Identify Signs & Symptoms of the Dying Process in Hospice
This comprehensive table is a valuable resource for hospice nurses, caregivers, and agency managers by detailing the signs and symptoms of the dying process in hospice, the reasons behind these changes, and recommended care strategies.
This knowledge empowers hospice professionals and caregivers to provide the best possible care, ensuring patients maintain dignity and comfort during their final moments while also offering support and reassurance to the patient’s family and loved ones. Consider hospice care training for your hospice team to build their caregiving skills further.
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| Time | Signs & Symptoms | Why does this happen? | What you can do |
|---|---|---|---|
| Early Sign of Dying Process in Hospice Care | Loss of Appetite | Lack of interest in eating and drinking. Hospice patients may report feeling full or that foods don’t taste right.
The ability to digest food and maintain the proper balance of fluid gradually slows as the body begins to shut down. The body does not require the fuel it once needed. | Help patients to sit up comfortably at mealtimes. Make the atmosphere as cheerful and appetizing as possible. Don’t lose the social ritual of sharing meals together. Encourage caregivers to join the patient at mealtimes, even if the patient can only eat a bite.
Offer small amounts of favorite “comfort” foods. Help hospice caregivers remember that a few bites of a favorite comfort food are an important gift. Recognize that it may take time and energy for the person to get the food down. Try cool, soft foods like applesauce, pudding or ice cream. Nutritional supplement drinks may be tolerated. Respect the changes the body is signaling. Urging someone to eat or drink when they don’t feel up to it won’t make them feel better and can make them uncomfortable. Show care in other ways. |
| Time | Signs & Symptoms | Why does this happen? | What you can do |
| Early Sign of Dying Process in Hospice Care | Sleeping more, increasing fatigue and weakness | Normal slowing of body rhythms. Sedation can also be temporarily caused by an increase in pain medications. Changes in a person’s level of conscious awareness and function are a common response to the failing circulatory system. | Alert hospice caregivers to be attentive to the times when the patient is more alert, use those times to engage in life closure talks.
Offer hospice aide to assist with activities of daily living in order to save energy for things most important to the patient. Consider use of bedside commode, electric bed, walker or other assistive devices to ensure comfort and safety. Encourage family and caregivers to spend this time with the patient by reminiscing, sharing loving feelings and retelling stories that invoke happiness and humor. |
| Early Sign of Dying Process in Hospice Care | Disorientation and confusion | Changes in a patient’s level of conscious awareness and function are a common response to the failing circulatory and metabolic systems.
In a patient with pre-existing cognitive impairment or a related dementia disease, confusion and memory loss may increase. | Speak calmly and offer reassurance. Don’t argue or try to correct. When a person says something happens yesterday and it was two weeks ago, it is not necessary to re-orient them.
Try to avoid asking questions that are difficult to answer. Instead of asking, “Do you remember seeing Sue yesterday?” say “Sue enjoyed seeing you.” Let the person repeat a story as many times as they need. Encourage happy memories. Help families and hospice caregivers adjust and allow for increased supervision needs and increasing care needs. |
| Time | Signs & Symptoms | Why does this happen? | What you can do |
| Early Sign of Dying Process in Hospice Care | Feeling Afraid | Fear is normal as people come to terms with the reality of death.
Common concerns and fears include: Pain and physical suffering | Listen to the person’s concerns with an open mind. Allow them to express what they are worried about. Avoid the pitfall of gratuitous reassurance. “You shouldn’t worry about that. Provide information to address their concerns and information about the dying process and the person’s end stage disease process. Tailor education to a person’s ability and readiness to understand. |
| Withdrawal from friends and family People sleep more, talk less and lose interest in things they used to enjoy, such as TV shows, reading the paper, hobbies. Later they may not feel like talking to friends or care for a favorite pet. | The patient’s focus turns to inner concerns. This withdrawal is a preparation for the final separation that death represents. | Help friends and family understand that what is happening is a natural part of letting go and not a personal rejection.
Encourage caregivers to let the patient set the pace for being around others or participating in activities. Help caregivers consider ways to say goodbye. Provide psychosocial and spiritual support as needed to help them share their feelings and adjust to the changes that are occurring. | |
| Later Sign of Dying Process in Hospice Care | Difficulty Swallowing | Coughing, gagging and choking are signs that the swallowing reflex is failing.
The natural slowing of the body’s physical systems includes neurological and muscular changes which affect the ability of a person to swallow, digest and eliminate food and fluids. | Offer ice chips or small sips of fluid if the person is awake and able to swallow without coughing.
Provide mouth care every few hours to relieve drying mouth membranes and bad taste. Moisten lips with a damp cloth and use lip balm. Medications can be given in other ways when the person is not able to safely and comfortably swallow them. This is the time to focus on medications that are related to comfort. |
| Time | Signs & Symptoms | Why does this happen? | What you can do |
| Early – Late can occur at any time | Skin Breakdown | The combined effect of immobility from weakness and decreased blood circulation can easily lead to bedsores. Staying in the same position puts pressure on skin and can cause breakdown in a few hours. Bedsores first appear as a reddened or discolored area. Back, buttock, heels and shoulders are common points of pressure. | Add cushioning to chairs and wheelchairs. Whether sitting or in bed, reposition at least every two hours.
If repositioning causes discomfort, give pain medication before moving. Keep skin clean, dry and apply moisturizer. Learn ways to relieve pressure and maintain comfortable body alignment by proper positioning with pillows, pads, and blankets. |
| Primarily Late, but can occur at any time | Near Death Awareness | Appear confused, state they have seen or spoken to someone who has already died.
Speak to people and see places or things not visible to you. Describe seeing spiritual beings, lights, or other symbolic or meaningful visions. Talk about going on a trip, going home or leaving. Tell you when they will die. | These messages may be a symbolic communication asking for permissions to die or address an end of life need.
These behaviors do not necessarily indicate the person is confused or hallucinating. They may be trying to communicate the dying experience or describe the transition from life to death. Listen. Do not contradict or try to explain away or correct. Be present and open to the person’s attempt to communicate to you what is happening to them. Sit with the person. Respectful, attentive listening is important at this time, even if the person appears to be confused.< |