As the end of life nears, your loved one’s appetite might diminish significantly, and they may refuse food or drinks altogether. While this can be difficult to witness, it's important to understand that the lack of hunger and thirst often causes more distress to caregivers than to the dying person. Offer soft foods and sips of water as long as they are conscious, but respect their wishes if they refuse. To prevent discomfort from a dry mouth, lubricate their lips with petroleum jelly or lip balm and moisten their mouth with a few drops of water or a moistened swab.

Terminal restlessness, a form of delirium, can manifest as anxiety, agitation, or confusion. Look for signs such as restlessness, picking at clothing or sheets, or trying to get out of bed. This condition may be caused by pain, a full bladder, constipation, or medication side effects. Notify your healthcare provider immediately if symptoms appear, as early intervention can improve your loved one’s comfort.

Near the end of life, significant temperature fluctuations are common. If your loved one has a fever, administer acetaminophen if they can swallow pills or use a suppository if they cannot. Apply cool compresses to reduce fever, but avoid placing ice directly on the skin. If they are shivering, add blankets or soft socks to keep them warm. Changes in circulation, such as blue or mottled extremities, are also normal indicators that death is approaching.

Assessing and managing pain is crucial, especially as your loved one’s consciousness diminishes. Recognizing and assessing pain is vital to ensuring their comfort, and observing body language and other physical clues becomes increasingly important as your loved one becomes unable to communicate their pain. Here are some signs of pain and discomfort to watch for:

You might notice these signs during certain movements or activities or spontaneously. If your loved one has been on a regular pain medication schedule, maintain it even if they lose consciousness. Your healthcare provider should have developed a pain-management plan for this scenario.

If your loved one has not been on regular pain medication, it's still crucial to monitor them for signs of discomfort and have medications ready in case pain arises. Hospice comfort kits often include morphine, which is effective for pain management.

Shortness of breath (dyspnea) can be distressing for both the dying person and their loved ones. If your loved one is breathing rapidly (more than 24 breaths per minute) and appears uncomfortable, morphine might be the recommended treatment. Morphine slows breathing, allowing for more effective breaths and reducing the sensation of breathlessness. If morphine isn't suitable, other opioid medications may help manage dyspnea. Other treatments for dyspnea include:

Another common occurrence near the end of life is the "death rattle," a loud, wet-sounding breathing caused by a buildup of secretions in the throat and airways. This sound can be more distressing for loved ones than for the dying person. Medications that dry up excess secretions are usually effective in treating this symptom.

As death approaches, you might notice irregular breathing patterns known as Cheyne-Stokes respiration. Your loved one might breathe very fast at times, then slowly, or even temporarily stop breathing (apnea). Cheyne-Stokes breathing may not require treatment, but if your loved one seems short of breath, the treatments for dyspnea mentioned above can be helpful.

As death nears, breathing typically slows or continues with Cheyne-Stokes respirations until it finally ceases, and the heart stops beating. Signs that death has occurred include:

If your loved one was not enrolled in hospice, call 911 or your local law enforcement agency. If they were receiving hospice care, contact the hospice agency personnel or nurse.

After your loved one passes, you will need to plan a funeral, memorial, and/or interment services if these arrangements haven't been made in advance. Most importantly, take care of yourself in the hours, days, and weeks ahead. As a caregiver, you have likely experienced caregiver stress, which can compound the grief you naturally feel at this difficult time.