In end-of-life care, "transitioning" refers to the final stage before death, a gradual process where the body slows down, marked by significant physical and mental changes like increased sleep, decreased appetite, altered breathing, and withdrawal from surroundings, indicating the person is moving from living to dying. It's a natural, often days-to-weeks phase where consciousness fades, and the focus shifts inward, preparing for the moment of death.
Transitioning is the first stage of dying. It describes a patient's decline as they get closer to actively dying. Generally, when one is transitioning, they likely have days — or even weeks — to live. I have seen some patients completely skip the transitioning phase and some stay in it for weeks.
When someone is dying, their heartbeat and blood circulation slow down. The brain organs receive less oxygen than they need and so work less well. In the days before death, people often begin to lose control of their breathing. It's common for people to be very calm in the hours before they die.
The active stage of dying is the final phase before passing. This can last from a few hours to a few days. During this time, significant physical changes, such as irregular breathing, nonresponsiveness, and minimal vital signs, occur.
The Final Days and Hours
When death is likely to be within a few days or hours, your loved one may: Be unconscious or drift in and out of awareness. Hallucinate (see things that aren't there) or seem restless or confused. Stop producing urine and stool.
The transition into active dying typically begins when a person stops eating and drinking, becomes mostly unresponsive, and shows significant physical decline. Breathing patterns may shift dramatically—pausing for long intervals or becoming more rapid and shallow.
Words of affection, letters, and gifts can help your loved one understand that they're appreciated. People who are dying want to feel like their life is meaningful. Ask your loved one to reminisce and tell important stories from their lives. Let them know how much they mean to you.
Everyone's life is different. Death is an individual experience, too. For some people, the dying process may last weeks. For others, it may last a few days or hours.
Facial muscles may relax and the jaw can drop. Skin can become very pale. Breathing can alternate between loud rasping breaths and quiet breathing. Towards the end, dying people will often only breathe periodically, with an intake of breath followed by no breath for several seconds.
Hospice Isn't About Giving Up
It's not a place to speed up the process of dying. A doctor suggesting hospice does not mean they're giving up on providing care and medical treatment. It's end-of-life care, but this doesn't mean giving up hope. It means shifting focus from curative treatments to comfort and support.
Speak soothing words
Tell Them It's Okay to Let Go
First, assure them that while it's normal to want to hold on at the end of life, it's okay to let go. Don't force things, but do remind your loved one of how much you love them. Let them know you're not angry and don't hold any resentment that they're dying.
Their eyes may appear glazed or may not close all the way. Some people experience a brief surge in energy in the hours or days before death. This may last from a few minutes to several hours. During this time, your loved one may talk more, be interested in engaging in conversation, or interested in eating or drinking.
Defining "Transitioning" in Hospice Care
Transitioning marks the body's shift from active living to active dying, hence the usage of the term transition. During this stage, the body begins preparing itself for death in natural ways as organs slow down and stop performing their usual functions.
Research suggests that even as your body transitions into unconsciousness, it's possible that you'll still be able to feel comforting touches from your loved ones and hear them speaking. Touch and hearing are the last senses to go when we die.
The final stage of transition is all about forward momentum. It's a time for planning, visualising the end goal and achieving some early wins along the way. While blips in confidence may still occur, there's a growing sense of stability and comfort.
What other signs might there be that death is near? One is 'terminal agitation' or restlessness. This often appears as a need to get out of bed, agitated behaviour or commonly plucking of the sheets or 'knitting' of the hands. They might reach out as if towards something or somebody.
Actively Dying: 24 - 48 Hours before Death
In the final days and hours, a person may “wait” for someone to arrive—or let go when everyone is out of the room. Hospice nurse Barbara Karnes, RN, explains the limited control we have over the timing of when we die.
Title Signs that someone is dying:
Make them feel comfortable talking about any emotions and uncertainties they may be feeling. Ask them what they need from you, and try to give it to them wholeheartedly. It may be that they simply want you to sit beside them in quiet presence. Help them practice the self-care they need.
Agonal means: “of, relating to, or associated with the act of dying: occurring just before death.” There are several medical conditions associated with death that contain the word agonal, such as agonal breathing or respiration, the agonal state (state of the body just prior to death) and agonal rhythm.
The “three magic phrases”—you will not be alone, you will not feel pain, we will be okay—struck a chord with me not only as someone who has sat beside dying friends, but as someone who has wondered what I would want to hear if it were me.
You can simply sit with the person and perhaps hold their hand. Hearing is said to be the last sense to go, so you may want to talk to the person or even have a conversation among the people in the room so that the person knows they are not alone. You could read aloud, sing or hum or play some of their favourite music.
The 3 C's of grief are Control, Connection, and Continuity - three fundamental psychological needs that become disrupted after loss and require intentional attention during the grieving process.