When a person is in hospice care, the focus shifts from curing an illness to providing comfort and supporting the best quality of life possible. The term “transitioning” is used by hospice professionals to describe the final stage of the life journey, often called active dying. This phase signals that the body is beginning its natural process of shutting down and that the end of life is approaching, typically within hours or a few days. Understanding this process can help reduce the fear and uncertainty often associated with it, allowing loved ones to shift their focus to presence and providing emotional support. The hospice team is prepared to manage this natural physiological progression with compassion and expertise.
Understanding the Transition Phase
The transition phase is distinct from the general decline experienced earlier in hospice care. While a patient may have been weakening for weeks or months, the transition signifies a more rapid and profound biological shift. This stage marks the body’s internal systems beginning to slow down and fail as energy reserves are depleted. The phase is often measured in days or sometimes just hours, as the body can no longer sustain its core functions. Hospice care recognizes this process as normal and focuses entirely on ensuring the patient is peaceful and free from distress.
Physical and Behavioral Indicators
As the body transitions, several observable physical changes occur due to the circulatory and respiratory systems slowing down. Changes in circulation often become noticeable first, as the body directs blood flow toward the core organs and away from the extremities. This causes the hands, feet, arms, and legs to feel cool to the touch, and the skin may develop a purplish, marbled appearance known as mottling. The lips and nail beds may also take on a bluish or pale color as oxygen circulation decreases.
A patient’s breathing pattern will also change significantly during this phase. Breathing may become irregular, characterized by periods of rapid, shallow breaths alternating with periods of no breathing (apnea), a pattern known as Cheyne-Stokes respiration. Secretions can accumulate in the back of the throat due to the inability to cough or swallow, creating a gurgling or rattling sound with each breath. This sound, sometimes called the “death rattle,” can be alarming to families, but it is not painful to the patient.
A noticeable decrease in responsiveness is another strong indicator of transitioning, as the person will spend significantly more time sleeping. It becomes increasingly difficult to wake the person, and when they are awake, they may appear confused, disoriented, or restless. The patient will also have little to no desire for food or water, as the body no longer requires nutrition or hydration for energy. Forcing intake at this stage can cause discomfort and is generally not recommended.
Comfort and Symptom Management
The primary goal of the hospice team during the transition phase is to anticipate and manage any potential discomfort, ensuring the patient remains peaceful. This proactive approach involves adjusting medication doses to manage pain, anxiety, and restlessness, often through the use of comfort kits containing fast-acting medications. These medications are administered as needed to prevent symptoms before they become severe. The team works to maintain a pain-free state, which may require more frequent dosing of analgesics than previously needed.
Non-pharmacological measures are also an important part of comfort care. Gentle repositioning can help address restlessness and may also reduce the noisy breathing sounds caused by secretions. Keeping the patient’s mouth moist with a sponge swab and applying lip balm can prevent dryness, as the patient breathes more through the mouth. The hospice nurse provides ongoing guidance to family members on how to provide physical comfort, such as gentle massage or a cool washcloth on the forehead.
Support for Families and Loved Ones
During this final phase, the hospice team shifts its focus to supporting the emotional and spiritual well-being of the family and loved ones. Families are encouraged to maintain a constant presence and to communicate with the patient, even if the patient appears unresponsive. Hearing is often considered the last sense to fade, so speaking softly, reading, or playing comforting music can be a source of peace for both the patient and the family. Simple actions like holding a hand or offering a gentle touch convey presence and love.
Hospice provides dedicated support services, including social workers and spiritual care providers, who assist with emotional processing, spiritual needs, and logistical concerns. These team members help navigate the intense emotions that arise when witnessing a loved one transition. Following the death, the hospice nurse guides the family through the immediate logistical steps, including contacting necessary authorities and the funeral home. They remain available for support and guidance in the initial hours after the passing.