Virtually all dying patients go through a stereotypical pattern of symptoms and signs in the days prior to death.

This trajectory is often referred to as “actively dying” or “imminent death.”
Prompt recognition of this trajectory is key for clinicians to provide the most appropriate interventions for both the patient and family.

Stages

Early:
- bed bound
- loss of interest and/or ability to drink/eat
- cognitive changes, such as: increasing time spent sleeping and/or delirium

Middle:
- further decline in mental status to obtundation (slow to arouse with stimulation; only brief periods of wakefulness)
- death rattle – pooled oral sections that are not cleared due to loss of swallowing reflex

Late:
- coma
- fever – usually from aspiration pneumonia
- altered respiratory pattern – periods of apnea, hyperpnea, or irregular breathing
- mottled extremities

Time course
The time to traverse the various stages can be less than 24 hours or as long as ~14 days.
Patients who enter the trajectory who are nutritionally intact, with no infection (e.g., acute stroke), are apt to live longer than cachectic cancer patients.

Adapted from Weissman DE. Palliative Care Network of Wisconsin. Fast facts and concepts #3. Syndrome of imminent death. Internet. Accessed on June 21, 2016.