This article is intended for family members, caregivers, and nurses, new and old. As an experienced hospice nurse, I’ve learned that when a family member or caregiver tells me their loved one is or has “goldfish breathing,” “fish out of water breathing,” or “taking guppy breaths,” the patient is now at the end of their life.
Family members and caregivers who are seeing and hearing this type of breathing pattern, please journal what you are seeing and call your hospice provider if they are unaware of this critical change in condition.
When a hospice nurse hears those words, we should plan a nursing visit as soon as possible (ideally, the same day) to perform a comprehensive head-to-toe assessment.
Early Signs vs Late Signs
An early sign of end-of-life typically means the loved one may have up to a month to live, but it is often two weeks or less. Late signs usually mean two weeks or less; some very late signs frequently mean the loved one is in their last three days.
Goldfish breathing, fish-out-of-water breathing, and taking guppy breaths are extremely late signs and critical to be taken seriously in preparing everyone for the last breath.
The Assessment
The hospice nurse should perform a complete head-to-toe assessment to confirm the patient has minutes, hours, and days to live. This assessment should include looking for the following group of signs:
Breathing — Cheyne Stokes, Kussmaul, Goldfish breathing, fish-out-of-water breathing, taking guppy breaths (very late sign)—typically indicates less than three days.
Cool extremities (early sign) — Are the person’s hands cold? Their calves, their feet? — Frigid cold (very late sign — typically indicates less than 36 hours).
Comatose state (late sign) — unresponsive, cannot be awakened?
Cyanosis (varies based on the disease process in terms of early, middle, and late) — Assess cheeks, lips, fingernail beds, toenails, and toes.
Death Rattle (very late sign) — gurgling, gargling sound with breathing (can be an early sign for loved ones who have congestive heart failure).
Ears pinning (early sign) — Pinned ears look like the person has their lower earlobe pinned to their neck. This effect occurs in most people in the last two weeks of life due to a non-suffering form of dehydration.
Eyes glassy, tearing, half-open (late sign) — unable to track or focus on those around the person.
Mottling (late sign, but in some disease processes, can be middle) — their skin looks blotchy or has different colors in patches. It happens because their body is not getting enough blood and oxygen as they near the end of their life.
Restlessness (unless habitual, late sign) — unsettled, frequently changing position, high fall risk.
Temperature deregulation (late sign unless brain cancer or brain injury) — too hot even when it’s cool or very cold for others, too cold even when everyone is sweating. Often, it involves taking clothes off and putting on clothes or blankets.
If the patient is not yet admitted to hospice, if the family/power of attorney is willing, consider an emergency admission to hospice, especially if there are late signs present.
Conclusion
Understanding the breathing patterns of a loved one during their last hours is crucial. When someone mentions “goldfish breathing,” “fish out of water breathing,” or “taking guppy breaths,” it often means the person is nearing the end of their life. It’s essential to journal these changes and inform the hospice provider immediately.
As a hospice nurse, I’ve learned that early signs may indicate up to a month to live, while late signs often mean two weeks or less, and extremely late signs may mean the person has only three days left. “Goldfish breathing,” “fish-out-of-water breathing,” and “taking guppy breaths” are extremely late signs, and they should be taken very seriously as the person prepares for their last breath.
To confirm the person’s condition, a hospice nurse should perform a thorough head-to-toe assessment, looking for various signs, such as abnormal breathing patterns, cool extremities, a comatose state, cyanosis, a death rattle, pinned ears, glassy eyes, skin mottling, restlessness, and temperature deregulation.
If the patient is not yet admitted to hospice, consider emergency admission, especially if late signs are present. Remember, during these challenging times, showing love, comfort, and support can make a significant difference to your loved one.
Let’s stay compassionate and attentive to their needs as they approach the end of their life journey.
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Compassion Crossing Academy — Free and paid online courses are available to teach caregivers, nurses, social workers, chaplains, end-of-life advocates, and educators, including death doulas, how to confidently coordinate complex care.
Currently, there is no official organization regulating end-of-life doulas (EOLDs). Keep in mind that some listed EOLDs in directories might no longer be practicing, so verifying their current status is essential.
End-of-Life Doula Schools
The following are end-of-life (aka death doula) schools for those interested in becoming an end-of-life doula:
Compassion Crossing Academy: While it’s not a dedicated death-doula school, it offers distinctive classes that can help a death doula expand their business. It’s a valuable resource for those eager to grow and deepen their knowledge in this meaningful field.
Remember that there is no official accrediting body for end-of-life doula programs. Certification only shows you’ve completed an unaccredited program and received a graduation certificate. It’s advisable to have discovery sessions with any death doula school you’re considering — regardless of whether it’s listed here — to see if it meets your needs. Also, ask questions and contact references, such as former students, to assess whether the school gave you a solid foundation to start your own death doula practice.
