There are many signs that death is approaching, particularly when someone has been ill for some time. In fact, there is some evidence that cognitive decline begins as long before death as two or three years and many people actually have some idea of how long they have left to live, especially within the last year of life.

My mother had COPD for the last 10 years of her life. During the last year, she while she lived with me, I asked “Do you have any thoughts about how long you might live? Do you think you’ll live out the year?” She told me she didn’t think she’d make it through the year, and she was right. When my son-in-law, Don, died this year, it had been so up and down that we had little hope of knowing how long he had left. Three weeks before he died, however, he called my daughter and told her he had less than a month. We don’t how he knew this, but he was right. Such premonitions are not unusual.

During the last two months, he began to sleep more and more, a pretty typical sign that death is near. In the last month, he ate a total of a couple of enchiladas , some chocolate, and several jars of applesauce. He was having a good deal of trouble swallowing, and drank very little. Once he was home, we did not have him on IV fluids. We offered him food and water by mouth. He had indicated he did not want any tubes.

Healthline, an organization that partners with the FDA to disseminate information about healthy living, lists 11 signs that a person is near death. These include loss of appetite and increased sleep, but they also note that people are likely to withdraw from social interaction, and it’s important not to take it personally. This kind of withdrawal is normal and likely to occur in the last few days or weeks.

Finally, vital signs begin to change. Within a few days of dying, blood pressure may drop and the heartbeat becomes irregular. Dying people begin to have trouble breathing—perhaps taking a few breaths and then stopping for a few seconds. In the final days, muscles get weak, body temperature drops, and the skin gets pale and seems thin. In the last day or two, it may even get blue. This never happened to Don because he was so young, and his heart was so strong.

Confusion, delusions, and even visions are common. The best thing to do when any of these occur is to stay calm and listen to the person without judging. Hearing is often the last thing to go, so you can continue to talk to the person, to hold hands, offer gentle massages, read or sing quietly.

In the last few hours, breathing becomes labored and noisy. Many people grimace or cry out in pain. Medical procedures, like suction the airway, and pain medications can help. As the authors point out in “It’s Okay to Die”,  there is little need for anyone to die in pain these days. Here is where it helps to have a Hospice or Palliative Care team to keep the person comfortable and pain free. It may also be important to the dying person for those around them to provide reassurance that it’s okay to let go. As WebMD points out, however, many people seem to prefer to die when no one is around, waiting until loved ones have left the room or the hospital.

Finally, the national hospice in Britain points out that people often make final requests to see a particular person or play a special piece of music or a movie they loved. Many dying people also talk about going on a trip . When the doctor asked my mother where she was when she entered the ER, she said “London. It’s lovely.” She had never been to London. Six days before Don died, he told us that he had to get to Oregon. He needed his keys and phone. He was in Ventura, California. He had been saying this for some time, but that night, knowing the end was near, we put his keys and phone in the hospital bed, turned on the radio (Pandora) and shook the bed gently, talking as though we were on our way to Portland. As he got sleepier, we suggested pulling over to rest. He said, “Okay, I’ll sleep for a while.”

“Text us when you get there,” my daughter said. “Let us know you’re okay.”

After he died, I got a text that said, “Everything is okay.” It was a message from a new piece of software that Team Mobile had slipped into the phone during an update. Nevertheless, we also felt strangely relieved and happy. As my mother used to say, “There are more things in heaven and earth than are dreamed of in your philosophy, Horatio.” It’s a quote from Shakespeare, but also reminds us to be humble in the presence of the unknowable.