The Labor of Leaving

“Why are they breathing like that?” “Are they uncomfortable?” “Is there something we should be doing?”

In the movies, death is often dramatic or traumatic. Or someone says a few meaningful last words, closes their eyes, and quietly falls asleep. Those images can shape what we expect when we sit beside someone who is dying.

A natural death doesn’t always look like either of those things. There might be sounds, movements, and changes we weren’t expecting. Changes in breathing are especially common in the final days and hours of life. And if no one has explained them, they can be frightening.

There is some labor to come into the world, and there’s a labor in leaving. That doesn’t mean everyone suffers as they die. However, dying is a physical process, and it doesn’t always look like simply falling asleep. When someone you love is dying, it can be hard to pay attention to anything but their breathing. You watch their chest rise and fall. You notice every little change. A pause feels impossibly long, and you hold your breath until they take their next.

As someone approaches death, their breathing might become slower, shallower, or irregular. There might be periods of deeper, faster breathing followed by lighter breaths and a pause before breathing begins again. One pattern like this is called Cheyne-Stokes breathing. You don’t need to remember the name! What matters is understanding that these changes can be part of the natural dying process.

“But their breathing looks labored. Are they struggling?”

Labored breathing is a description used when breathing looks more effortful than usual. It deserves attention, but appearance alone doesn’t tell us exactly what the person is experiencing. Changes in rhythm or depth don’t necessarily mean someone feels short of breath. Breathlessness can happen though, and we shouldn’t assume someone is comfortable just because this is a normal part of the dying process.

If a person can tell us how they feel, we listen. If they can’t, the hospice team looks for signs of discomfort, including changes in facial expression, restlessness, or increased effort with breathing. If you notice labored breathing, a change, or anything that worries you, call the hospice nurse. You don’t have to decide on your own whether what you’re seeing is expected or whether they need more help.

There are ways to ease breathlessness. Change in position, a gentle fan, a calm environment, or using prescribed medications may bring relief. Morphine is sometimes used to ease the uncomfortable sensation of air hunger. Oxygen may help in certain situations, but it isn’t automatically the most helpful treatment for everyone. The care team can explain what they recommend and why. It’s all individualized.

“What is that rattling sound?”

Sometimes breathing becomes wet, gurgly, or rattly. You may have heard this called the “death rattle”. An unsettling term for an unsettling sound, especially if no one has explained it to you.

Throughout the day, we swallow saliva without even noticing. As someone approaches death, their swallowing reflex diminishes and might even stop altogether. They may also become too weak to cough and clear their throat. Saliva and mucus that would ordinarily be swallowed or cleared can collect, creating a rattling sound as air moves past them. This sounds alone does not mean the person is choking. In fact, it is unlikely to be painful or distressing to them, although it can be very difficult for the people beside them to hear.

Let the hospice team know. They can assess what’s happening. A position change might help, or medications may be appropriate to help reduce new secretions. The goal is the person’s comfort.

“Does this mean it’s happening now?”

Breathing changes can tell us that someone may be getting closer to death, but they can’t give us an exact timeline. Irregular breathing and pauses may occur for hours or sometimes days, and those patterns may fluctuate. Some people may even have a rally, becoming temporarily more alert or engaged. Very close to death, you may notice the mouth opening and the jaw moving with each breath, sometimes described as “guppy” breathing. These changes help us recognize that death may be near, but they can’t tell us exactly when. That uncertainty is hard. You may feel like you need to watch constantly, as though looking away could mean missing something important.

You can sit beside them. Hold their hand if they find that comforting (or don’t if you’re not hand holders). Speak to them. If you need someone to sit with you, or explain what you’re seeing again, ask. Understanding something when the nurse explains it and feeling comfortable with that information in real time can be two very different things. Don’t be afraid to ask the same questions and seek the same reassurance as often as you need to.

Most of us have seen far more deaths on a screen than we have in person. How would we know what to expect unless someone explained it? A natural death can look different from what we imagined. A comfortable death can look different from what we imagined. Understanding those differences can help us feel less afraid, recognize when someone needs help, and spend less time worrying about whether we’re doing enough.