Synopsis
Recognise possible dying without false certainty, distinguish reversible deterioration, communicate the working diagnosis and repeatedly reassess comfort, goals and recovery signals.
- Dying is a clinical conclusion based on trajectory and multiple domains, not a single observation or prognostic score.
- Common changes include increasing fatigue, reduced intake, dysphagia, worsening mobility, altered communication, drowsiness and social withdrawal.
- Cheyne–Stokes breathing, mottling, falling consciousness and noisy secretions can support the diagnosis but are not individually definitive.
- Always compare with the person's baseline and review for reversible causes whose treatment could restore comfort or valued function.
- Use existing tests first and request new investigations only when the result could change care in the available time.
- Describe the person as possibly dying, deteriorating, stable or improving and explain uncertainty plainly.
- Create an individual plan for symptoms, hydration, mouth care, medicines, family contact, spiritual needs and care after death.
- Reassess at least every 24 hours, and sooner when symptoms or observations change quickly.
Key red flags
A sudden change over minutes or hours suggests haemorrhage, seizure, hypoglycaemia, stroke, aspiration or medicine toxicity rather than uncomplicated gradual dying.
New severe pain, urinary retention, abdominal distension, faecal loading or an occluded catheter requires active assessment despite a comfort-focused plan.
Pinpoint pupils, bradypnoea, myoclonus, hallucinations or marked sedation raise concern for opioid accumulation, especially after renal deterioration.
An apparently terminal decline follows a new sedative, insulin, diuretic or antihypertensive change that may be reversible.
The team has declared dying from one isolated sign without reviewing baseline function, existing results, reversible causes or the multiprofessional view.
The person or family has not been told that recovery or temporary stabilisation remains possible.
Investigation priorities
Distinguish progressive decline from sudden change.
Management branches
Several physiological, symptomatic or functional changes suggest possible entry into the last days of life.
- Gather trajectory, goals, current signs, existing results and views from the person, important people and all involved disciplines.
- Examine for reversible causes of distress and decide which limited tests or treatments could change comfort or meaningful recovery.
- Record whether the person appears nearing death, deteriorating, stable or improving, including the degree and source of uncertainty.
- Seek experienced palliative or senior advice when signs conflict or temporary recovery remains plausible.
The working judgement is that dying is likely and burdensome routine care should be refocused.
- Review goals, escalation recommendations, medicines, hydration, nutrition, mouth care, pressure care, continence and spiritual or cultural needs.
- Stop interventions without current benefit while preserving symptom relief and treatment of reversible causes that fit the person's goals.
- Prescribe anticipatory routes and arrange nursing, equipment, pharmacy and out-of-hours support for the chosen setting.
- Prepare those important to the person for expected changes and offer practical participation they find acceptable.