The journey at the end of life is as natural as its beginning, yet it remains one of the least understood phases of the human experience. Julie McFadden, a seasoned hospice nurse, has become a trusted voice in explaining this process. Drawing from her 16 years at the bedsides of the dying, she outlines three common physical signs that typically appear in the last 24 hours. Her goal is not to clinicalize death, but to humanize it, providing families with the knowledge they need to provide comfort and recognize that these changes are a normal, peaceful part of life’s conclusion.
The first sign she addresses is the auditory cue known as the “death rattle.” This gurgling sound is produced when a person can no longer swallow their own secretions. As the body’s reflexes fade, saliva and phlegm gather in the back of the throat. When air passes over this fluid during breathing, it creates a rattling noise. For families, this can be one of the most distressing signs to witness. However, Julie provides essential context: the patient is not aware of this sensation. They are not choking or in pain; their body is simply progressing through its final stages.
The second cluster of signs involves the rhythm of life itself: breathing. In the final day, a person’s breathing pattern becomes noticeably irregular. It may slow dramatically, with long, unsettling pauses between breaths. These pauses, known as apnea, can last for 10 to 30 seconds. Eventually, breathing may shift to agonal respirations, which are sudden, gasping breaths. Julie is quick to point out that this is an involuntary reflex originating from the brain stem, not a sign of conscious struggle. It is the body’s last effort to oxygenate vital organs.
The third sign is a change in consciousness and responsiveness. Patients often enter a state where their eyes are open but they are not seeing or reacting to the world around them. Julie describes this as a “vacant” or “glassy” stare, where the person appears to be looking through you. While this can be difficult for loved ones, it is important to know that the person is not in distress. In fact, this is often a very tranquil period. Julie encourages families to continue speaking to the patient, as the sense of hearing is thought to persist until the very end, offering a final thread of connection.
Julie McFadden’s work is a powerful reminder that knowledge can be a profound source of comfort. By understanding the “death rattle,” breathing changes, and decreased responsiveness as natural parts of the body’s shutdown sequence, families can shift their focus from fear to presence. They can spend the final hours offering words of love and support, confident that their presence is a comfort, and that the process they are witnessing is a universal, natural transition.
