Breathing Patterns Before End of Life: Critical Clues for the Last Hours!

Published on August 21, 2023

Updated on December 25, 2023

This article is intended for family members, caregivers, as well as nurses new and old. As an experienced , I've learned that when a family member or caregiver tells me their loved one is or has “goldfish breathing” or “fish out of water breathing” or “taking guppy breaths” that 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 of condition.

When a hears those words, we should plan on a nursing visit as soon as possible (best case is same day) to perform a head-to-toe assessment.

Early Signs vs Late Signs

An early sign for end of life typically means the loved one may have up to a month to live but is often two weeks or less. Late signs often mean two weeks or less, and some very late signs often mean the loved person is in their last three days.

Goldfish breathing, fish-out-of-water breathing, taking guppy breaths is an extremely late sign; and a critical one to be taken very seriously in terms of 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, 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?
  • Comatose state (late sign) — unresponsive, cannot be awakened?
  • Cyanosis (varies based on disease process in terms of early, middle, late) — assessing cheeks, lips, fingernail beds, toenail beds, toes.
  • (very late sign) — gurgling, gargling sound with breathing.
  • Ears pinning (early sign) — pinned ears look as if the person has their lower earlobe pinned to their neck. This effect occurs to 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.
  • (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.
  • (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 sweating. Often it involves taking clothes off, putting clothes or blankets on.

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.


Understanding the breathing patterns of a loved one during their last hours is crucial. When someone mentions “goldfish breathing” or “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 like breathing patterns, cool extremities, comatose state, cyanosis, , pinned ears, glassy eyes, of the skin, , 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.


Interviewing and Observation as part of the assessment

The Importance of Caregiver Journaling

Tips for recognizing terminal restlessness

Tips for new nurses on recognizing the approaching end of life

Providing Comfort During the Last Days of Life with Barbara Karnes RN (YouTube Video)

Preparing the patient, family, and caregivers for a “Good Death”

Velocity of Changes in Condition as an Indicator of Approaching Death (often helpful to answer how soon? or when?)

The Dying Process and the End of Life

The Last Hours of Life

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Gone from My Sight: The Dying Experience

The Eleventh Hour: A Caring Guideline for the Hours to Minutes Before Death

By Your Side , A Guide for Caring for the Dying at Home

End of life breathing. Gasping. Fish breathing (video)

End of life breathing. Gasping…PART 2 (video)

Trigger warning – educational video of actively dying- examples of changes in breathing (video)

Video of Actively dying (video)

Changes in breathing at the end of life are normal! (video)

Real-life video of cheyne-stokes breathing (video)

How to recognize a dying patient? | 5 signs of approaching death (video)

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