LAST DAYS OF LIFE

• This is a core skill for all clinicians
• High quality care in the last days of life is essential to ensure a peaceful and dignified death
• Involves complex decision making and can be emotionally challenging

• Based on clinical assessment
• Consider potentially reversible conditions which can mimic dying
• e.g. renal failure, infection and hypercalcaemia
• If patient clearly in the dying phase, treatment of specific medical problems may not provide benefit to the patient
• In cases of uncertainty or disagreement, a second opinion may be helpful 

Responsibility for decision making

• Unless urgent and unavoidable, the responsible consultant decides in-hours that patient is dying and any changes in treatment plan

Communication

• Involve patients and their family in decisions about their care as far as possible
• Be open and honest
• explain that patient is in the last days of life
• acknowledge uncertainty about exact prognosis
• explain any changes to the plan of care
• allow patient and their family opportunity to ask questions
• build confidence and trust
• Can be challenging as patients often fatigued, confused or with a reduced level of consciousness

Treatment escalation and limitation plan

• Assess whether current treatments and interventions provide a benefit to patient
• e.g. making them more comfortable
• Decide which interventions would be helpful or not in the future
• If a resuscitation decision has not been made, address it now
• the cessation of cardiac and respiratory function is part of the natural dying process
• resuscitation cannot reverse this
• Document these decisions

Does patient have specialist palliative care needs?

• Refer to the Palliative Care Team if:
• pain or other symptoms, particularly if patient has required >2 doses of any PRN medication
• psychological distress
• complex social or family concerns
• assessment for a hospice bed
• difficult decision making

Nutrition and hydration

• Give all patients regular mouth care and support to take food and fluids when able
• Decide with each patient whether to continue/commence clinically assisted nutrition or hydration

Medications

• Prescribe SC anticipatory medications to treat common symptoms without delay. See Anticipatory prescribing below
• If patient experiences symptoms or takes regular medications for symptom control (e.g. strong opioids), they may require continuous SC infusion of medication. See Continuous subcutaneous infusions (CSCI) in palliative care guideline

Anticipatory prescribing

• Prescribe the following for all patients
• midazolam 2.5–5 mg SC hourly PRN for agitation or dyspnoea
• haloperidol 1.5–2.5 mg SC 4-hrly PRN for nausea and vomiting (maximum 5 mg/24 hr)
• hyoscine butylbromide 20 mg SC 4-hrly PRN for respiratory secretions (maximum 120 mg/24 hr)
• morphine sulphate 2.5–5 mg SC hourly PRN for pain or dyspnoea

Circumstances when prescribing may differ

• If patient has renal impairment (i.e. eGFR <50), hepatic impairment or is taking regular strong opioid, dose or type of opioid medication may need adjustment
• If patient has severe renal impairment (i.e. eGFR <20, on peritoneal or haemodialysis) adjust medications and doses as follows:
• midazolam 1.25–2.5 mg SC hourly PRN for agitation or dyspnoea
• haloperidol 0.5–1.5 mg SC 4-hrly PRN for nausea and vomiting (maximum 5 mg/24 hr)
• hyoscine butylbromide 20 mg SC 4-hrly PRN for respiratory secretions (maximum 120 mg/24 hr)
• oxycodone 1.25–2.5 mg SC hourly PRN for pain or dyspnoea 

• Document clearly decisions, plan of care and discussions with patient or family
• Use local documentation
• Use the purple bow scheme