I’m sharing a little here about the active dying process, especially some of the physical signs that can be alarming, even though they are often common and a natural part of the sometimes laborious act of leaving the physical body.
My hope is to bring awareness to what this stage can look like, so people tending to loved ones have a clearer sense of what’s happening and feel less alone or afraid.
When you’re caring for someone you love, changes in breathing, appetite, or responsiveness can be unsettling. This is rarely talked about, yet deeply important to understand.
These changes do not happen in a fixed order, and not everyone will experience all of them. This is not a diagnostic or medical guide, but a orientation to what is commonly seen in the natural dying process, especially when comfort-focused care is in place.
For some, the process is long and drawn out. For others, it unfolds quickly. Each journey is individual, and it’s often said that we die as we have lived.
Above all, it’s important to remember that when someone is already in the natural dying process and receiving comfort-focused care, death itself is not a medical emergency.
As Ram Dass said, “Death is absolutely safe. It’s like taking off a tight shoe.”
Portions of this article are adapted from the work of Barbara Kearns, who offers a clear and compassionate description of the active stages of dying. I have used her text as a starting point, adding supplemental information.
One to Three Months Prior to Death
Withdrawal
During this time, a person may begin to withdraw from the world around them. There is often a growing awareness that the end is near, and with that comes the beginning of separation from this world and the journey back into oneself.
Interest lessens in things that once mattered deeply—and sometimes even in the people they love most. What we may experience as rejection is often a deep withdrawal, a necessary turning inward as an important inner journey begins.
Much of this period is spent in deep inner sorting and reflection, as a person reviews and evaluates their life. This is work that often can only be done alone.
This may look like increased sleep: extra naps, more time asleep than awake. This “sleep state” is often a space of very deep inner work.
It’s important to allow and support this rest. The work happening beneath the surface is meaningful and necessary—part of the process of closing the circle of a life.
Decreased Interest in Food and Drink
A decrease in appetite is very common. Liquids are often preferred to solid foods, and eventually a person may stop eating or drinking altogether.
This is a natural part of the dying process and not the same as starvation. As the body slows, it no longer needs the same fuel, and forcing food or fluids can cause discomfort, nausea, or distress. Offering presence, moistening the lips, or simply sitting nearby is often more supportive than encouraging intake.
Hypersensitivity
As the veil begins to thin, a person’s sensitivity can significantly increase—especially to sound, smell, and physical touch. What was once comforting can become overwhelming.
Loud sounds, unnecessary conversation in the person’s presence, fragrances (including essential oils), and physical touch may feel unbearable. A quieter, simpler environment is often more supportive during this time.
Bed Sores
Also known as pressure ulcers or pressure injuries, these are wounds caused by prolonged pressure on fragile skin that reduces blood flow. As the body’s healing mechanisms shut down, bedsores can develop within days.
They commonly appear on the tailbone, hips, heels, ankles, elbows, and shoulder blades. Bedsores can occur despite proper turning, padding, and attentive nursing care. Their appearance is not automatically a sign of neglect.
Professional wound care to prevent infection, gentle repositioning, and pain medication are commonly used to support comfort. End-of-life skin breakdown can be very difficult for families to witness, but it is a natural occurrence and not a reflection of poor care.
One to Two Weeks Before Death
Disorientation
During this time, a person may be disoriented and sleep most of the day. There is often a sense of having one foot in this world and one elsewhere, which can bring confusion and a gradual loosening of grounding in the physical world.
They may speak of seeing or talking with loved ones who have already died. This is commonly reported and can be comforting for some, confusing for others.
There may also be periods of restlessness or agitation.
Physical Changes
Blood pressure often lowers, and the pulse may become significantly faster or slower than usual. Body temperature can fluctuate between feeling warm or feverish and feeling cold. Increased perspiration or clamminess is common.
Skin color may change, appearing flushed or bluish. The hands, feet, and nail beds often become pale or bluish as circulation slows and the heart is no longer pumping as effectively.
Breathing Changes
Normal breathing is about 16–20 breaths per minute. As death approaches, breathing may become much faster or much slower—sometimes increasing to 40–50 breaths per minute, or slowing to as few as 6 breaths per minute. Breathing patterns often shift between rapid breaths and long pauses.
Fluid can collect in the lungs and throat, creating a rattling sound when breathing. This can be very alarming to hear. Although the sound can be distressing to those nearby, it does not usually indicate that the person is suffering or in pain. Breathing changes at end of life are typically not painful, even when they sound labored.
One to Two Days to Hours Prior to Death
Energy Surge
There can sometimes be a surge of energy. A person may suddenly seem more alert, speak clearly, or appear more engaged after a period of disorientation. It can feel as though they are improving.
This is a phenomenon many caregivers and hospice workers observe. It is often understood as a final gathering of energy before death and commonly occurs very close to the time of passing. While it can be confusing or hopeful for loved ones, it usually does not indicate recovery.
Other Common Occurrences
Increased restlessness or discomfort due to reduced oxygen in the blood
Congestion that may become louder
Eyes may be partially open but not seeing, appearing glassy or tearful
Hands and feet may become purple; knees, ankles, and elbows may appear blotchy
The person may become non-responsive
What seems like a final breath is often followed by one or two long, spaced-out breaths before the body fully lets go
It is also common for people to die when they are alone, after others have stepped out. This final letting go is sometimes understood as something that can only happen in the privacy of one’s own inner space. Stepping away does not mean abandonment.
Pain Management and Comfort
Pain and discomfort at the end of life are commonly addressed with the support of hospice teams or the medical providers involved in care. Comfort medications are used to ease distress, not to hasten death.
It’s important to know that pain medications can sometimes increase drowsiness, reduce alertness, or make a person sleep more. For some, they may also increase confusion or anxiety. Finding the right balance is an ongoing conversation and should be guided by the wishes of the person who is dying whenever possible, along with the care team supporting them.
A Special Note for Caregivers
Tending to someone at the end of life can bring a complex range of emotions. Fear, guilt, shame, grief, confusion, helplessness, and deep sadness are all common and natural responses. There is no “right” way to feel during this time.
Many caregivers feel pressure to do everything right. Being with someone at the end of life is not about doing more. Sitting nearby, being quiet together, or offering a few gentle words is often enough.
This can be exhausting. Rest when you can. Step outside if you need to. Let others help you. You don’t have to carry this by yourself.
Hearing and Presence at the End of Life
Even when a person appears non-responsive, with eyes closed and no visible reaction, hearing is often one of the last senses to diminish.
This means that your voice, your tone, and your presence may still be felt. Speaking gently, saying what you need to say, offering reassurance or love, and simply being present can still be meaningful, even if there is no outward response.
I hope this information is supportive. If you have any questions, or if you need additional support during this time, please feel free to reach out.
