Linking To And Excerpting From PCN Of Wisconsin: Syndrome Of Imminent Death

Posted on April 3, 2026 by Tom Wade MD

Today, I review, link to, and excerpt from Palliative Care Of Wisconsin‘s Syndrome Of Imminent Death.

All that follows is from the above resource.

Syndrome Of Imminent Death

Fast Fact Number: 03

By: David E Weissman MD

Categories: End of Life Care, Hospice, Hospice/End of Life Care
Published On: April 1, 2024

Background   Virtually all dying patients go through a stereotypical pattern of symptoms and signs in the days prior to death.  This trajectory is often colloquially referred to as “actively dying” or “imminent death”.  Prompt recognition of this trajectory in patients with an untreatable, terminal illness (e.g., metastatic cancer, advanced heart failure, ALS, end-stage liver disease) is key for clinicians to provide the most appropriate interventions for both the patient and family.

1. Stages

Early 

  • Bed-bound
  • Loss of interest and/or ability to drink/eat
  • Cognitive changes: increasing time spent sleeping and/or delirium (see Fast Fact #1)

Middle

  • Further decline in mental status to obtundation (slow to arouse with stimulation; only brief periods of wakefulness)
  • Decreased urine output

Late

  • Death rattle – pooled oral secretions that are not cleared due to loss of the swallowing reflex
  • Coma
  • Fever – usually from aspiration pneumonia
  • Altered respiratory pattern – periods of apnea, hyperpnea, or irregular breathing.
  • Neck hyperextension
  • Mottled extremities

2. Time Course   The time to traverse the various stages can be less than 24 hours or as long as ~14 days.  Not all patients proceed through the stages in a delineated, step-wise fashion.  Hence, clinicians often must utilize their gestalt when prognosticating to families.  Patients who enter the trajectory who are nutritionally intact, with no infection (e.g., acute stroke), are apt to live longer than cachectic patients with advanced cancer for example.

3. Common Family Concerns   Family members present during the dying process often express the following concerns/questions.  Clinicians can best help families by expecting these questions, providing education, reassurance, and responding to emotions (see also Fast Fact #2 and Fast Fact #149).

  • Is my loved one in pain; how would we know?
  • Aren’t we just starving my loved one to death?
  • What should we expect; how will we know that time is short?
  • Should I/we stay by the bedside?
  • Can my loved one hear what we are saying?
  • What do we do after death?

4.  Treatment

  • Confirm treatment goals; recommend stopping treatments that are not contributing to comfort – pulse oximetry, IV hydration, antibiotics, finger sticks, etc.
  • Communicate clearly to others what is going on.  Write in progress notes: “patient is dying,” not “prognosis is poor”.
  • Treat symptoms/signs as they arise: common among these are: oral secretions (see Fast Fact #109, Fast Fact #158); delirium (Fast Fact #1, Fast Fact #60); dyspnea (Fast Fact #27), fever (Fast Fact #256) and pain (Fast Fact #53 and Fast Fact 54).
  • Provide excellent mouth and skin care.
  • Provide daily counseling and support to families. This might mean refining the communicated prognosis to families daily.

References

  1. Rousseau P. Management of symptoms in the actively dying patient.  In: Principles and Practice of Palliative Care and Supportive Oncology. Berger AM, Portenoy RK, and Weissman DE, eds. 2nd Edition. Philadelphia, PA: Lippincott, Williams, & Wilkins; 2002.
  2. Breitbart W, Alici Y.  Agitation and delirium at the end of life. “We couldn’t manage him.” JAMA.  2008; 300(24):2898-2910.

Version History:  This Fast Fact was originally edited by David E Weissman MD.  2nd Edition published July 2005; 3rd Edition May 2015. 4th Edition December 2023 by Jessica R Bumgarner NP.

Fast Facts and Concepts are edited by Sean Marks MD (Medical College of Wisconsin) and associate editor Drew A Rosielle MD (University of Minnesota Medical School) with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW). The authors of each individual Fast Fact and the Fast Fact and Concepts editors are solely responsible for that Fast Fact’s content. The full set of Fast Facts are available at Palliative Care Network of Wisconsin with contact information, and how to reference Fast Facts.

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