Advanced Illness: What to Expect in the Last Months of Life

By Joseph Shega, MD, Chief Medical Officer, VITAS Healthcare

If your loved one has an advanced illness and curative care is no longer effective, it is normal to wonder—and worry—about what will happen as their condition progresses, and they near the end of life. Knowing what to expect and how you can support them can empower you during this challenging time.

If your loved one has been referred to a hospice provider, the interdisciplinary care team will provide support in a variety of ways:

Education: The care team can prepare you for the physical and emotional changes that your loved one may experience.
Clinical Guidance: Some symptoms may indicate the need for a higher level of care. The care team is available 24/7/365 and can guide you.
Care Tips: The care team can provide tips on how to keep your loved one comfortable based on the symptoms they are exhibiting.
Emotional Support: The care team can help you navigate anticipatory grief. Grief and bereavement services continue for up to 13 months after your loved one has passed away.

Families, learn more about hospice:

What is hospice care?

Chronology of the End-of-Life

Dying is a natural process, but how long it takes and the signs a patient exhibits are unique to each person. Our timeline provides clear and gentle insights into each stage to help you navigate the end-of-life journey with understanding and peace:

Months Before Death
Weeks Before Death
4-6 Days Before Death
2-3 Days Before Death
Less Than 2 Days Before Death

Months Before Death

During this phase, patients may experience decreased appetite, increased sleepiness, ambivalence toward their surroundings, heightened pain and nausea, and visible weight loss. Emotional changes may lead to increased withdrawal, reduced activity, decreased communication, and introspection.

What to Watch For	What You Can Do
Decreased appetite	Offer smaller, more frequent meals Provide foods high in nutrition Use favorite foods to stimulate appetite Discuss dietary preferences with patient
Increased sleepiness	Allow for sufficient rest and sleep Ensure comfortable sleeping environment Encourage relaxation techniques
Increased sense of ambivalence	Respect patient’s need for solitude Provide emotional support and reassurance Encourage open communication
Increased pain and nausea	Discuss pain medication with care team, as needed Use anti-nausea medications as prescribed Provide comfort measures
Increased risk of infections	Discuss hygiene and infection control with care team Learn the signs of infection Discuss preventative measures with care team
Noticeable weight loss	Address modifiable contributors to weight loss Recognize nutritional supplements are generally not helpful Monitor skin for signs of breakdown

Weeks Before Death

As the end of life nears, extreme fatigue, confusion, and social withdrawal become more pronounced. Patients may engage in life review and focus on funeral planning, revealing their emotional state.

What to Watch For	What You Can Do
Even greater desire to sleep	Allow patient to rest as needed Create a comfortable sleeping environment Learn about changes in sleep pattern
Stopping all eating	Monitor for signs of distress or discomfort Respect patient’s choices regarding eating Offer small sips of fluids to prevent dehydration Provide mouth care to alleviate dry mouth
Increased restlessness	Discuss possibility of underlying causes with care team Provide gentle repositioning for comfort Learn relaxation techniques to calm patient
Increased congestion	Elevate patient’s head to ease breathing Use a humidifier to moisten the air
Increased levels of confusion	Use clear and simple language Use visual aids to aid communication Create a calm and quiet environment
Increased hallucinations or visions	Offer reassurance and emotional support Validate patient’s experiences with empathy Engage in non-confrontational conversation
Changes in vital signs	Focus on the patient’s overall well-being Learn what expected changes will look like Provide comfort measures for temperature fluctuations

4-6 Days Before Death

This stage occurs four to six days before death. It is characterized by intensifying emotional and physical symptoms.

What to Watch For	What You Can Do
Abnormal vital signs	Learn what abnormal vital signs mean Discuss cardiac medications with care team
Decreased level of consciousness	Learn about the signs of decreased consciousness and somnolence Ensure patient’s comfort and position for sleep or rest Speak calmly and reassuringly
Difficulty swallowing	Learn about the difficulties of swallowing liquids and potential risks Use wet sponges, oral swabs, crushed ice, and lip balm to maintain oral moisture Discuss alternatives for hydration with care team

2-3 Days Before Death

As the end approaches in two to three days, the active stage of dying begins. Common symptoms include unresponsiveness and a significant drop in blood pressure, indicating impending death.

What to Watch For	What You Can Do
Patient is bedbound, unable to do any activity, and shows evidence of extensive disease	Lean on the hospice team for support Offer strategies for comfort and support
Bluish discoloration of skin	Anticipate changes in skin color Keep patient comfortable and warm Observe for development of skin breakdown and alert the clinical team (but this is normal with the dying process)
Decreased response to visual stimuli	Anticipate a decreased response to visual stimuli Maintain a calm and soothing environment
Drooping of the nasolabial fold	Prepare yourself for significance of facial changes Ask friends, family, and the hospice team for emotional support and comfort
Hyperextension of the neck	Learn about hyperextension of the neck and its potential implications Reposition patient for comfort Discuss opioid pain relief with care team if discomfort is present
Cheyne-Stokes breathing	Learn about Cheyne-Stokes breathing and its normal occurrence at end of life Provide reassurance and maintain patient comfort Discuss opioid use with care team for managing shortness of breath Ensure patient's comfort and position
Nonreactive pupils	Learn about nonreactive pupils
Decreased response to verbal stimuli	Ensure patient's comfort and position Provide emotional support

Less Than 2 Days Before Death

In the final hours, patients exhibit specific clinical signs that indicate the approach of death.

What to Watch For	What You Can Do
Death rattle	Prepare yourself for the nature of the sound Reposition the patient to promote drainage Discuss medications with care team if the patient is suffering
Apnea	Be prepared for irregular breathing Discuss medications with care team to provide relief
Breathing with the mouth open and jaw movement	Learn about changes in breathing patterns
Decreased urine output	Learn about the natural decrease in bodily functions
Pulselessness of radial artery	Learn about changes in circulation
Inability to close eyelids	Learn about the physical changes in muscle control Use a wet washcloth if eyes are dry or irritated
Grunting of vocal cords	Learn about the possibility of vocal cord tension Discuss opioids with care team if pain is present
Fever	Place a cool washcloth on the patient’s forehead Remove excess blankets Use a fan Administer acetominophin if necessary

Clinical signs are based on studies of cancer patients but are generalizable to other causes of death (e.g., heart disease, advanced lung disease, sepsis and dementia). This list is not exhaustive but includes some of the most common end-of-life symptoms.