Dying is not a moment but a process. Internationally, palliative medicine distinguishes three phases — and a fourth point at which dying passes over into clinical death.
Pre-final phase
Weeks to months before death. Clinically marked by increasing weakness, loss of appetite, social withdrawal, sleep disturbances. The person as a rule remains capable of communication and judgment.
In terms of personal ontology, this is the phase in which the Personalist Norm is especially demanded: the person must not be reduced to her illness. Her First Dimension (personhood as such) is untouched; her Second and Third Dimension begin to change without thereby being extinguished.
Terminal phase
The last days up to one or two weeks. Clinically marked by increasing confinement to bed, changes of consciousness (delirium possible), reduced intake of food and fluids, changes in the breathing pattern. In the intensive care unit, the terminal phase is often the period in which a withdrawal of treatment (WLST) is decided — the controlled practice of donation after circulatory death begins here.
The person is restricted in the actual exercise of her faculties (Deutera Energeia). Her personhood (Prote Energeia) remains untouched by this — the same principle that also holds for the irreversible loss of brain function.
Actively dying phase
The last hours up to at most a few days. Clinically marked by loss of responsiveness, irregular or rattling breathing, mottling of the skin, coolness of the extremities, fixed pupils immediately before death.
The human person remains a person until the last breath. This principle distinguishes hospice work from euthanasia: where hospice work affirms personhood until the end, euthanasia ends it prematurely — a grave form of practical oblivion of the person.
Clinical death
The moment at which breathing and cardiac activity end, the pupils become fixed, and the body becomes still. Clinically and medically it marks the end of the dying phase.
Ontologically, the identification of clinical death with certain death is a normative stipulation, not an ontological identity. The question of when the separation of body and spiritual substance is really accomplished is answered by the ontology not through a clinical criterion but through the precautionary principle (Benedict XVI). In donation after circulatory death, clinical death is the starting point of the five-minute observation that is meant to secure permanence.
Ontological classification
Superordinate concepts: Dying (process), Death (event)
Ontological relations:
- sequence of phases: pre-final → terminal → actively dying phase → clinical death
- preserve personhood in every phase: the person remains a person
- clinical context of controlled donation after circulatory death (Maastricht III): typically the terminal/actively dying phase in the intensive care unit
- total-pain reference: in every phase the dimensions of Total Pain interact
Chapter assignment: Chapter 4: What Is Human Personhood? (German)
The point in terms of personal ontology
The differentiation of phases is not only clinically useful, it is load-bearing for personal ontology: whoever ties personhood to current functions sees the dying person as “less of a person.” Whoever follows the substance-ontological position advocated here sees in every phase the same whole person — only in different forms of actualization.
Sources: Generated by querying the Personhood ontology. Bexten 2017 — see the sections on dying, certain death, and the distinction between Prote Energeia and Deutera Energeia.
Further sources:
- Hui, David; dos Santos, Renata; Chisholm, Gary; et al.; Bruera, Eduardo (2014). Clinical signs of impending death in cancer patients. Oncologist 19(6): 681—687. Observational study of clinical markers of the dying phase.
- Hui, David; Hess, Karlie; dos Santos, Renata; Chisholm, Gary; Bruera, Eduardo (2015). A diagnostic model for impending death in cancer patients: Preliminary report. Cancer 121(21): 3914—3921. Diagnostic markers for the last days.
- Marie Curie UK: Stages of dying / End of life timeline. https://www.mariecurie.org.uk/information/end-of-life/stages-of-dying
- Crossroads Hospice & Palliative Care: What Is Active Dying? Signs, Symptoms, and 3 Stages Explained. https://www.crossroadshospice.com/hospice-resources/end-of-life-signs/what-is-active-dying/
- Lumina Hospice: Stages of Dying While in Hospice Care. https://www.luminahospice.org/stages-of-dying/
- Bundesärztekammer (2022): Richtlinie zur Feststellung des irreversiblen Hirnfunktionsausfalls (fifth revision).
- Benedict XVI (2008): Address to the International Congress on Organ Donation (“A Gift for Life”), Rome, 7 November 2008. https://www.vatican.va/content/benedict-xvi/en/speeches/2008/november/documents/hf_ben-xvi_spe_20081107_acdlife.html