End-of-Life Timeline: Clinical Signs by Stage

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

Dying is a natural process accompanied by decrements in neurocognitive, cardiovascular, respiratory, and muscular function.

The dying process is highly variable and can last up to several weeks in some instances. The expression of clinical end-of-life signs varies substantially among patients, but a greater number of clinical signs present in an individual increases the likelihood of death.

End-of-Life Stages Timeline

Here is a breakdown of the different stages of the end-of-life journey:

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

Identifying the transition to imminent death is crucial for educating patients and families about the natural dying process. This information enables effective, compassionate decision-making and allows families to prepare for the passing of their loved one.

It's important to update the care plan to reflect the patient's changing status, including any required clinical visits. A higher level of care may be necessary in moments of crisis or when symptoms are uncontrolled.

The tables below provide a general overview of each stage of death.

Months Before Death

During this phase, which occurs one to three months before death, 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.

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.

4-6 Days Before Death

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

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.

Less Than 2 Days Before Death

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

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.

Link Between Clinical Signs of Dying and Impending Death

A direct relationship exists between the number of clinical signs of dying and death:

• Persons with two clinical signs of dying had a 40% chance of dying in the next three days
• Persons with eight clinical signs of dying had more than an 80% chance of dying in the next three days

The likelihood of dying in the next three days death increases with the number of present end-of-life signs. Physicians should make a care plan update as end-of-life signs escalate.

How Long Does the Active Stage of Dying Last?

The active stage of dying generally spans about three days following a roughly three-week pre-active dying stage.

Typical symptoms include unresponsiveness and a significant drop in blood pressure.

What Is the Difference Between Transitioning and Active Dying?

Transitioning and active dying are distinct stages at the end of life.

Transitioning is the initial phase in which a patient's decline becomes evident. During this time, they may exhibit noticeable changes in physical and cognitive function, as well as emotional withdrawal.

Active dying is the stage that directly precedes death and is characterized by a significant decline in the patient's overall condition, often accompanied by symptoms like unresponsiveness and a drop in blood pressure.

This differentiation helps caregivers and medical professionals understand and respond appropriately to the evolving needs of patients during this delicate period.

What Are the Emotional Signs of Death?

Clinical indicators and symptoms are not the only signs of impending death. Analyzing emotional signs can also shed light on a patient’s end-of-life status. Some of these signs include:

• A prolonged state of excessive fatigue, sleep, appearing catatonic
• Confusion and/or disorientation; hearing or seeing people and events not visible or not present to you
• Social withdrawal and detachment
• The desire to conduct a life review or settle something unresolved
• The desire to focus on funeral planning

Hospice Team Involvement During Stages of Dying

When clinical signs of dying emerge, the hospice interdisciplinary care team initiates a care plan update that includes:

• Revisions to necessary interdisciplinary visits
• Education on the dying process
• Medication adjustments
• Assurance that appropriate HME is in place to assist your patient and their family

The hospice team provides support in a variety of ways specific to each team member's discipline.

A nurse, nurse practitioner, and/or physician may:

• Discuss the discontinuation of non-beneficial or burdensome treatments
• Ensure symptom medications and necessary equipment are available
• Educate family on use of medications to manage symptoms and/or pain, and describe physiological changes associated with the dying process

The social worker and chaplain:

• Help patients and families explore their feelings and relationships
• Participate in life review, including the search for meaning and contributions
• Conduct life closure, including forgiving and facing regrets, saying goodbye, and coming to terms with the acceptance of ongoing losses and death

Hospice aides:

• Recognize the clinical signs of dying and communicate them to the other team members, as well as support the patient and family through the dying process.

How to Help Families Cope After a Loved One Has Died

Family members need time to process their feelings after a patient dies. They should not be subjected to additional stress with the logistics of legal forms or removal of the body. Be empathetic.

Medical professionals and care teams should keep in mind that the time, setting, and specific events surrounding a loved one’s death shape lasting memories for their family members—solemn moments that deserve to be respected and honored.

To support families as they begin the grieving process:

• Give private time alone with their loved one after a death to say their goodbyes and share memories
• Answer family members’ questions factually, calmly, and with empathy
• Explain clearly and compassionately what will happen in the next several hours or days

Honor rituals

• Honor families’ needs for specific rituals at the time of or shortly after death, such as bathing of the body, recitation of prayers, or dressing of their loved one in special clothing or garments.
• Make sure the immediate environment—whether the patient’s home, hospital room, nursing home/care facility room, inpatient hospice room, etc.—is as uncluttered, clean, and orderly as possible, with no offensive odors

Encourage a healthy grieving process

• Remind family members and caregivers that each person’s grief is unique and will ebb and flow over the following days, weeks, months, and years. If the patient was on hospice care, Medicare-certified hospices provide up to a year of grief and loss counseling for their family following the patient’s death.
• Invite family members and friends to stay in touch and rely on each other as they move through their grief.

References:

• Hui D, dos Santos R, Chisholm G. et al. Bedside Clinical Signs Associated With Impending Death in Patients With Advanced Cancer: Preliminary Findings of a Prospective, Longitudinal Cohort Study. Cancer 2015;121:960-967.
• Hui D, dos Santos R, Chisolm G, et al. Clinical Signs in Cancer Patients. The Oncologist 2014;19:681–687