What Is Active Dying?

July 9th, 2025

When a doctor or healthcare professional uses the term “active dying,” they are referring to a period of about the three to five days that immediately precedes death. Active dying generally follows a pre-active phase of dying that lasts about two weeks. Keep in mind, however, that it is impossible to predict how long a single individual may take to die. Sometimes a person appears to be entering the active dying stage only to recover for a short time. This brief  period of recovery is often referred to as a “death rally,” says author and end-of-life educator Barbara Karnes. 

Jump Ahead to: 

• Physical Symptoms of Active Dying
• Behavioral and Cognitive Signs of Active Dying
• Caring for Someone Who Is Actively Dying
• Treating Terminal Agitation (H2 or H3?)
• Signs of Death

Physical Symptoms of Active Dying 

As a dying person moves closer to death, their body begins to shut down and all of their bodily functions begin to fail. According to Hospice Foundation of America, this typically manifests as:

• Extreme lethargy or a semi-comatose or comatose state. The person may not be arousable or respond to questions or verbal commands. 
• Erratic breathing. As death draws closer, a dying person may breathe in a pattern known as Cheyne-Stokes breathing, during which the breath is very rapid and shallow, then very slow, then absent for a period of time. (This is known as apnea). This pattern may continue for some time.
• Noisy respiration, sometimes referred to as a “death rattle”
• No desire for food or drink

• Loss of bladder and bowel control
• Cold extremities; the person may also say that they can’t feel their arms or legs
• Changes in skin color; extreme paleness and/or blue color (cyanosis), especially around the mouth, hands and feet. The skin may also take on a yellowish tinge.
• Mottling; a reddish-purple marbled appearance of the skin, particularly in the extremities
• Very little or no urine output
• Muscle rigidity
• Unstable heart rate and blood pressure; both the heart rate and blood pressure typically decrease
• Skin ulcers that develop suddenly, known as “Kennedy ulcers.”
• Increased pain: Dying is not inherently painful, but issues such as prolonged immobility or disease progression can cause physical pain to increase.

Behavioral and Cognitive Signs of Active Dying

According to Medscape’s The Last Hours of Living, there are “two roads to death.” The first, and most common, is a gradual decrease in consciousness. In these cases, the person becomes more and more sleepy and eventually loses consciousness. They remain unresponsive until the moment of death. 

The second “road to dying” is far less pleasant. For reasons that are not well understood, some people experience a phenomenon known as “terminal delirium or terminal agitation” during the days or hours leading up to death. When this happens the person may exhibit the following behaviors:

• Agitation and restlessness
• Irritability
• Confusion
• Jerking movements
• Hallucinations 
• Delusions 
• Crying out as if they are in pain

According to Medscape, terminal delirium is rarely a sign that a dying person who was previously comfortable is in physical pain. In fact, it is extremely rare for a person who has not been in pain in the weeks and days leading up to death to suddenly develop severe pain while actively dying. Rather, it is far more likely that the behavior is simply the brain’s response to the many physiologic changes that occur when death is near. 

Caring for Someone Who Is Actively Dying

When someone is dying, caregivers and loved ones may feel helpless, especially if the person is unresponsive and unable to tell them how they feel. However, there are still a number of measures that family and loved ones can use to help ease the transition and make the dying person’s last days as comfortable as possible. According to hospice nurse Barbara Karnes’ “The Eleventh Hour,” caregivers should:

• Change the person’s position frequently: Even if they appear unresponsive or comatose, they may still be uncomfortable if left in one position for too long
• Continue any previous pain management regimen. Contact the hospice provider or attending physician if pain isn’t adequately controlled. 
• Keep bed linens clean and dry. Adult diapers may be necessary if the person is incontinent of urine or stool
• Clean the person’s mouth with a damp “toothette” or glycerine swap. Moisten the lips with lip balm
• Provide gentle touch. Hold their hand. Stroke their forehead. Gently stroke their cheek.
• Talk to the person as if they can hear you. Studies show that hearing is the last sense to disappear when someone is close to death.
• Perform whatever bedside rituals seem appropriate to you. Pray; meditate; sing or play calming music; use essential oils (do not use candles if oxygen is in use)

Treating Terminal Agitation 

When confronted with symptoms of terminal agitation in someone who is dying, it’s best to first try comfort measures such as turning or repositioning them, giving them tiny sips of water, or using a weighted blanket to calm anxiety and provide extra warmth. If the person appears too warm, simply taking off some of their bed covers and placing a cool cloth on their forehead may help. 

Gentle massage or holding the person’s hand may also provide a measure of relief. If your loved one is religious, you can ask a member of the clergy or a spiritual advisor to perform an appropriate end-of-life ritual. This may give the dying person a sense of closure and peace. 

Unfortunately, however, in many instances of terminal delirium, every effort made to comfort the dying person seems to fail. This is extremely distressing for friends and family in attendance, who are often traumatized by what they perceive to be their loved one’s “horrible, painful death.” In these cases, the doctor may institute palliative sedation using a combination of medications that induce deep sedation or complete unconsciousness. These may include an opiate such as morphine or fentanyl to ease any physical discomfort and shortness of breath as well as a benzodiazepine such as midazolam (Versed) or lorazepam (Ativan) to alleviate anxiety, promote muscle relaxation and prevent seizures. The doctor may also order an antipsychotic medicine such as haloperidol, especially if the dying person seems to be having hallucinations.

Palliative sedation is considered a treatment of last resort to relieve unbearable suffering at the end of life. It usually results in the dying person remaining unresponsive until death occurs. 

Signs of Death

Although it would seem that the signs of death should be readily apparent, they may be difficult to detect when a person has been nearing death for some time. A person who is in a deep coma, for example, may have very shallow respirations and be unresponsive to touch or voice commands, but still be alive. Thus, it’s advisable to take the time to check for these definitive signs that death has occurred:

• There is an audible sigh as air leaves the body, and no further effort to inhale. Breathing stops completely.
• Pulse is absent (Check for a pulse on the side of the neck below the ear, as wrist pulse may not be present even if the person is alive).
• Skin becomes pale and cool to the touch.
• Eyes may be open or closed; pupils are dilated and unresponsive to light.
• Lack of blink reflex when the eye is touched.
• Jaw slackens, mouth may fall open.
• Relaxation of bowel and bladder sphincters, potentially leading to the release of urine or stool 

To learn about what to do after someone dies, see our Comprehensive Step-by-Step Planning Guide: Immediately Upon Death

Sources

“Signs of approaching death”. Hospice Foundation of America. https://hospicefoundation.org/Hospice-Care/Signs-of-Approaching-Death

“The Last Hours of Living: Practical Advice for Clinicians”. Medscape. https://www.medscape.com/viewarticle/716463?form=fpf

“Haloperidol”. WebMD. https://www.webmd.com/drugs/haloperidol-haldol

“Cheyne Stokes Breathing: What to Know”. Healthline. https://www.healthline.com/health/cheyne-stokes