused by the progression of the terminal disease, a failing respiratory system (providing less oxygen to the brain), or medications they are taking.

There may even be episodes of hallucination where they see or hear things that are not there

Kidney failure common near the end of life can also flood the body with chemicals that affect the brain. Even constipation and dehydration can trigger delirium in people approaching death.

Delirium is often a sign of impending death. Effort is typically placed on making your loved one as comfortable as possible.

The "Death Rattle"

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The "death rattle" is a sign that death is near. Also known as "end-stage wet respirations," it is when saliva and mucus build up in the airways due to the weakening of the muscles in the lungs and trachea (windpipe). With each breath, the passing of air through these fluids causes a rattling sound.

At this stage, the focus will be placed on preventing your loved one from choking, This may involve turning them on their side or elevating their head.

When someone is nearing the end of their life, they will experience a variety of characteristic symptoms. Pain, shortness of breath, anxiety, constipation, loss of appetite, fatigue, and change in skin tone and texture are just a few. Death is considered imminent with the loss of bowel control, delirium, and the "death rattle."

Carr D, Luth EA. Well-being at the end of life . Annu Rev Sociol. 2019 Jul;45:515–534. doi:10.1146/annurev-soc-073018-022524

Hendriks SA, Smalbrugge M, Galindo-Garre F, Hertogh CMPM, van der Steen JT. From admission to death: prevalence and course of pain, agitation, and shortness of breath, and treatment of these symptoms in nursing home residents with dementia .  J Am Med Directors Assoc. 2015;16(6):475-481. doi:10.1016/j.jamda.2014.12.016

Sandvik RK, Selbaek G, Bergh S, Aarsland D, Husebo BS. Signs of imminent dying and change in symptom intensity during pharmacological treatment in dying nursing home patients: a prospective trajectory study .  J Am Med Directors Association . 2016;17(9):821-827. doi:10.1016/j.jamda.2016.05.006

Hui D, Dev R, Bruera E. The last days of life: symptom burden and impact on nutrition and hydration in cancer patients .  Curr Opinion Supportive Palliative Care . 2015;9(4):346-354. doi:10.1097/SPC.0000000000000171

Dzierżanowski T, Ciałkowska-rysz A. The occurrence and risk factors of constipation in inpatient palliative care unit patients vs. nursing home residents . Prz Gastroenterol . 2018;13(4):299-304. doi:10.5114/pg.2018.79809

Crockett SD, Greer KB, Heidelbaugh JJ, Falck-Ytter Y, Hanson BJ, Sultan S.  American Gastroenterological Association Institute guideline on the medical management of opioid-induced constipation .  Gastroenterology . 156(1):218-226. doi:10.1053/j.gastro.2018.07.016

Abedini NC, Choi HJ, Wei MY, Langa KM, Chopra V. The relationship of loneliness to end of life experience in older Americans: a cohort study . J Am Geriatr Soc. 2020 May;68(5):1064–1071. doi:10.1111/jgs.16354

Hui D, dos Santos R, Chisholm G, Bansal S, Souza Crovador C, Bruera E. Bedside clinical signs associated with impending death in patients with advanced cancer: Preliminary findings of a prospective, longitudinal cohort study .  Cancer . 2015;121(6):960-967. doi:10.1002/cncr.29048

Hosker CMG, Bennett MI. Delirium and agitation at the end of life .  BMJ . :i3085. doi:10.1136/bmj.i3085

Bramati P, Bruera E. Delirium in palliative care . Cancers (Basel). 2021 Dec;13(23):5893. doi:10.3390/cancers13235893

By Angela Morrow, RN Angela Morrow, RN, BSN, CHPN, is a certified hospice and palliative care nurse.

Last Days of Life (PDQ®)–Patient Version

The end of life may be months, weeks, days, or hours. It is a time when many decisions about treatment and care are made for people with cancer. It is important for families and health care providers to talk openly with the person about their end-of-life plans and know their wishes ahead of time. This will make it easier for family members to make major decisions for the person at the end of life.

When treatment choices and plans are discussed before the end of life, it can lower the stress on both the patient and the family. It is most helpful if end-of life planning and decision-making begin soon after the cancer is diagnosed and continue during the course of the disease. Having these decisions in writing can make the person's wishes clear to both the family and the health care team.

When a child is terminally ill , end-of-life discussions with the child's doctor may reduce the time the child spends in the hospital and help the parents feel more prepared.

This summary is about end of life in adults with cancer and, where noted, children with cancer. It discusses care during the last days and last hours of life, including treatment of common symptoms and ethical questions that may come up. It may help patients and their families prepare for decisions they must make during this time.

For more information on end-of-life planning, including palliative and hospice care, see Planning the Transition to End-of-Life Care in Advanced Cancer .

Care in the Final Hours

Knowing what to expect in the final days or hours helps comfort the family., people may not want to eat or drink in the final days or hours., people near death may not respond to others., a number of physical changes are common when a person is near death., cultural or religious beliefs and customs may be important at the time of death..

Most people don't know the signs that show death is near. Knowing what to expect can help them get ready for the death of their loved one and make this time less stressful and confusing. Health care providers can give family members information about the changes they may see in their loved one in the final hours and how they may help their loved one through this.

In the final days to hours of life, people often lose the desire to eat or drink, and may not want food and fluids that are offered to them. The family may give ice chips or swab the mouth and lips to keep them moist. Food and fluids should not be forced on the person because it can cause discomfort or choking.

People may withdraw and spend more time sleeping. They may answer questions slowly or not at all, seem confused , and may not be interested in what's going on around them. Most people are still able to hear after they are no longer able to speak. It may give some comfort if family members continue to touch and talk to the person, even if they do not respond.

Certain physical changes may occur in a person at the end of life:

• They may feel tired or weak.
• They may pass less urine , and it may be dark in color.
• Their hands and feet may become blotchy, cold, or blue. Caregivers can use blankets to keep the person warm. Electric blankets or heating pads should not be used.
• Their heart rate may go up or down and become irregular.
• Blood pressure usually goes down.
• Breathing may become irregular, with very shallow breathing, short periods of not breathing, or deep, rapid breathing.

However, these signs and changes don't always occur in everyone. For this reason, it may be hard to know when a person is near death.

After a person dies, family members and caregivers may wish to stay with them awhile. There may be certain customs or rituals that are important to the person and family at this time. These might include rituals for coping with death, handling the person's body, making final arrangements for the body, and honoring the death. It’s important to let the health care team know what customs or rituals are important to the person and their family after the person’s death.

Health care providers, hospice staff, social workers , or spiritual leaders can explain the steps that need to be taken once death has occurred, including contacting a funeral home.

For more information, see Spirituality in Cancer Care .

Symptoms During the Final Months, Weeks, and Days of Life

Delirium can have many causes at the end of life., delirium may be controlled by finding and treating the cause., hallucinations that are not related to delirium often occur at the end of life., fatigue is one of the most common symptoms in the last days of life., feeling short of breath is common and may get worse during the final days or weeks of life., the use of opioids and other methods can help the person breathe more easily., pain medicines can be given in several ways., pain during the final hours of life can usually be controlled., cough at the end of life can be treated in several ways., constipation may occur in the last days of life., people may have trouble swallowing food and fluids at the end of life., rattle occurs when saliva or other fluids collect in the throat and upper airways., non-drug treatments for rattle include changing the person's position and giving less fluid., death rattle is a sign that death may soon occur., myoclonic jerks may be caused by taking very high doses of opioids for a long time., fever may be caused by infection, medicines, or the cancer itself., sudden hemorrhage (heavy bleeding) may occur in people who have certain cancers or disorders., making the person comfortable is the main goal of care during hemorrhage at the end of life..

Common symptoms at the end of life include the following:

• feeling very tired
• shortness of breath
• constipation
• trouble swallowing
• rattle sound with breathing
• myoclonic jerks

Delirium is common during the final days of life. Most people have a lower level of consciousness. They may be withdrawn, be less alert, and have less energy. Some people may be agitated or restless, and have hallucinations (see or hear things not really there). People near death should be protected from having accidents or hurting themselves when they are confused or agitated.

Delirium can be caused by the direct effects of cancer , such as a growing tumor in the brain. Other causes include the following:

• A higher- or lower-than-normal amount of certain chemicals in the blood that keep the heart, kidneys , nerves , and muscles working the way they should.
• Side effects of drugs or drug interactions (changes in the way a drug acts in the body when taken with certain other drugs, herbal medicine , or foods).
• Stopping the use of certain drugs or alcohol .
• Dehydration (the loss of needed water from the body).

Depending on the cause of the delirium, doctors may do the following:

• Give drugs to fix the level of certain chemicals in the blood.
• Stop or lower the dose of the drugs that are causing delirium, or are no longer useful at the end of life, such as drugs to lower cholesterol .
• Treat dehydration by putting fluids into the bloodstream.

For some people in the last hours of life, the decision may be to treat only the symptoms of delirium and make the person as comfortable as possible. There are drugs that work very well to relieve these symptoms.

It is common for people near death to have hallucinations that include loved ones who have already died. It is normal for family members to feel distress when these hallucinations occur. Speaking with clergy , the hospital chaplain , or other religious advisors may help.

Fatigue (feeling very tired) is one of the most common symptoms in the last days of life. A person's fatigue may become worse every day during this time. Drowsiness, weakness, and sleep problems may occur. Drugs that increase brain activity, alertness, and energy may be helpful. For more information, see Cancer Fatigue .

Shortness of Breath

Shortness of breath or not being able to catch your breath is often caused by advanced cancer . Other causes include the following:

• build-up of fluid in the abdomen
• loss of muscle strength
• hypoxemia (a condition in which there is not enough oxygen in the blood )
• chronic obstructive pulmonary disease (COPD)

Opioids may relieve shortness of breath in people near death. Other drugs, such as bronchodilators or steroids may be considered if they are in line with the person’s goals of care.

Other ways to help people who feel short of breath include the following:

• Give extra oxygen if shortness of breath is caused by hypoxemia .
• Aim a cool fan toward their face.
• Have them sit up.
• Give antibiotics if the shortness of breath is caused by an infection.

In the last days of life, a person may not be able to swallow pain medicine . When medicines cannot be taken by mouth, the pain medicine may be given by injection or infusion . These methods can be used at home with a doctor's order.

Opioid analgesics work very well to relieve pain and are commonly used at the end of life. Some patients and family members worry that the use of opioids may cause death to occur sooner, but studies have shown no link between opioid use and early death. For more information about opioids, see Cancer Pain .

Cough at the end of life may add to a person's discomfort. Repeated coughing can cause pain and loss of sleep, increase tiredness, and make shortness of breath worse. At the end of life, the decision may be to treat the symptoms of the cough rather than to find and treat the cause. The following types of drugs may be used to make the person as comfortable as possible:

• Over-the-counter cough medicines with expectorants to increase bronchial fluids and loosen mucus .
• Medicines to decrease mucus production that can cause coughing in people who have trouble swallowing.
• Opioids to stop the coughing.

For more information, see Cardiopulmonary Syndromes .

Constipation

People with cancer may have constipation in the last days of life. People who have trouble swallowing may not be able to take laxatives by mouth to treat the constipation. If needed, laxatives may be given rectally to make them comfortable.

Trouble Swallowing

People with cancer may have trouble swallowing in the last days of life. Both fluids and food may be hard to swallow, causing a loss of appetite , weight loss and muscle wasting , and weakness. Small amounts of food that the person enjoys may be given if they want to eat. Supplemental nutrition does not benefit patients in the last days of life and may increase the risk of aspiration and infections.

When the person cannot swallow, medicine may be given by placing it in the rectum , giving it by injection or infusion , or by placing a patch on the skin.

Death Rattle

Rattle occurs when saliva or other fluids build up in the throat and airways in a person who is too weak to clear the throat. There are two types of rattle. Death rattle is caused by saliva pooling at the back of the throat. The other kind of rattle is caused by fluid in the airways from an infection, a tumor , aspiration, or extra fluid in body tissues .

Drugs may be given to decrease the amount of saliva in the mouth or to dry the upper airway.

Raising the head of the bed, propping the person up with pillows, or turning them to either side often relieves rattle. If the rattle is caused by fluid at the back of the throat, the fluid may be gently removed from the mouth using a suction tube.

Death rattle is a sign that death may occur in hours or days. Rattle can be very upsetting for those at the bedside. It does not seem to be painful for the person and is not the same as shortness of breath.

Myoclonic Jerking

Myoclonic jerks are sudden muscle twitches or jerks that cannot be controlled by the person having them. A hiccup is one type of myoclonic jerk. Brief, shock-like jerks can occur in one or more different muscle groups anywhere in the body. Taking very high doses of an opioid for a long time may cause this side effect , but it can have other causes as well.

When opioids are the cause of myoclonic jerking, changing to another opioid may help. People respond to opioids in different ways, and certain opioids may be more likely than others to cause myoclonic jerking in some people.

When a person is very near death, medicine to stop the myoclonic jerking may be given instead of changing the opioid. When myoclonic jerking is severe, drugs may be used to calm the person down, relieve anxiety , and help them sleep.

Treatment of fever in the last days of life depends on whether it causes the person distress or discomfort. Fever may be caused by infection, medicines, or the cancer itself. Although infections may be treated with antibiotics , people near the end of life may choose not to treat the cause of the fever.

Hemorrhage (heavy bleeding in a short time) is rare but may occur in the last hours or minutes of life. Blood vessels may be damaged by certain cancers or cancer treatments. Radiation therapy , for example, can weaken blood vessels in the area that was treated. Tumors can also damage blood vessels. People with the following conditions have an increased risk of hemorrhage:

• advanced cancer , especially head and neck cancers
• mucositis caused by chemotherapy
• blood clotting disorders

The person and family should talk with the doctor about any concerns they have about the chance of hemorrhage.

It is hard to know when hemorrhage might occur. When sudden bleeding occurs at the end of life, people usually become unconscious and die soon afterwards. Resuscitation (restarting the heart) usually will not work.

The main goal of care is to make the person comfortable and to support family members. If hemorrhage occurs, it can be very upsetting, and it may be helpful for the family to ask questions about it and talk about their feelings with one another and their care team.

Care Decisions in the Final Weeks, Days, and Hours of Life

Decisions about chemotherapy, decisions about targeted therapy, decisions about immunotherapy, decisions about hospice, decisions about place of death.

Decisions about whether to continue or stop chemotherapy are made by the patient and doctor together. About one-third of people with advanced cancer continue to receive chemotherapy or other treatment near the end of life.

Treatment with chemotherapy at this time can result in the following:

• serious side effects
• spending more days in the hospital
• spending the last days of life in an intensive care unit

However, some people with cancer choose to continue chemotherapy because they feel it helps them to live in the present and focus on active treatment. Other people choose palliative or comfort care to treat pain and other symptoms . These decisions are based on the person's goals of care and the likely risks and benefits of treatment.

Decisions about whether to continue or stop targeted therapy are made by the patient and doctor together. Targeted therapies may help people with tumors that have spread to other areas in the body.

Treatment with targeted therapy at the end of life can result in the following:

• spending the last days of life in a hospital
• poor awareness of prognosis
• less time to prepare for the end of life

Decisions about whether to continue or stop immunotherapy are made by the patient and doctor together. Many people taking immunotherapy are older or are no longer helped by chemotherapy, but these drugs may still have unwanted side effects.

Treatment with immunotherapy at the end of life can result in the following:

• being less likely to use hospice services
• spending the last days of life in the hospital
• having problems related to medical costs ( financial toxicity )

Hospice care is an important end-of-life option for people with advanced cancer. People may feel that beginning hospice care means they have given up. Some people fear losing the relationship with their oncologist . However, many patients and caregivers feel they receive important benefits from hospice care.

People who receive hospice care seem to have the following:

• better mental outlook
• better relief of symptoms
• better communication
• better end-of-life care
• more days spent at home
• less stressful death (without causing death to happen sooner)

Hospice-related services include:

• visiting nurse
• home health aide
• respite care

Doctors, patients, and caregivers should discuss hospice care and when it should begin.

When hospice benefits are covered by Medicare , physicians are required to certify that the person is not expected to live more than 6 months and is not being treated to be cured . Other policies may be different, depending on the hospice and the state.

Many people with advanced cancer wish to die at home. People who die at home with hospice services and support seem to have better symptom control and quality of life. They also feel better prepared for death than people who die in a hospital or intensive care unit. Grieving caregivers have less trouble adjusting to their loss and feel they have honored the person's wishes when their loved one dies at home.

People who get hospice care are more likely to be able to die at home. Hospice care can help control the person's symptoms and give the caregiver the help they need.

However, not all people choose to die at home. It is important for the person, caregivers, and doctors to discuss where the person wants to die and the best way to fulfill the person's decision.

For children with advanced cancer, families and doctors should discuss wishes for the place of death early in the course of the disease. Children who die in the hospital may have more intense treatments and their parents may have more complicated grief than those of children who die at home.

Decisions about Life-Sustaining Treatments in the Last Days of Life

In the last days of life, patients and family members will have to make decisions about treatments to keep the person alive., choices about care and treatment at the end of life should be made while the person is able to make them., care that supports a person's spiritual health may improve quality of life., the goals of giving fluids at the end of life should be discussed by patient, family, and doctors., the goals of nutrition support for patients in the last days of life are different from the goals during cancer treatment., making plans for nutrition support in the last days is helpful., two types of nutrition support are commonly used., the benefits of using antibiotics in the last days of life are unclear., the decision to use blood transfusions in advanced cancer depends on goals of care and other factors., people should decide whether or not they want cardiopulmonary resuscitation (cpr)..

Decisions about whether to use life-sustaining treatments that may extend life in the final weeks or days cause a great deal of confusion and anxiety . Some of these treatments are ventilator use, parenteral nutrition , and dialysis .

People near death may be guided by their oncologist , but they have the right to make their own choices about life-sustaining treatments. The following are some of the questions to discuss:

• What are the person’s goals of care?
• How would the possible benefits of life-sustaining treatments help reach the person's goals of care, and how likely is the desired outcome?
• How would the possible harms of life-sustaining treatments affect the person's goals of care? Is the possible benefit worth the possible harm?
• Besides possible benefits and harms of life-sustaining treatments, what else can affect the decision?
• Are there other resources, such as palliative care , a chaplain , or a medical ethicist, that could help the person or family make decisions about life-sustaining treatments?

A person may wish to receive all possible treatments, only some treatments, or no treatment at all in the last days of life. These decisions may be written down ahead of time in an advance directive , such as a living will . Advance directive is the general term for different types of legal documents that describe the treatment or care a patient wishes to receive or not receive when he or she is no longer able to speak their wishes.

Studies have shown that people with cancer who have end-of-life discussions with their doctors choose to have fewer procedures, such as resuscitation or the use of a ventilator. They are also less likely to be in intensive care, and the cost of their health care is lower during their final week of life. Reports from their caregivers show that these people live just as long as those who choose to have more procedures, and have a better quality of life in their last days.

For more information, see Planning the Transition to End-of-Life Care in Advanced Cancer .

A spiritual assessment is a method or tool used by doctors to understand the role that religious and spiritual beliefs have in the person's life. This may help the doctor understand how these beliefs affect the way the person copes with cancer and makes decisions about cancer treatment.

Serious illnesses like cancer may cause people or family caregivers to have doubts about their beliefs or religious values and cause spiritual distress . Some studies show that people with cancer may feel anger at God or may have a loss of faith after being diagnosed . Other people may have feelings of spiritual distress when coping with cancer. Spiritual distress may affect end-of-life decisions and increase depression .

Doctors and nurses , together with social workers and psychologists , may be able to offer care that supports a person's spiritual health. They may encourage the person to meet with their spiritual or religious leaders or join a spiritual support group . This may improve a person's quality of life and ability to cope. When people with advanced cancer receive spiritual support from the medical team, they are more likely to choose hospice care and less aggressive treatment at the end of life.

Fluids may be given when the person can no longer eat or drink normally. Fluids may be given with an intravenous (IV) catheter or through a needle under the skin.

Decisions about giving fluids should be based on the person's goals of care. Giving fluids has not been shown to help patients live longer or improve their quality of life. However, the harms are minor and the family may feel there are benefits if the person is less fatigued and more alert.

The family may also be able to give the person sips of water or ice chips or swab the mouth and lips to keep them moist.

Nutrition Support

Nutrition support can improve health and boost healing during cancer treatment. The goals of nutrition therapy for people during the last days of life are different from the goals for people in active cancer treatment and recovery . In the final days of life, people often lose the desire to eat or drink and may not want food or fluids that are offered to them. Also, procedures used to put in feeding tubes may be hard on them.

The goal of end-of-life care is to prevent suffering and relieve symptoms. If nutrition support causes the person more discomfort than help, then nutrition support near the end of life may be stopped. The needs and best interests of each person guide the decision to give nutrition support. When decisions and plans about nutrition support are made by the person near death, doctors and family members can be sure they are doing what the person wants.

If the person cannot swallow, two types of nutrition support are commonly used:

• Enteral nutrition uses a tube inserted into the stomach or intestine .
• Parenteral nutrition uses an intravenous (IV) catheter inserted into a vein .

Each type of nutrition support has benefits and risks. For more information, see Nutrition in Cancer Care .

Antibiotics

The use of antibiotics and other treatments for infection is common in people in the last days of life, but it is hard to tell how well they work. It is also hard to tell if there are any benefits of using antibiotics at the end of life.

Overall, doctors want to make the person comfortable in the last days of life rather than give treatments that may not help them live longer.

Transfusions

Many people with advanced cancer have anemia . People with advanced blood cancers may have thrombocytopenia (a condition in which there is a lower-than-normal number of platelets in the blood ). Deciding whether to use blood transfusions for these conditions is based on the following:

• goals of care
• how long the person is expected to live
• the benefits and risks of the transfusion

The decision can be hard to make because people usually need to receive transfusions in a medical setting rather than at home.

Many people with cancer are used to receiving blood transfusions during active treatment or supportive care and may want to continue transfusions to feel better. However, studies have not shown that transfusions are safe and effective at the end of life.

Resuscitation

An important decision for a person near death to make is whether to have cardiopulmonary resuscitation (CPR) (trying to restart the heart and breathing when it stops). It is best if people talk with their family, doctors, and caregivers about their wishes for CPR as early as possible (for example, when being admitted to the hospital or when active cancer treatment is stopped). A do-not-resuscitate (DNR) order is written by a doctor to tell other health professionals not to perform CPR at the moment of death, so that the natural process of dying occurs. If the person wishes, he or she can ask the doctor to write a DNR order. The person can ask that the DNR order be changed or removed at any time.

Last Days in the Hospital or Intensive Care Unit

Choices about whether to use intensive care should be discussed., before a ventilator is turned off, family members will be given information about what to expect..

Near the end of life, people with advanced cancer may be admitted to a hospital or intensive care unit (ICU) if they have not made other choices for their care. In the ICU, patients or family members have to make hard decisions about whether to start, continue, or stop aggressive treatments that may make the person live longer but harm their quality of life . Families may be unsure of their feelings or have trouble deciding whether to limit or avoid treatments.

Sometimes, treatments like dialysis or blood transfusions may be tried for a short time. However, at any time, patients or families may talk with doctors about whether they want to continue with ICU care. They may choose instead to change over to comfort care in the final days.

Ventilator use may keep a person alive after normal breathing stops.

A ventilator is a machine that helps people breathe. Sometimes, using a ventilator will not improve the person's condition but will keep them alive longer. If the goal of care is to help the person live longer, a ventilator may be used, according to the person's wishes. If ventilator support stops helping or is no longer what the person wants, the person, their family, and the health care team may decide to turn the ventilator off.

Family members will be given information about how the person may respond when the ventilator is removed and about pain relief or sedation to keep the person comfortable. Family members will be given time to contact other loved ones who wish to be there. Chaplains or social workers may be called to support to the family.

Suffering and Palliative Sedation at the End of Life

The emotions of patients and caregivers are closely connected., palliative sedation lowers the level of consciousness and relieves extreme pain and suffering..

Patients and caregivers share the distress of cancer, with the caregiver's distress sometimes being greater than the patient's distress. Since caregiver suffering can affect the person's well-being and the caregiver's adjustment to loss, early and constant support of the caregiver is very important.

Palliative sedation uses drugs called sedatives to relieve extreme suffering by making a person calm and unaware.

The decision whether to sedate a person at the end of life is a hard one. Sedation may be considered for a person's comfort or for a physical condition such as uncontrolled pain. Palliative sedation may be given on and off, or until death. A person's thoughts and feelings about end-of-life sedation may depend greatly on his or her own culture and beliefs. Some people who become anxious facing the end of life may want to be sedated. Some people and their families may wish to have a level of sedation that allows them to communicate with each other. Other people may wish to have no procedures, including sedation, just before death.

Studies have not shown that palliative sedation shortens life when used in the last days.

It is important for the person to tell family members and health care providers of their wishes about sedation at the end of life. When a person makes their wishes about sedation known ahead of time, doctors and family members can be sure they are doing what the person would want. Families may need support from the health care team and mental health counselors while palliative sedation is used.

Grief and Loss

Grief is a normal reaction to the loss of a loved one. People who feel unable to cope with their loss may be helped by grief counseling or grief therapy with trained professionals. For more information, see Grief, Bereavement, and Coping With Loss .

About This PDQ Summary

Physician Data Query (PDQ) is the National Cancer Institute's (NCI's) comprehensive cancer information database. The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries come in two versions. The health professional versions have detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions have cancer information that is accurate and up to date and most versions are also available in Spanish .

PDQ is a service of the NCI. The NCI is part of the National Institutes of Health (NIH). NIH is the federal government’s center of biomedical research. The PDQ summaries are based on an independent review of the medical literature. They are not policy statements of the NCI or the NIH.

Purpose of This Summary

This PDQ cancer information summary has current information about patient care during the last days to last hours of life. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.

Reviewers and Updates

Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary ("Updated") is the date of the most recent change.

The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Supportive and Palliative Care Editorial Board .

Clinical Trial Information

A clinical trial is a study to answer a scientific question, such as whether one treatment is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. During treatment clinical trials, information is collected about the effects of a new treatment and how well it works. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become "standard." Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Clinical trials can be found online at NCI's website . For more information, call the Cancer Information Service (CIS), NCI's contact center, at 1-800-4-CANCER (1-800-422-6237).

Permission to Use This Summary

PDQ is a registered trademark. The content of PDQ documents can be used freely as text. It cannot be identified as an NCI PDQ cancer information summary unless the whole summary is shown and it is updated regularly. However, a user would be allowed to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks in the following way: [include excerpt from the summary].”

The best way to cite this PDQ summary is:

PDQ® Supportive and Palliative Care Editorial Board. PDQ Last Days of Life. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/about-cancer/advanced-cancer/caregivers/planning/last-days-pdq . Accessed <MM/DD/YYYY>. [PMID: 26389429]

Images in this summary are used with permission of the author(s), artist, and/or publisher for use in the PDQ summaries only. If you want to use an image from a PDQ summary and you are not using the whole summary, you must get permission from the owner. It cannot be given by the National Cancer Institute. Information about using the images in this summary, along with many other images related to cancer can be found in Visuals Online . Visuals Online is a collection of more than 3,000 scientific images.

The information in these summaries should not be used to make decisions about insurance reimbursement. More information on insurance coverage is available on Cancer.gov on the Managing Cancer Care page.

More information about contacting us or receiving help with the Cancer.gov website can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the website’s E-mail Us .

End-of-Life Care: Your Patient Has Died, Now What?

This post may contain affiliate links. I will make a small commission if you make a purchase through one of these links, at no extra cost to you.  Please read  full disclosur e  for more information.

End-of-life care is intimate and unique for every patient.  As a nurse, when your patient dies, you might be thinking now what should I do? 

Maybe this is your first death and you’re anxious about what you should say. 

Perhaps you’ve never met the patient/family and you’re worried about building trust. 

Regardless of the situation, your role is to comfort the family and take care of the patient. 

You should also remember to provide the patient with the same dignity and respect you would give to them if they were alive.

My First Patient Death

I’ll be honest.  I had only been off orientation for less than a month before I experienced my first patient death. 

And to be frank, I was not ready when it happened.

To begin, I didn’t even recognize the signs of transition to active death. 

To make matters worse, I had never performed end-of-life care.

(I was busy doing other tasks like the new nurse I was.)

 The CNA came to me and said your patient is dying.

My first thought was: “Please, not on my shift!”

My next statement was: “How do you know?”

She was awesome and walked me through all the physical changes and helped me prepare the family.

Ultimately, when the patient died, she taught me how to perform post-mortem care.

She was so compassionate and took her time with me and the family.

Most of all, I remember how respectful she was to the patient.  She bathed her, dressed her, and combed her hair.  All while teaching me who to call, and what to say. 

My charge nurse was also amazing.  It was at that moment that I knew I wanted to learn everything I could about caring for the dying including post-mortem care.

Where Hospice Patients Die

While nearly 80% of people say they want to die at home , only 20% do. 

Believe it or not, many people still end up dying in acute care settings or nursing homes.  ( That’s a discussion for a different day! )

However, as a home hospice nurse, you are more likely to perform death visits in the patient’s personal residence or nursing home.

Yes, patients absolutely die in hospitals while on GIP and at hospice houses. 

While this article is focused on home deaths, the steps of post-mortem care can apply to most settings. 

Regardless of where your patient dies, these nursing tips can help you provide the best care to your patients and their families.

Pronouncement During End-of-Life Care

From the moment your patient enrolls in hospice, you should begin education with the patient and family.

For starters, you should make sure the family knows to call the hospice agency when the patient dies.  They should NOT call 911, the hospital, or you!

One of the roles of hospice is to confirm the absence of vital signs and comfort the family.

TANGENT ALERT:   If you aren’t going to show up, why do they need you!  There are few things that break my heart more than hearing from patients that the hospice didn’t show up for the death.  AGAIN, why do they need you if you’re not even going to do the basics! 

It happens folks, especially in the nursing home setting.  It also happens when you try to be the hero and have the patients call your personal cell phone.

But I digress!

How to Perform a Pronouncement

1. Observe the absence of respirations.   It’s not unusual for a patient to have long periods where they stop breathing (apnea).  While it can be difficult to watch while the whole family is anxious and looking over your shoulder, take your time.  This will also give you time to think of what you want to say to the family.

2. Assess for signs of life.   Check for a heartbeat, respiration, pupil fixation.  Do not skip this step.  Remember, your confirmation can offer peace and closure to the family. 

3. Listen for a heartbeat with your stethoscope for a full for 2-3 minutes.   Some organizations require that you listen for 5 minutes.  Regardless, of the time, don’t underestimate how important this step is to the family.

4. Condole the family and offer to assist with calls that may need to be made to family, friends, or spiritual care.  This is also a good time to call the coroner’s office, physician, and funeral home.

Expert-Tip:   Once you’ve pronounced the patient cover them with a light sheet or blanket to their shoulders.  Fold their hands and place them on their stomach.  ( Never cover the patient’s face or head unless instructed by the family .)

Your Patient Had Died, Now What?

Now that you have given the family time to grieve, you can begin post-mortem care also known as “ preparing the body .”

Before you begin, you can offer to allow the family to participate. 

In my experience, this can be traumatic for some individuals.  In most instances, I perform end-of-life care on my own or with another staff member.

For home hospice nurses, you will likely perform these tasks by yourself.

Post-Mortem Care Tips

Even though your patient is dead, make to maintain their dignity.  After all, you are being entrusted with someone’s loved at a very delicate time.

** You should perform post-mortem care within the first 1-2 hours after the patient’s death and no more than 4 hours after the death due to rigor mortis (stiffening of the muscles).

• Wear PPE and follow universal precautions
• Lay the patient flat and remove all but one pillow
• Remove all jewelry and watches (except wedding rings)
• Remove all tubes, IVs, and catheters (if not coroner’s case)
• Give your patient a bed bath as if they were alive
• Clean their mouth and replace dentures if necessary
• Comb or brush their hair
• Do not shave the patient as this may cause unintentional bruising.  (The funeral home can do this later.)
• Place one pillow underneath their head to help keep the mouth closed
• If mouth won’t close, place a small, rolled washcloth or towel under the patient’s chin
• Close the eyes by pressing lightly on the eyelids (Sometimes the eyes will not close, reassure the family that the funeral home can help with this.)
• Ensure wound dressings are clean
• Use a chux or adult diaper under the buttocks to catch any fluids that may leak from the body
• Dress the patient and cover with a sheet or blanket to the shoulders.
• Leave the patients hands on the stomach so that they family can touch their loved one
• Place a chair next to the bed in case the family wants to sit at the bedside
• Fold clothes and give them to the family
• Assist family in disposing of hospice comfort medication

End-of-Life Care in a Nursing Home

While this might seem like a no-brainer, you should show up if the patient dies, even if it is a nursing home.  I’ve had so many nurses say that they did not go to death because the nursing home staff took care of everything.  In some instances, this is ok, however, sometimes families are disappointed when their hospice nurse doesn’t show up.

Pro-Tip : When working with the nursing home, clarify the process for handling a death.  Also, you should understand their processes and expectations.

Furthermore, if you’ve built a relationship with the NH and family, you shouldn’t treat the death any differently. 

Ways to Assist the Nursing Home  

If you are new to hospice, you might not realize how much of a help you are to the nursing home. For instance, nursing homes can be short-staffed and by taking care of the hospice patient, you are allowing them to continue to provide care to other patients.

Also, this is a great way to build great relationships with the nursing home and continue to be a benefit to them.

• Document the death
• Call the coroner,
• Notify the funeral home
• Console the family. If family is not present, you can call and notify them of the patient’s death.
• Perform post-mortem care
• Gather and bag the patient’s belongings

Typically, the NH will usually dispose of medications according to their facility’s policies and procedures.

End-of-Life Care Death Documentation

In addition to post-mortem care, you will need to complete your death visit documentation.  Yep, it never goes away!

To begin, your documentation will include your death assessment, disposition of the body, notifications, and funeral home. 

You will also want to document education, emotional support, and bereavement that was offered to the family.

Death Note Narrative Example:

Arrived at home at 11:35 pm and found the patient to be unresponsive with no respirations noted.  No heart sounds were noted after three minutes of auscultation.  Pupils fixed and dilated.  No response noted to verbal and painful stimuli.  TOD 11:38 p.m. Nurse SuzyQ, RN pronounced.

Patient’s wife at the bedside at the time of death.  Notified coroner’s office of absent vital signs and body was ok’d to release to the funeral home.  Called Funeral Home (include name, address, phone number) to inform of patient’s death.

Post-mortem care provided by this nurse.  Family grieving appropriately.  Bereavement services offered and the family accepted.

Notified hospice IDG of patient’s death.

12:25 am- Funeral home arrived and transported patient from the home.  Family grieving appropriately at the end of the visit.

Additional Death Visit Tasks

• Cancel upcoming visits (varies by agency)
• Notify hospice aid so they don’t make a visit
• Contact DME for equipment removal (ask family if ok to pick up DME same day)
• Notify Pharmacy Benefit Manager (PBM)
• Complete documentation
• Notify bereavement and spiritual care
• Verify who’s completing the death certificate

Take care of yourself

Finally, losing a patient can be hard.  Even the most experienced nurses cry and it is ok.  If you need a moment before you begin post-mortem care, take it.

End-of-Life care can be stressful so don’t be afraid to ask for help if you need it.

After your visit, you can try listening to your favorite song or sitting in silence. Remember self-care doesn’t have to be expensive.

Most importantly, do what works for you.  You can also check out these self-care tips for nurses. 

Related Article: Self-Care: 10 Ways to Cope When Your Patient Dies

In summary, end-of-life care can be overwhelming. However, when you follow a systematic approach, you are less likely to miss important steps during the death visit. Always remember that your goal is to comfort the family and to treat the patient with dignity and respect.

• Pronounce patient by verifying absence of vital signs
• Condole the family
• Notify the coroner (if required) and the funeral home.
• Document the death assessment
• Offer bereavement services
• Notify IDG, pharmacy, DME, and bereavement services

RECOMMENDED ARTICLE: Hospice Documentation What You Need to Know

Sept. 12 issue: RSF Senior Center offers a…

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Rancho Santa Fe Review Rancho Santa Fe Review Things to Do

Sept. 12 issue: rsf senior center offers a variety of events, classes, resources and more.

Doctors and Doulas: Partnering to Transform End of Life Journeys

Part 3 of a 3-part series with Dr.  Bob Uslander

Thursday, Sept. 12, from 2 p.m. – 3:30 p.m. Doulas are an increasingly important  piece of the end of life puzzle. Dr. Uslander will discuss the role of the end of life doula, explain how traditional  care partners can partner with doulas, and identify opportunities to engage end of life doulas.

Fairy & Gnome Garden Design

Monday, Sept. 16, from 2 p.m. – 4:30 p.m.  Join Erin Trissler in the  magical world of fairy garden design. You will learn how to build miniature gardens using pots, soil, and  miniature figurines and furniture. Fairy gardens can be a great addition to your outside garden or even be  displayed inside. If you have a passion for crafts, design, and fun, please join her class! Erin has been designing  fairy / gnome gardens for over 25 years.

She has taught classes at the Rancho Santa Fe Library and created a  Halloween and Christmas fairy garden town display at the San Diego Botanic Garden last year. Creating fairy  gardens is relaxing, fun and a great way to socialize with fellow garden and craft lovers. There is a $40 fee paid  to the instructor for supplies.

Paint with Alex Schaefer

Wednesday, Sept. 18, from 1 p.m. – 3 p.m. All level painters are  welcome to join us in the studio with working artist and educator Alex Schaefer. Learn techniques to further  your painting skills. Bring your own artwork and supplies (acrylic, oil, or watercolor) to work with Alex and  fellow artists. There is a $20 fee per class paid to the instructor.

Readers & Writers Workshop (monthly)

Tuesday, Sept. 24, at 10 a.m. Join critically-acclaimed best selling local author Elizabeth St.John, as she introduces and discusses a variety of novels written by author friends  from around the world. In a social and relaxed environment, you will discuss the writer’s journey from inspiration to  perspiration, discover insider techniques and tricks, and practice basic writing crafts from three-act drama to character  arcs. Enjoy a monthly book or two to read with the author’s insights, helpful writing exercises, and a lively  discussion. All readers and writers, beginners and experienced, are welcome. Please bring a notebook. This class  meets on the last Tuesday of each month at 10 a.m.

8-week Intermediate Bridge Lessons with Scott Farr

Each Thursday, Sept. 26 – Nov. 14,  from 2 p.m. – 4 p.m. Intermediate topics include No Trump Opening Bids, Stayman & Transfer Bids, Weak 2  Opening Bids, Preemptive Bids, and 2 Clubs Opening Bid. The first hour of each class will be lecture followed by an hour of supervised play of the hands. There is a $250 fee for the 8-week series paid to Scott Farr.

8-week Advanced Bridge Lessons with Scott Farr

Each Friday, Sept. 27 – Nov. 15, from  10 a.m. – noon.  Advanced topics include Review of Intermediate Course, Hand Re-evaluation, Competitive  Bidding, Overcalls & Double, and Intervening Bids. The first hour of each class will be lecture followed by an  hour of supervised play of the hands. There is a $250 fee for the 8-week series paid to Scott Farr.

Healthy Eating Habits for Brain Health

Part 2 of a 3-part Series on Gut Health with Dr. Joe Weiss

Friday, Sept. 27, from 2 p.m. – 3 p.m. Diet and nutrition are key to virtually all health concerns,  including brain health. Adopting eating habits consuming brain healthy foods, and avoiding foods associated  with Alzheimer’s, stroke, and other neurological conditions can greatly preserve memory and cognitive  function. Thank you to our sponsor Sage Health Systems.

Music in the Garden

Friday, Oct. 11, from 2 p.m. – 4 p.m.  In celebration of Rancho Days, join us for  a delightful afternoon of music and delicious hors d’ oeuvres served in the beautiful Senior Center Garden.  Enjoy the music of High Tide Society, a local band paying tribute to the smooth hit songs of the ’70s and early ’80s. This is a free community event with valet parking included. Please register at  www.rsfseniorcenter.org/event-details/rancho-days or call 858-756-3041

Book Club hosted by RSF Library Branch Manager Christina Patterson

Wednesday, Oct. 16, from 10 a.m. – 11 a.m. – Join us for a lively discussion at the Senior Center of  “The Gown” by Jennifer Robson. Pick up your copy of the book at the Senior Center or download a copy using  your Libby app.

ONGOING CLASSES

New Class Time! Tai Chi / Longevity Self-Care

Monday (weekly) from 10 a.m. – 11 a.m.  Learn Tai Chi and  longevity self-care techniques to enhance health, energy, and balance with Dr. Abraham Kim from Synaptic  Integrated Medicine. Dr. Abraham brings his background of integrated medicine in neurology and longevity  practices to share tips on how to work with the aging process and prevent degenerative neurological conditions. There is a $10 fee per class paid to the instructor.

Open Play Mah Jongg

Monday (weekly) from 10 a.m. – noon

Enjoy a friendly game of beginner  American Mahjongg, a tile-based game that is enjoyed by individuals throughout the world! A basic understanding of the tiles and rules is required.

Texas Hold’em Poker for Beginners

Monday (weekly) from 2 p.m. – 4 p.m. This beginners’ class is  designed to teach the fundamentals of Texas Hold’em in a fun and engaging environment. If you’ve never  played poker before, this class will provide you with the knowledge and confidence to participate in a friendly  game. Instructor George Bullette, Senior Center board president, has years of experience playing poker and will  teach basic rules and strategies in a real game setting. Chips and cards are provided, and ongoing open poker  play will be available for beginners. This class is ideal for absolute beginners with no prior poker experience.

Calling All Chess Players!

Tuesday (weekly) – 2 p.m.-4 p.m. Come and enjoy a friendly game of chess at  the Senior Center and get a workout for your brain! Research has found evidence that playing chess may result  in improved brain function, memory, cognitive abilities, and strategic thinking. Each Tuesday, enjoy a friendly game of chess at the RSF Senior Center. All levels of players are welcome. Free instruction is provided for  beginners. Tables and playing pieces are furnished.

Thursday (weekly) 10 a.m.-11 a.m. Peggie Moore, a certified yoga instructor, Reiki Master,  and BEWELL Yoga for Cancer teacher, offers a weekly outdoor, in-person chair yoga class. This class will  teach you techniques to improve core strength and balance, increase flexibility, and reduce stress. There is a $10  per person fee paid to the instructor. The first class is free.

Conversational Spanish

Friday (weekly) – Beginner class 1 p.m. – 2 p.m. and Intermediate class 2  p.m. – 3 p.m. Jeannette Caruth learned Spanish solely through conversation and invites you to become more  familiar with the language. Each class is a one- hour adventure of hearing and speaking another language. All  levels are welcome. There is a $10 fee per class paid to the instructor.

Stay Active and Engaged with our Virtual Classes: Visit our website www.rsfseniorscenter.org and click  the “Online Programs” tab.

Please Note: visit www.rsfseniorcenter.org/in-person-classes or call the Senior Center at 858-756-3041 to  register for in-person classes. To receive our newsletter by email, visit our website: www.rsfseniorcenter.org  and provide your email address or send an email to [email protected].

Resource and Referral Service: Available Monday through Friday, 9 a.m. – 5 p.m. Seniors and their  family members can speak with a staff member in person or by telephone and receive valuable information to  address a wide variety of needs. Please call 858-756-3041 or email [email protected] for assistance.

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10th Annual Taste of Rancho Santa Fe returns Sept. 29

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Making End-of-Life Decisions

Readers discuss unwanted medical care and choosing to die.

To the Editor:

Re “ Doctors Saved Her Life, Even Over Her Wishes ” (front page, Aug. 28):

I read with great interest your story about when doctors don’t follow “do not resuscitate” orders. As a practicing anesthesiologist, I have been surprised by how often surgeons, operating room nurses and anesthesiologists refer to the “automatic suspension” of D.N.R. orders during a patient’s surgery or procedure. Such a practice is a violation of a patient’s fundamental right of autonomy and self-determination.

For these reasons the American Society of Anesthesiologists, the American College of Surgeons and the Association of periOperative Registered Nurses have stated since the 1990s that it’s unethical to automatically suspend D.N.R. orders in the operating room. Yet, 30 years later, I still hear this.

It is correct that some surgeries cannot be performed without a breathing tube. And treatable conditions often arise in the operating room, such as bleeding, allergic reactions or decreases in blood pressure. However, it is still entirely appropriate for patients to request that some things be off limits. Examples might include chest compressions, electrical shocks or drugs to maintain their blood pressure.

In the consent process, doctors can advise patients whether their surgery can be completed within the boundaries of what a patient is willing to consent to.

Samuel C. Seiden Granite Bay, Calif.

This informative and discouraging article touches on a continuing health care crisis: an excess of unwanted medical care, particularly at life’s end. The expressed wishes of patients are too often inappropriately ignored. This must change.

A survey 10 years ago revealed that about one in four Americans ages 50 and over say that they or a family member experienced excessive or unwanted medical treatment. That is about 25 million people. Nearly two-thirds of those surveyed supported withholding payments to health care providers who do not honor their end-of-life wishes.

Although lawsuits can be costly and time-consuming, some litigants have prevailed when unwanted treatment was provided in disregard of the wishes of the patient. At least two lawsuits are now pending in New York on these grounds.

Health care practitioners should be as concerned about potential liability for providing unwanted treatment as they are about undertreating patients.

David C. Leven Pelham, N.Y. The writer is the executive director emeritus of End of Life Choices New York.

Your article clearly illustrates the real world effect, or lack thereof, of even the most well crafted and documented “do not resuscitate” forms. However, it is important to note an important additional option for effective implementation of a patient’s end-of-life decisions.

Patients can appoint a trusted family member or friend as their “health care proxy” to optimize the chances that their wishes will be followed. Such a proxy has the authority to make all decisions on the patient’s behalf when the patient is unable to express her wishes herself.

It is crucial that a proxy knows and has accepted this responsibility, and it would be wise to give the proxy copies both of authorization to act as proxy and the advance directives to be shown to the health care providers when needed.

No method can be foolproof as long as there are providers unaware of or unwilling to follow a patient’s wishes, but such an action can help minimize unwanted outcomes, such as those described in the article.

Robert S. Klein Hastings-on-Hudson, N.Y. The writer is a retired infectious diseases physician.

Re “‘ That’s What I Would Have Liked, to Live in a Wild Sea ’” (Opinion Op-Doc, nytimes.com, Aug. 28), about a woman’s decision to end her life :

Should the elderly get to choose when they die? Absolutely.

At 75, I am more certain than ever that the quality of my life is more important to me than the quantity. Independent active living is more important to me than longevity.

I fear and resent possibly having to make my death a dodgy do-it-yourself project rather than a medically efficient process. I worry about some accident depriving me of agency and condemning me to an unwanted debilitated life — despite an explicit medical directive.

In the case of a successful suicide, I am saddened at the thought of the imposition on those who find my remains and that my organs will not be available to improve the lives of those who could benefit.

I’ve been fortunate to have a good run in life. I value being frugal and generous. I dread being forced into an extravagantly expensive, and to my mind selfish, staggering last mile.

Annlinn Kruger Bar Harbor, Maine

Kudos to this documentarian, Guillermo F. Flórez.

To be sure, there are some who live into their 90s and maintain a decent quality of life, but most people do not. As America ages, there are still few solutions for our elderly … unless they’re wealthy. It’s a tragic, heartbreaking mess.

Taking one’s own life as an elderly person who has simply had enough is a personal decision and should be legal, as should assisted suicide in all states.

I live in Massachusetts, have a fatal cancer and will definitely not see it through to the end. The most humane politicians in America understand these circumstances.

The film, capturing the filmmaker’s fear of death and Carmen’s readiness, explored how we all think of death at different stages of our lives as we age.

Please, please, cover more elder care research and services, especially as the election nears. Both candidates should be pressed hard on assisted suicide and elder care facilities.

Melissa Fox Cummaquid, Mass.

My mother died of cancer. She fought, appeared to beat it, only to have it return in a different form three times. She fought for five years. Long and painful years. Finally, she gave up. She wanted to die at home.

She lasted a year on a morphine drip. At the end, she was a morphine-addicted skeleton with a 20-pound tumor. Think she wanted to go out like that? Hard to say, because she was completely unresponsive.

So yeah, if people want to die a dignified death, they should certainly not have someone standing in their way. I would defy anyone who had watched my mother suffer to call it humane.

Rob Paul Santa Clara, Calif.

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