Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
!
Catastrophic symptom or decision crisis
Major haemorrhage, airway obstruction, status epilepticus, severe agitation, uncontrolled pain or breathlessness, or urgent treatment conflict when capacity and wishes are unclear requires immediate comfort, physiological and legal decision support.
Action: Stay with the patient, call appropriate emergency and palliative help, provide rapid symptom relief and use dark towels and calm presence for catastrophic bleeding while applying any valid refusal or agreed ceiling. Establish decision-specific capacity, consult the health-and-welfare attorney or best-interests team when required and do not equate DNACPR with withholding other beneficial treatment.
Synopsis
Start voluntary future-care conversations before crisis, document values, capacity, decision-makers and treatment limits accurately, distinguish reversible deterioration from the last days of life and provide individualised symptom, communication, family, spiritual and bereavement care.
Advance care planning is a voluntary, revisable conversation about values, worries, acceptable outcomes, preferred care, decision-makers and treatments if health worsens; it is not one form.
Start when the patient is well enough to think and revisit after progression, hospital admission, treatment change or functional decline; ask permission and match the pace.
Record what matters, what the person understands, whom they want involved and any health-and-welfare lasting power of attorney, advance statement or advance decision to refuse treatment.
Key red flags
Sudden deterioration must be assessed for reversible sepsis, bleeding, hypercalcaemia, obstruction, thrombosis, opioid toxicity or treatment complication before it is labelled dying.
Uncontrolled terminal symptom
Repeated rescue need, grimacing, tachypnoea, panic, agitation, vomiting or distressing secretion requires prompt reassessment of cause, dose, route and infusion.
Investigation priorities
01
First-line goals and understanding conversationFirst stepFirst line
Establish what the person knows, values, fears, hopes to preserve and wants family and clinicians to decide if illness worsens.
Management branches
Advance planningBuild a portable values-and-decision record
The person is living with advanced cancer and willing to discuss future care.
Ask permission, explore understanding, values, unacceptable outcomes, preferred people and place and explain prognosis as a range with uncertainty.
Offer advance statement, attorney, advance-decision and emergency-care-plan information in accessible language without making completion a condition of care.
Key medicines
Subcutaneous morphine for pain or breathlessnessIn an opioid-naive adult in the last days, give morphine 2.5 to 5 mg subcutaneously every 2 to 4 hours as needed; derive any 24-hour infusion from response and prior total exposure.
Subcutaneous midazolam for terminal agitationGive midazolam 2.5 mg subcutaneously as needed, often hourly under the local last-days protocol, and use a 24-hour infusion only after assessing effective rescue requirement and reversible causes.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.