Twitching on its own does not tell you how close someone is to death, but sudden jerks are common in the last days of life. They usually come from the body’s chemistry shifting as organs fail and from the medicines used for comfort.1Palliative Care Network of Wisconsin. Myoclonus The care team can treat them, and in most cases they look more distressing than they feel.
What End-of-Life Twitching Looks Like and Why It Happens
These quick, shock-like muscle jerks are called myoclonus, and you may hear the word from the hospice team. They can hit an arm, a leg, the face or the whole body, often irregularly and without warning. A hand might flick or a shoulder might jump every few minutes while your relative seems to be asleep. The jerks may get stronger when the person is touched or moved, and they can come and go over hours or days. Noting when they started and how often they happen gives the nurse something useful to work with.
A myoclonic jerk is a single, brief, lightning-quick contraction, and the muscle relaxes right afterward. It looks like a sudden startle. A seizure usually involves stiffening or rhythmic shaking that goes on for a longer stretch, and the person may lose awareness or show changes in color or breathing. That is why very strong or sustained rhythmic shaking should be reported. Purposeful movements such as reaching, scratching or adjusting a pillow look smooth and aimed, quite unlike a jerk.
Near the end of life, jerks most often come from chemical imbalances in the body and from medicines.2Palliative Care Network of Wisconsin. Myoclonus As the kidneys, liver and lungs slow down, waste products and salts build up and irritate nerves. Reduced oxygen reaching the brain adds to the restless, jerky movements.3Gilchrist Cares. What are the signs of active dying? Low oxygen alone can cause them. Even healthy people who briefly faint from low blood flow to the brain often jerk, so jerking is not proof of dying.4PubMed. Syncope: a videometric analysis of 56 episodes of transient cerebral hypoxia
Twitching is a poor clock. It can start days before death, or appear and fade. It can even happen in people who go on to recover from an illness. Breathing changes, cooler skin and less responsiveness are better clues to timing, and you can ask the hospice nurse which signs they are watching in your relative.
Many people in the last days are drowsy or unconscious, so they are often unaware of the jerks even when the movement looks dramatic. Someone who is awake and alert may find frequent jerks tiring or frightening, and may be able to tell you so. Watch the face: a relaxed face between jerks is one sign of little distress, while a grimace is a reason to tell the team.
Pain Medicines and Body Chemistry as Causes
Higher doses of opioid painkillers such as morphine more often cause jerks, though the link with dose varies from person to person.5Palliative Care Network of Wisconsin. Neuroexcitatory Effects of Opioids: Patient Assessment One reason is that byproducts the body makes when breaking down some opioids can overexcite nerves as they build up.6Palliative Care Network of Wisconsin. Neuroexcitatory Effects of Opioids: Patient Assessment So jerks may appear when doses rise, or when failing kidneys can’t clear these byproducts. High-dose methadone given by injection has also caused jerks in hospice patients with cancer.7PubMed. Myoclonus associated with high-dose parenteral methadone
Jerks do not always follow a dose increase. They can appear on a steady dose when the kidneys weaken and the drug’s byproducts stop being cleared. Dehydration can slow the clearing too, adding to the buildup. New jerks on an old dose are still worth mentioning to the nurse.
Kidney failure lets waste build up in the blood, which can trigger jerks and confusion.8PubMed. Myoclonus, Uremia, and Delirium in a Liver Transplant Recipient: A Case Report and Literature Review In one reported case, jerks improved once the blood was cleaned by dialysis.9PubMed. Myoclonus, Uremia, and Delirium in a Liver Transplant Recipient: A Case Report and Literature Review Low magnesium can cause tremor, jerks and even seizures.10PubMed. Magnesium deficiency. Etiology and clinical spectrum At the very end, though, testing and correcting these levels is often not part of comfort-focused care.
Don’t stop or cut an opioid yourself, because pain can return quickly. The team may lower the dose, switch to a different opioid, or add a calming drug. Report new jerks soon after a dose increase so they can link the two.
Besides the dose, the team has other levers. Some opioids leave fewer irritating byproducts than others. Splitting the same total into smaller, more frequent doses can smooth out peaks that provoke jerks. Other medicines on the list may contribute too, so the team may review all of them rather than only the painkiller. Which option fits depends on the person’s kidney function and how well pain is controlled.
Some questions worth asking the care team:
- Could this be from a medicine change?
- Are the kidneys or liver slowing down?
- Is a blood test worth doing given the goals of care?
- What should I do if the jerks get stronger overnight?
Twitching as Part of End-of-Life Restlessness
Hospice staff may call it terminal restlessness, an agitated confusion that is common in the last days.11PubMed. Terminal restlessness in the nursing facility: assessment, palliation, and symptom management It shows up as thrashing, twitching or jerks, fidgeting, tossing and turning, yelling or moaning.12PubMed. Terminal restlessness in the nursing facility: assessment, palliation, and symptom management It is especially frequent in late-stage cancer.13The Pharmaceutical Journal. Dealing with the dying patient — treatment of terminal restlessness
It can begin subtly, with being unable to settle, plucking at clothes or seeming distracted, and then build over hours. Some people are agitated mostly in the evening or night and calmer by day. Others swing between restlessness and deep sleep, which can be confusing to watch. Sometimes it eases on its own or after treatment, and the person becomes peaceful again.
Restlessness and pain can look alike. Grimacing, guarding a body part or moaning when moved can point to pain. Restlessness with confusion and picking may be delirium instead. Describe exactly what you see so the nurse can judge; both are treatable and often treated together.
The team will also look for fixable causes. A full bladder or constipation can cause restlessness in someone who can’t say what is wrong, and both are easy to fix. Some medicines, including opioids at high doses, can add to agitation and confusion. Trouble breathing, fever, or an uncomfortable position can show up as restlessness as well. Checking these is usually the first step before adding calming medicine.
It can be very upsetting to watch. Your relative may not recognize you or may seem frightened. This reflects brain changes, not your care or their feelings toward you, and many families find it easier once they know it is common.
How the Care Team Treats Twitching
Lorazepam is a first choice for twitching and jerks in palliative care.14Fraser Health. B.C. Inter-Professional Palliative Symptom Management Guidelines: Twitching/Myoclonus/Seizures It works quickly, lasts a good while, and slows breathing less than diazepam.15Fraser Health. B.C. Inter-Professional Palliative Symptom Management Guidelines: Twitching/Myoclonus/Seizures Midazolam is an option, especially when jerks come from kidney failure, and it can be given under the skin or inside the cheek.16Fraser Health. B.C. Inter-Professional Palliative Symptom Management Guidelines: Twitching/Myoclonus/Seizures Clonazepam by mouth, often starting at 0.5 mg once or twice a day, is another choice.17Fraser Health. B.C. Inter-Professional Palliative Symptom Management Guidelines: Twitching/Myoclonus/Seizures In children, a continuous midazolam infusion usually controls jerks.18Royal Children’s Hospital. Neurological symptoms
The team picks among these based on the person’s kidneys, liver, ability to swallow and how fast relief is needed. If one drug causes too much drowsiness or doesn’t work well, the team can switch or adjust rather than stop treatment.
When someone can’t swallow, drops or tablets can be placed inside the cheek or under the tongue. A small needle under the skin can deliver medicine by pump. Nurses can teach families to give “as needed” doses at home, and it helps to keep a log of times and doses.
Relief from a fast-acting dose can come within minutes to an hour, depending on how it is given. Jerks may lessen rather than vanish, and fewer or gentler jerks is a realistic goal. The person usually becomes sleepier, which is expected and often welcome. If jerks return before the next dose is due, tell the nurse so the schedule can be changed.
Some families worry the medicine will speed death. These drugs are used to ease distress, at doses adjusted to the person, and drowsiness can be a relief. Raise concerns with the team rather than skipping doses.
What You Can Do at the Bedside
Holding down or restraining the movements does not help.19Gilchrist Cares. What are the signs of active dying? Speaking quietly and naturally can calm the person, and lightly massaging the forehead, reading aloud or playing soft music may soothe them.20Gilchrist Cares. What are the signs of active dying?
Gentle touch can be as simple as resting your hand on their arm. If a touch seems to make the jerks or agitation worse, ease off and try your voice alone. Tell the person who you are and that you are there, since hearing is thought to be one of the last senses to fade. A quiet room with soft lighting and fewer visitors at once often calms someone restless.
For safety, use padded bed rails or pillows if limbs hit hard surfaces, and keep sharp or hot objects out of reach. If the person tries to get up, lower the bed and clear the floor. Call the nurse if movements become a fall risk.
Call the hospice line for sudden strong shaking of the whole body, for jerks with signs of pain or fear that don’t settle, or for twitching that started after a medicine change.
Can a Body Move After Death
On a ventilator after brain death, as many as 40 to 50 percent of people show some movement.21Canadian Journal of Neurological Sciences. Movements in Brain Death: A Systematic Review These include leg withdrawal, belly contractions and breathing-like motions.22Canadian Journal of Neurological Sciences. Movements in Brain Death: A Systematic Review The most striking is the Lazarus sign, where both arms lift and bend toward the chest.23Medical Hypotheses. The Lazarus’ sign: A novel hypothesis on its hodology and neurophysiological mechanisms It comes solely from the spinal cord, with no brain activity involved.24PubMed. Lazarus Sign, a Misnomer to an Anatomical Spinal Reflex These movements do not undo a brain death diagnosis or rule out organ donation.25Canadian Journal of Neurological Sciences. Movements in Brain Death: A Systematic Review
Brain death means the entire brain, including the brainstem, has permanently stopped working, which is legally and medically death. A ventilator can keep the heart beating and the chest moving, so the body can look warm and pink even though the person has died.
A reflex is a loop that runs through the spinal cord without needing the brain, like the knee jerk a doctor tests with a hammer. After brain death the spinal cord can stay active for a time, so a touch or a change in oxygen can still trigger a movement. The movements are automatic, not signs of awareness, pain or recovery. They tend to be brief and can be set off by turning or handling the body.
If you see your loved one move in intensive care, know that staff test for brain death with set exams before declaring it. Ask the team to explain the reflexes before the ventilator is stopped. Feeling shaken is a normal reaction, and they understand it.
After death, muscles stiffen as their energy supply runs out and calcium and magnesium build up inside them.26PubMed. The concentrations of free magnesium and free calcium ions both increase in skeletal muscle fibres entering Rigor mortis This is a slow stiffening, not twitching.
Is Your Own Twitching Something to Worry About
Up to 70 percent of adults have sudden whole-body jerks while falling asleep at some point.27PubMed Central. Hypnic Jerks, Major Depressive Disorder, and Antidepressant Use: A Possible Relationship They often come with a racing heart and a feeling of falling.28PubMed Central. Hypnic Jerks, Major Depressive Disorder, and Antidepressant Use: A Possible Relationship They happen as the body shifts from wakefulness to sleep, when muscle control briefly misfires. They can be more frequent when you are overtired or stressed, and may startle you awake. Better sleep habits often reduce them, and if they keep you from sleeping, mention it to a doctor.
Small flickering muscle twitches are common and usually harmless. A benign twitch is a fleeting flicker under the skin, often in the eyelid, calf or thumb. It can repeat in the same spot for days and then disappear, and it does not stop you from using the muscle normally. Common triggers include caffeine, stress, poor sleep, hard exercise and some medicines, including antidepressants. Twitches without weakness or other symptoms rarely need tests. When twitching comes with weakness or muscle wasting, a doctor should check for nerve disease.