⚕️Care Handbook

Recognising When Someone Is Dying

Recognising that a person is entering the dying phase is essential for providing appropriate care. It enables the care team to adjust the focus of care from active treatment to comfort, ensure the right medications are available, and support the person and their family through this time.

Understanding the Dying Process

Dying is a natural process, but recognising it can be difficult. NICE guideline NG31 advises that the dying phase should be identified based on a holistic assessment — not any single sign. The multi-professional team should agree that the person is dying, and this should be communicated sensitively to the person and those important to them.

The signs described below are common but not universal. Some people show only a few of these signs; others show many. The speed of decline also varies — some people die within hours, others over days or weeks. Support from a district nurse, hospice team, or palliative care specialist can help you assess and manage the person's care effectively.

Signs of Dying

The following signs are commonly observed as a person approaches the end of life. They are grouped into physical signs and psychological or cognitive signs. Not every person will show all of these signs, and the presence of a single sign does not necessarily mean the person is dying.

Physical Signs

Progressive weakness and fatigue

The person becomes increasingly drowsy, spends more time sleeping, and may be difficult to rouse. This is a normal part of the dying process.

Reduced food and fluid intake

As the body slows down, the need for food and drink decreases naturally. Forcing food or fluids can cause discomfort. Offer small sips if the person is able.

Changes in breathing pattern

Breathing may become irregular — Cheyne-Stokes breathing (cycles of deep and shallow breaths) or periods of apnoea (pauses). This can be distressing to observe but is not usually uncomfortable for the person.

Noisy or rattling breathing

Often called 'death rattle' — caused by secretions pooling in the throat when the person can no longer swallow. Repositioning on their side can help. Anticholinergic medication may be prescribed.

Skin changes

Extremities (hands and feet) may become cool, pale, mottled, or cyanotic (blue-purple). The skin may become fragile. This is due to reduced circulation.

Urinary and bowel changes

Urine output decreases and may become darker. Loss of continence may occur. Constipation is common if the person is on opioid medication.

Restlessness and agitation

Terminal agitation can occur — the person may pick at bedclothes, appear distressed, or call out. This should be assessed — it could indicate pain, urinary retention, or delirium.

Psychological and Cognitive Signs

Increasing drowsiness

The person spends increasing amounts of time asleep and may be difficult to wake. When awake, they may be confused or disoriented.

Communication changes

Speech may become slower, softer, or less coherent. Eventually, the person may stop speaking altogether but may still hear and understand.

Visions or dream-like experiences

Some people describe seeing or speaking to people who have died. This is common and should be accepted respectfully — do not dismiss or argue.

Withdrawal

The person may become less interested in their surroundings and social interaction. This is a natural part of the process of letting go.

Surge of energy

Occasionally, a dying person may have a brief period of increased alertness or energy — sometimes called a 'terminal lucidity'. This can give families false hope and is not a sign of recovery.

What to Expect in the Final Hours

In the final hours of life, the person will typically be unconscious or semi-conscious. Breathing patterns may change significantly — periods of no breathing (apnoea) are common. The person's skin may become mottled, particularly on the hands, feet, and knees.

It is important to reassure family members that these changes are normal and part of the natural dying process. Hearing is thought to be the last sense to diminish, so encourage families to continue speaking to and being with the person.

When death occurs, the person will stop breathing and their heart will stop. The pupils will become fixed and dilated. The person will not respond to touch or sound. A doctor or qualified professional must confirm death — follow your care home's policy for verification and certification.

Comfort Care Measures

When a person is dying, the focus of care shifts from active treatment to comfort and dignity. These measures help ensure the person is as comfortable as possible and that families feel supported.

Physical Comfort

  • Regular mouth care — moisten lips with swabs, offer small sips of water if safe to swallow
  • Position for comfort — on the side with pillows for support if unable to sit up
  • Keep the person clean and dry — gentle personal care
  • Manage pain proactively — assess using appropriate tools
  • Ensure the room is a comfortable temperature and well-ventilated
  • Reduce unnecessary interventions (e.g., routine observations if they cause distress)
  • Use a syringe driver if multiple SC medications needed — reduces injection frequency
  • Consider catheterisation only if urinary retention is causing distress
  • Gentle massage with unscented lotion can be soothing

Emotional and Spiritual Support

  • Be present — sit with the person, hold their hand if appropriate
  • Speak gently and reassuringly — hearing is thought to be the last sense to go
  • Play the person's favourite music softly
  • Read aloud from a preferred book, prayer, or religious text
  • Facilitate visits from family and important people
  • Support the person's spiritual or religious practices
  • Create a calm, peaceful environment — dim harsh lighting, reduce noise
  • Acknowledge and validate family members' feelings

Supporting Family and Carers

  • Explain what is happening and what to expect — demystify the dying process
  • Encourage family to talk to and be with the person
  • Offer refreshments and a private space for family
  • Provide written information about the dying process
  • Discuss after-death arrangements sensitively if the family wishes
  • Offer referral to bereavement support services
  • Ensure family know who to contact for support after the death

Official Resources

⚠️ Important Notice

The guidance on recognising dying on Care Handbook is for informational purposes only and does not constitute medical or nursing advice. Recognising the dying phase should be carried out by the multi-professional care team following NICE guideline NG31. Always consult the resident's GP, district nurse, or palliative care team for clinical assessment and management. Every person's experience of dying is unique.