It is important that the patient is known to have advanced disease or frailty and that reversible causes of deterioration have been excluded.
The dying phase can usually be recognised from a combination of the following features:
- Evidence of ongoing deterioration despite active treatment indicative that their condition is irreversible
- Profound weakness
- Being bed-bound or comatose
- Little interest in food/fluids
- Unable to swallow tablets
- Changes in breathing pattern
- Skin changes due to peripheral vasoconstriction
The assessment that a patient is in the last days of life should be made by the multidisciplinary team in discussion with the patient and relatives as appropriate.
Priorities for care of the dying person.
When it is thought that a person may die within the next few days or hours:
- This possibility is recognised and communicated clearly, decisions made and actions taken in accordance with the person’s needs and wishes, and these are regularly reviewed and decisions revised accordingly
- Sensitive communication takes place between staff and the dying person, and those identified as important to them
- The dying person, and those identified as important to them, are involved in decisions about treatment and care to the extent that the dying person wants
- The needs of families and others identified as important to the dying person are actively explored, respected and met as far as possible
- An individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, coordinated and delivered with compassion
At this stage, only drugs that are required for comfort and symptom control should be prescribed:
a) Stop non-essential medication e.g.
- Cholesterol-lowering agents such as statins
- Anti-hypertensive drugs
- Levothyroxine
b) Prescribe medication via a suitable route (e.g. subcutaneous injection or syringe driver/pump) for:
- Pain
- Nausea and vomiting
- Agitation
- Secretions
- Breathlessness
There will be geographical variation in recommended drugs for the dying phase (eg morphine vs diamorphine). Please cross reference with local guidelines/prescribing policies.
Consider appropriate dose reductions in severe frailty or organ failure (see previous chapters)
c) Essential drugs that cannot be given by the usual route should be changed to an alternative (e.g. anticonvulsants converted to subcutaneous midazolam, steroids to dexamethasone sc).
Disclaimer
This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.