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.
Free Daily Symptom Tracker: Each headache, flare, or fatigue spike reveals a clue. This two-page Daily Symptom Tracker records sleep quality, food intake, triggers, severity, and effective relief methods—all in one place. Use it daily for 31 days and share the pages with your healthcare provider or health navigation expert. Together, you can move from guessing to addressing the root cause. Instructions on how to use the free daily symptom tracker and the free daily symptom tracker.
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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.
The Death Deck is often a wonderful conversation starter.
Compassion Crossing, LLC, via Peter M. Abraham, BSN, RN, EOLD, offers on-site services in Madison County, KY, as well as in the seven nearby counties—Clark, Estill, Fayette, Garrard, Jackson, Jessamine, and Rockcastle—and provides virtual options when no local provider is available.
Hospice Buddy: Although Jamie Haberman, RN, CHPN, isn’t a certified end-of-life doula, her virtual services are highly valuable.
Currently, no official organization regulates end-of-life doulas (EOLDs). Remember that some EOLDs listed in directories may no longer be practicing, so it’s important to verify their current status.
End-of-Life Doula Schools
Before you consider a death doula school, please volunteer with a local hospice provider as a “companion volunteer” to gain experience with strangers who are dying, as well as with family and staff dynamics. The author also recommends reading the article Economic rant: The death doula crisis we aren’t talking enough about, as most death doula schools do not emphasize that being a death doula is a calling rather than a career.
The following are end-of-life (aka death doula) schools for those interested in becoming an end-of-life doula:
Compassion Crossing Academy: Although it isn’t a dedicated death-doula school, it offers unique classes that can help death doulas expand their practice. It serves as an important resource for individuals looking to deepen their understanding and grow in this meaningful profession.
Remember that there is no official accrediting body for end-of-life doula programs. Certification simply shows you’ve completed an unaccredited course and received a certificate of completion. It’s advisable to have discovery sessions with any death doula school you’re considering — even if it isn’t listed here — to see if it meets your needs. Also, ask questions and reach out to references, such as former students, to assess whether the school provided a solid foundation for launching your own death doula practice.
