Doctor Tim O’Hanlon is currently writing a book tentatively entitled “The Four Stages of Active Dying.” He writes “I divide the dying into two groups - the actively dying, such as the patients under hospice care and the passively dying, which includes everyone else. My primary concern of late has been on providing music for the actively dying. However, as far as choosing appropriate music is concerned, the same rules apply to the living. This is because they are based, not on the level of physical or mental deterioration but on the level of cognition and conscious awareness.

It's important to note that, by dividing the dying process into four stages, I am using a linear gauge. The actual process is cyclical, like a downward spiral. The four stages are not separate or distinct divisions but overlapping phases that flow and blend into one another, like the colors in the rainbow.

Remember that what distinguishes one stage from another is the level of cognition and awareness and the degree to which the patient's attention is directed outward versus inward.

O’Hanlon then describes the general characteristics of the Four Stages of the Dying Process

Stage I: Mostly on “this side”

General characteristics:  High cognition and level of responsiveness. Most of the attention is directed outward. Patient is still mainly concerned and identified with externals, or things of this world: Family, friends, occupation, possessions, finances, etc. Patient is also more egocentric and identified with personality and personal preferences -- likes and dislikes play a major role at this stage and one would be wise to take these into consideration.

I recommend using music and other media (videos) that comforts and creates a pleasant, positive environment, while gently directing the attention inward, towards the business at hand. Whether the person is dying or suffering from dementia or a debilitating disease, I suggest that both the patient and the caregiver accept the process. I believe that Dylan Thomas was wrong when he advised: "Don't go gently into that good night". From what I have experienced and observed, resistance, or what the Tibetan Buddhists call clinging and grasping, invariably adds to stress and suffering.

If a patient is in Stage 1: First, determine the patient's preferences - ask if the person likes music and what kind he or she likes or dislikes. Find and use positive music or media that meets these criteria.

At this stage, you should pretty much provide what the patient wants, within reason. Try to encourage the patient to listen to and watch positive media.  Be aware of what the patient is watching on TV and try to direct his or her attention away from the negative and towards the positive.

Do not leave the TV on while the patient is sleeping, especially if it’s tuned to a commercial station (more about positive and negative music and media).

Stage II: Turning Inwards

Characteristics of Stage 2: Noticeable change in orientation, or direction, of attention, from outward to inward.  Patient is more reconciled to the fact that he or she is dying and his attention starts turning away from the things of this world. Though the patient is still mostly here, this stage marks the beginning of a shift in attention and values, from materialistic to spiritual. These values can be reflected and supported by the music or media that is chosen.

Stage III: Mostly Inward

Characteristics of Stage 3: Attention is now mostly directed inward. Patient is in and out of consciousness. Most of the things, on the outside, that were important in Stage I and II are not important, or as important as they were before.

It's important to note that, as the patient goes deeper into the dying process and becomes outwardly less responsive, he or she is still very sensitive, in some ways, more sensitive and aware than in the waking state. Just because he does not respond to outside stimuli, does not mean that he or she is not aware of them. It has been proven that music has a measurable effect on people in comas or under anesthetics. When I go into surgery, or to the dentist's office, I always bring my own music and a device to play it on. Patients can also hear your voice and are aware of your presence, feelings and intentions.

They will also be conscious of the music that is playing, though they may not experience it as music but as vibration. It is my contention that they are not only aware of the music but that it contributes significantly to the visual and emotional content of their inner reality.

I recommend, from here on, that Stage 3 and 4 music be played softly in the background, continually, 24-hours a day, until an hour or so after the patient stops breathing.

Stage IV: Final Stage of “Active Dying”

 Characteristics of Stage 4: Consciousness of patient is totally inward-oriented. Patient is actively dying, seemingly oblivious to outside stimuli.

It's important that the music at this Stage be harmonious, peaceful, loving and reassuring, so that the dominant idea or impression in the mind of the dying person is that he or she is loved and cared for. The music should embody the words voiced by the Father at the baptism of Jesus: "This is my beloved Son (child), in whom I am well pleased."

My wife, Mary, and I were privileged to care for Mary's mother and father for the last three years of their lives. Mary's mother, Elizabeth, passed away, under hospice care, in our home. From the time that she entered Stage 3, until she died, we played harmonic music continually, 24-hours a day.

I was with Elizabeth, about six hours before she died. For the past day or so, she had been mostly unconscious and unresponsive. When I finished turning her that morning, she suddenly woke up, with a beautiful, beaming expression on her face. She reached out to me and, firmly grasping my hand, looked into my eyes and said two words, "Thank you". Obviously, she had gotten the message.