Most people have never watched someone die. When it happens, the changes are frightening precisely because nobody explained them — and families spend the last days panicking about things that are normal, or trying to fix things that cannot be fixed.
Knowing roughly what to expect doesn't make it easy. It does make it less terrifying, and it frees you to be present rather than alarmed.
Every death is different, and none of this follows a schedule. Someone can show all of these signs and live for weeks, or almost none and go quickly. If hospice is involved, their nurse is the person to ask — this is exactly what they're there for, and calling them at 2am is not an imposition.
Weeks out
Sleeping much more, and being harder to rouse. Awake periods get shorter.
Withdrawing. Less interest in television, news, visitors, even conversation. This is not depression and it is not rejection of you. People turn inward as they die, and the circle of what feels relevant contracts to the room and a few faces.
Eating and drinking less. This is the one families struggle with most, and it deserves its own explanation below.
Less energy for everything. Getting to the bathroom becomes the day's major undertaking.
About the eating
Families experience someone stopping eating as starvation — as though if you could just get them to eat, they'd have more time. It is the reverse. The body slows down and stops needing food; the reduced appetite is a result of dying, not a cause of it.
A dying body cannot process food and fluid the way a healthy one can. Pushing food often causes nausea, discomfort, and choking. Artificial feeding at this stage generally doesn't extend life and can add fluid to lungs and limbs, making the person less comfortable, not more.
This is genuinely hard, because feeding someone is one of the oldest ways we have of caring for them. If you can, let go of the plate and find another way to do the same thing. Small sips if they want them. Ice chips. Mouth care — a moist swab on the lips and gums — relieves the dry mouth that actually causes discomfort, which thirst mostly doesn't at this stage.
Offer, never force. If they want something, give it. If they don't, that's information, not defeat.
Days out
Breathing changes. It may become irregular — fast then slow, with pauses of many seconds that feel alarmingly long. This pattern is common and is not distressing to the person.
Congested, rattling breathing. Caused by a small amount of saliva the person can no longer clear. It sounds dreadful and is one of the most upsetting things for families to hear, but there is good reason to believe it doesn't distress the person themselves. Repositioning helps; hospice can give medication to reduce it. Suctioning usually makes it worse.
Confusion, or talking to people who aren't there. Very common. Often the dead — a parent, a spouse. Some of it is medical, some of it isn't well explained by anything. It generally isn't frightening to them. You don't need to correct it; you can simply be with them in it.
Restlessness. Plucking at bedding, trying to get up, agitation. Tell hospice — this is treatable and shouldn't be endured.
Skin changes. Hands, feet and knees become cool, and mottled with a blotchy purple pattern as circulation withdraws to the core. This is one of the more reliable signs that time is short.
Temperature swings, and less urine, darker in colour.
What actually helps
Be there. You do not have to do anything. Sitting in the room is the whole job.
Talk to them. Hearing is widely believed to persist after someone stops responding. Say what you need to say. Say it even if they can't answer.
Touch them, if that's how your family is. A hand, a shoulder.
Mouth and lip care, which does more for comfort than almost anything else you can do.
Let them go if they need permission. Some people appear to hold on until they're told it's all right. Telling someone you love that you'll be fine, that they can stop, is among the hardest things you'll ever say and often the kindest.
Don't take it personally if they die when you step out. It happens constantly — people slip away in the ten minutes you went for coffee, after you sat there for three days. Some believe it's easier for people to go without their loved ones in the room. It is not a failure of vigilance.
When it happens
There is no emergency. Nothing needs to be done in the next minute.
If hospice is involved, call them — not an ambulance. They will come, confirm the death, and handle the notifications. If there is a do-not-resuscitate order, make sure it is visible; calling 911 without one can trigger resuscitation attempts nobody wanted.
You can sit with them for as long as you want. Many families find this matters more than they expected. There is no rule requiring you to hurry.
Afterwards, the first 48 hours covers what actually has to happen and in what order — and most of it can wait longer than you think.