Talking about the end of life is never easy.

For families caring for an older parent, grandparent, spouse, or loved one, noticing significant changes in their health can bring a mixture of worry, confusion, sadness, and uncertainty. Sometimes these changes happen gradually over months. In other situations, a person's condition may decline noticeably over days or weeks.

One of the most difficult questions families may ask is:

“Is this simply part of getting older, or could my loved one be approaching the end of life?”

There is no single sign that can answer that question.

Many changes commonly associated with the final stage of life can also occur because of infections, medication effects, dehydration, heart or lung problems, dementia, depression, or other treatable medical conditions. That's why a healthcare professional should evaluate significant or sudden changes whenever appropriate.

However, when someone has an advanced, life-limiting illness and is already receiving end-of-life or palliative care, certain physical and behavioral changes can occur as the body gradually begins to slow down.

Recognizing these changes can help families understand what may be happening and, perhaps most importantly, focus on comfort, dignity, and meaningful time together.

Here are five changes that may occur during the final stage of life.

1. Increasing Sleepiness and Less Interest in the Outside World

One of the changes families may notice is that an older adult begins sleeping much more than usual.

A person who previously spent most of the day talking, watching television, reading, or interacting with family may gradually become quieter and spend increasing amounts of time asleep.

They may:

• Sleep for longer periods

• Become difficult to wake

• Spend more time resting in bed

• Have shorter periods of alertness

• Speak less

• Lose interest in activities

• Become less responsive to their surroundings

This can be distressing for family members.

You may wonder whether the person is ignoring you or whether something is wrong.

During the natural dying process, however, increasing sleepiness can occur as the body's energy needs and activity levels decline.

The person may simply not have the energy they once had.

What families can do

Rather than repeatedly trying to wake the person, focus on gentle interaction.

You can:

• Sit beside them

• Hold their hand

• Speak calmly

• Tell them you're there

• Play familiar music

• Read something comforting

• Keep the room peaceful

Even when someone appears to be sleeping or minimally responsive, hearing may remain present for some time.

You don't necessarily need to fill the room with conversation.

Sometimes simply being present is enough.

2. Reduced Appetite and Less Interest in Food or Water

Another common change near the end of life is a significant reduction in appetite.

A person who once enjoyed regular meals may begin eating only a few bites—or may stop wanting food altogether.

They may also drink less.

This can be particularly difficult for families because feeding someone is closely associated with caring for them.

Loved ones may naturally think:

“If they don't eat, they're going to become weaker. We have to make them eat.”

But near the end of life, the body's needs can change considerably.

The digestive system may slow down, and the body may no longer process food and fluids in the same way.

Trying to force food or drinks can sometimes cause discomfort, choking, nausea, or aspiration.

Comfort may become more important than calories

When someone is actively dying, the goal often shifts from maintaining nutritional intake to maintaining comfort.

Depending on the person's condition and care plan, comfort measures may include:

• Offering small sips if they can safely swallow

• Providing ice chips when appropriate

• Moistening the lips and mouth

• Offering favorite foods in small amounts if desired

• Avoiding pressure to eat

• Keeping the mouth clean and comfortable

If swallowing becomes difficult, don't assume that a person should simply be given more liquid.

There can be a risk of aspiration—where food or liquid enters the airway.

A nurse, doctor, or hospice professional can provide guidance about what is safe.

3. Changes in Breathing

Breathing patterns can change considerably during the final phase of life.

Families may notice that breathing becomes:

• Irregular

• Slower

• Shallower

• Faster for periods

• Interrupted by pauses

• Noisy or congested

One recognizable pattern is Cheyne-Stokes respiration, in which breathing becomes progressively deeper or faster, followed by a period of increasingly shallow breathing and then a pause.

The cycle may repeat.