What Is the Pre-Active Phase of Dying?

The pre-active phase of dying is a period of several weeks or perhaps a month that precedes death. 

During the preactive phase of dying, the body is beginning to shut down, and digestion, brain and kidney function begin to deteriorate. These functions typically slow down in a predictable pattern, says James Hallenback, a palliative care physician at Stanford University, in his book “Palliative Care Perspectives.” “First hunger and then thirst are lost,” Hallenback writes. “Speech is lost next, followed by vision. The last senses to go are usually hearing and touch,” he adds.  

Physical Signs of Pre-Active Dying

• Decreased food and fluid intake due to the natural diminishment of hunger and thirst
• Lower temperature and blood pressure
• Pale skin
• Difficulty swallowing, especially pills. Many people at this stage of dying need to take their oral medicines in liquid form. Medicines that are not indicated for comfort are usually stopped at this time.
• Decreased urine output and fewer bowel movements
• Swelling of the hands or feet due to diminished kidney function and the accumulation of fluid in the extremities. 
• Increased sleepiness, less interaction with loved ones
• Confusion, agitation or restlessness. This may include behaviors such as “picking” at the covers, thrashing about, or trying to get out of bed without help.
• Breathing changes. Breathing may initially be rapid and shallow or irregular and labored.
• Slow wound healing. The skin is particularly vulnerable during this time, and bedsores can happen seemingly overnight. Frequent turning, gentle massage and soothing skin lotions can help prevent the skin from breaking down. 

Behavioral and Cognitive Signs of Pre-Active Dying

The brain, like the rest of the body, doesn’t die all at once. As different parts of the brain begin to fail, the dying person may experience hallucinations or especially vivid dreams. It is not uncommon during this period for the dying person to say they have seen loved ones who already died or have “conversations” with the dead. Additionally, the person may:

• Verbally acknowledge that they are dying
• Ask to see family members and loved ones one last time. 
• Withdraw from those around them and seem to be “in another world”
• Speak incoherently, often to no one in particular
• Near death awareness — an acute sensitivity to the reality that death is near

These behaviors can be alarming to loved ones, but they are very common and merely signs that the brain is beginning to shut down. 

Additionally, some individuals will experience a period of decreased social interaction before the physical changes associated with pre-active dying begin. This is typically a time when the person begins to consider their mortality and accept that death is near. Many people begin to withdraw from friends and loved ones and may even refuse visitors during this time as they come to terms with the reality that their life is coming to an end. Some may perform a formal or informal life review, in which they recollect and evaluate important memories and events from their lives. As part of this process, some dying persons will also work towards a sense of closure by reaching out to loved ones to reconcile, express love and gratitude, ask for forgiveness, and to remedy old hurts. 

Sources

“Life Review and Life-Story Work”. The Encyclopedia of Adulthood and Aging. https://onlinelibrary.wiley.com/doi/full/10.1002/9781118521373.wbeaa209