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.
- Capacity is presumed and decision specific. Support communication, treat delirium and assess whether the person can understand, retain, use or weigh and communicate the relevant information.
- A valid and applicable advance decision refusing life-sustaining treatment is legally binding when capacity is lost; an advance statement guides best interests but is not the same legal instrument.
- A health-and-welfare attorney can decide only within the authority granted and only when the person lacks capacity; consult the document rather than relying on a family title.
- DNACPR addresses CPR only. A treatment-escalation or ReSPECT plan separately explains hospital transfer, antibiotics, fluids, ventilation and other interventions likely or unlikely to help.
- Clinicians are not required to offer treatment that cannot work or provide overall benefit, but should explain the reasoning, involve the patient and offer review or second opinion when disagreement persists.
- Recognise possible last days through progressive bedbound weakness, reduced interaction, intake and urine, impaired swallowing, mottling and changing breathing, while checking reversible causes proportionately.
- Review every medicine: continue symptom benefit, stop non-beneficial prevention and convert essential treatment to subcutaneous, buccal, rectal or transdermal route when swallowing fails.
- Prescribe individual anticipatory medicines for pain and breathlessness, nausea, agitation and respiratory secretions with doses adjusted to current opioid, renal, liver, frailty and previous response.
- A continuous subcutaneous infusion is a reliable route for stable 24-hour requirements when swallowing fails; it is not inherently a higher dose or evidence that death is being hastened.
- Clinically assisted hydration is an individual therapeutic trial when thirst, delirium or dehydration might improve; review benefit and stop for oedema, secretion, discomfort or no response.
- Explain expected changes, provide mouth and pressure care, enable meaningful contact and give families a number to call, practical after-death information and bereavement support.
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.
A patient with capacity who refuses treatment must not be overridden because clinicians or relatives disagree; confirm understanding, voluntariness and the exact scope of refusal.
New fluctuating attention, hallucination or disorganised thinking suggests delirium and requires pain, urine, bowel, medicine, infection and metabolic assessment.
A DNACPR decision applies to cardiopulmonary resuscitation only and must never be used as shorthand for no antibiotics, fluids, transfusion, oxygen or hospital review.
Uncontrolled pain, breathlessness, agitation, nausea, secretion or repeated need for rescue medicine requires same-day palliative review and a reliable route.
Catastrophic haemorrhage or airway risk needs an anticipatory crisis plan, medicines and equipment available before the event whenever foreseeable.
Family conflict, concern about coercion or safeguarding, or uncertainty over attorney authority requires senior, legal, ethics or safeguarding support rather than informal compromise.
Investigation priorities
Establish what the person knows, values, fears, hopes to preserve and wants family and clinicians to decide if illness worsens.
Management branches
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.
- Document and share the agreed record with consent across oncology, primary, community, ambulance and palliative teams and review after major clinical change.