Withdrawal often begins one to three months prior to end of life. First, it is withdrawal from the world, then friends and finally those closest to your loved one. During these periods of withdrawal, your loved one may begin to sort out and process their life. Words may be associated with the physical life, while touch and wordlessness may take on more meaning.

Continue to talk to your loved one about everyday events just as you would have in the earlier months. (Remember, everything does not have to be serious; laughter can be great medicine).

Your loved one will gradually spend more and more time sleeping during the day and at times it will be difficult for them to awaken. This is a result of a change in the body's metabolism. Try to plan time with your loved one on those occasions when he or she is most alert. Silence can be golden, just being with them is reassuring.

Your loved one may experience a decrease in appetite and thirst because the body naturally begins to conserve energy expended on this task. Since the metabolism is slowing down, the body cannot utilize food taken in. Encourage small amounts of easily digested foods and liquids such as ice chips, juice, water and Popsicles.

At times, your loved one may become confused about the day, time, place and even the identity of close and familiar people. This is a result of chemical changes in the body. If this occurs, gently correct them. Remind your loved one frequently of the day and time and who is in the room. Try to talk slowly and clearly near his or her head, using short phrases. Explain things you do for his or her care, even if your loved one is unconscious.

You may notice changes in breathing patterns. There may be periods of 10 to 30 seconds of a delay in breathing (especially noticeable at night). These are called periods of apnea. This is common and may continue for weeks or months. It is caused by a decrease in circulation and a build-up of body waste products.

Clarity of vision and hearing may decrease. Keep the lights on in the room and never assume that your loved one cannot hear you. Hearing is the last of the five senses to be lost. During your visit, touch them as you speak.

Incontinence (loss of control) of urine and bowel movements are often not a problem until end of life becomes imminent. If this occurs, place a linen saver pad under your loved one. It is important to always keep them clean and dry. Don't be alarmed if urine is colorless, dark or ceases to flow. Problems with constipation may develop due to a decrease in activity, limited food and fluid intake, an increase in pain medications, as well as slowing of the metabolism and weakness. Please consult with your loved one's physician or nurse about treatment options for constipation.

The need for more pain medication due to increased pain is common and manageable. If this is the case, please consult with your loved one's physician or nurse immediately.

You may notice your loved one becoming restless, pulling at bed linens and having visions of people or things that do not exist. These symptoms are a result of a decrease in oxygen circulation to the brain and a change in the body's metabolism. Speak calmly and assuredly not to startle or frighten your loved one. Gently reorient and reassure them, then consult with the nurse or physician about appropriate medication that may relieve some of these symptoms.

His or her arms and legs may become cool to touch, blue and/or blotchy. The underside of the body may become spongy (with fluid) and darker in color. These are symptoms of decreased circulation. Warm blankets may make your loved one more comfortable; however, they may wish to remain uncovered. Support the body and extremities by padding with pillows or blankets and repositioning your loved one every two hours.

Oral secretions may become more profuse and collect in the back of the throat. You may have heard this referred to as "death rattle." This is a result of a decrease in fluid intake and an increase of weakness causing an inability to clear the throat. This is often frightening to the caregiver, but the individual does not usually experience any discomfort. You can roll or prop your loved one's head higher or position them on his or her side rather than on their back. If ordered, offer oxygen or humidified air. Hoag nurses will recommend and instruct you if suctioning is needed.

Heavy breathing with mouth open and/or sleeping with eyes open frequently occurs, both areas need to be kept moistened. The mouth needs to be moistened frequently with ice chips or drops of water. You can clean the mouth frequently with Toothettes (a disposable toothbrush) or lemonglycerin swabs. Moisten the eyes frequently with normal saline drops, liquid tears, or other non-medicated eye drops. To cleanse the nostrils, use a moist Q-tip. Apply a water-based lubricant jelly to the inside of the nostrils every one to four hours.

You may notice a decrease in blood pressure, along with an increased pulse rate. The body temperature may fluctuate, and you may notice some perspiration and clamminess. A cool washcloth to the forehead often provides comfort. Tylenol¨ suppositories are effective in reducing fever and do not require a prescription.