What to Expect in the Final Hours

The final hours often bring the changes families find hardest to witness — understanding what’s happening physically can help make this time feel a little less frightening.

Why does breathing change so much near the very end?

Breathing often becomes irregular in the final hours - sometimes faster, sometimes slower, sometimes with pauses between breaths (occasionally called Cheyne-Stokes breathing). A rattling or gurgling sound, sometimes called a “death rattle,” can occur from secretions the person is no longer able to clear by coughing or swallowing. This sound can be distressing for families to hear, but it’s generally understood not to be painful or distressing for the person themselves. These changes generally reflect the body’s changing physiology rather than distress or discomfort.

What is skin mottling?

As circulation slows, the skin - especially on the hands, feet, knees, and other extremities - can become cool to the touch and take on a blotchy, purplish or bluish appearance sometimes called mottling. This is a commonly observed physical sign in the final hours, reflecting the body’s systems gradually slowing, not an indication of pain.

Is the person aware or in pain during this time?

Many people become increasingly difficult to wake, or unresponsive, in the final hours. This varies significantly between individuals, and it isn’t always possible to know for certain how aware someone is. Hospice teams generally focus on ensuring comfort throughout this period specifically because pain and distress can still be treated even when someone is less responsive. Signs of actual distress - like grimacing or restlessness - are something the hospice team actively watches for and treats.

Should we still talk to our loved one during this time?

Many hospice professionals believe hearing may remain even when other responses aren’t possible - which is why many families find comfort in continuing to talk, play familiar music, hold hands, or simply be present, regardless of whether a response is possible.

Does comfort remain the focus?

Yes - hospice teams continue actively watching for and treating any actual signs of distress - like grimacing, restlessness, or labored breathing - throughout this period. The goal remains comfort, even as responsiveness decreases.

When should we call the hospice team?

Any concerning change, or simply needing support or reassurance in the moment, is worth calling the hospice team about - this is exactly the situation their 24/7 availability exists for. You don’t need to wait or wonder whether it’s “worth” calling.

For the final minutes and what you can do, see being with someone at the moment of death.

This is general educational information, not medical advice, and every person’s experience is different. A hospice team can help you understand what’s happening for your specific loved one in the moment, and can offer support to family members as well as clinical care for the patient.