01Purpose and principlesWhat the treatment does and how it fits into care.
Recognition combines the underlying illness with change over time. A person with advanced cancer may deteriorate over days, while organ failure or frailty can fluctuate. Ask the team and family whether there has been a step down in mobility, alertness, intake, communication and self-care. Consider whether treatment response has ended and whether the person is spending more time asleep or unable to leave bed.
Clinical signs become more frequent near death but are not individually diagnostic. Reduced appetite and thirst, dysphagia, increasing drowsiness, delirium, reduced urine, mottled cool limbs, weak pulse, noisy upper-airway secretions, irregular breathing and apnoeic pauses may develop. Cheyne–Stokes respiration can be striking but is not necessarily distressing to the unconscious patient; family need an explanation and ongoing symptom assessment.
Before concluding that dying is occurring, assess plausible reversible causes at a depth consistent with prior wishes and achievable benefit. Check glucose quickly, review opioids and sedatives, examine for retention and faecal impaction and consider infection, hypercalcaemia, renal failure, hypoxia, bleeding and treatment toxicity. A short treatment trial may be appropriate, but it needs a target and a review point rather than open-ended escalation.
Diagnosis should be shared across the team, ideally with a clinician experienced in the person's disease. Record the evidence, uncertainty, alternatives considered and the senior decision. Electronic flags and handover should state current goals and escalation. If there is disagreement or the course is unexpected, seek specialist palliative or disease-team advice and continue comfort care during review.
Communication is a clinical intervention. Ask how much the person wants to know and whether they want family present. Use direct but conditional language: the changes suggest they may be dying and time may be short, while exact timing cannot be known. Pause, listen and address questions about suffering, food, breathing and what relatives should do. Offer an interpreter rather than relying on family for complex conversations.
Create an individual last-days plan. Review symptom medicines and route because swallowing may fail; stop preventive medicines without short-term benefit; reduce routine observations and blood tests; decide oxygen, antibiotics, fluids and clinically assisted nutrition separately. Continue treatment that maintains comfort, such as anticonvulsants, corticosteroids preventing recurrent neurological symptoms or insulin preventing symptomatic metabolic crisis, with adapted monitoring.
Nursing care is central. Moisten and clean the mouth, manage dentures, position for comfort, use pressure-relieving surfaces and avoid painful turning without premedication. Assess urinary retention and whether catheterisation would reduce distress. Give privacy but do not leave a frightened person isolated. Explain to family that reduced intake is part of dying and invite safe participation in mouth and personal care if they want it.
Plan practical and cultural care before crisis. Confirm preferred place, overnight support, emergency contacts, anticipatory medicines and verification arrangements. Ask about prayers, rituals, modesty, visitors, music, organ or tissue donation wishes and care after death. Review at least daily; if alertness, intake or function improves, reopen diagnosis and previously stopped treatments without embarrassment.
Key points
- Dying is a clinical judgement based on trajectory, disease, function and a cluster of signs; no single observation, score or test proves that death is imminent.
- Common changes include becoming bedbound, profound weakness, reduced desire or ability to eat and drink, increasing sleep, reduced urine, altered breathing and peripheral cooling.
- First-line review asks whether infection, hypercalcaemia, medicine toxicity, hypoglycaemia, retention, constipation, bleeding or another reversible problem explains the change and whether treating it matches the person's goals.
- Use senior multidisciplinary assessment and repeat it when uncertainty remains. Document ‘may be dying’ rather than presenting an uncertain prediction as certainty.
- Tell the person, if they wish to know, and those important to them that time may be short; explain what changes may occur, what the team will do and whom to contact.
- Review medicines, observations, blood tests, oxygen, fluids, nutrition, devices and care setting individually; stop interventions whose burden now exceeds likely benefit.
- Prescribe anticipatory medicines for pain, breathlessness, agitation, nausea and respiratory secretions with a clear route, dose, indication and escalation plan.
- Frequent mouth care, comfortable positioning, pressure protection, bladder and bowel attention and calm presence remain active clinical care even when intake falls.
- Explore cultural, spiritual, religious and family needs, preferred visitors, rituals, privacy and place of care without making assumptions from identity.
- Reassess at least daily and whenever the condition changes; people can stabilise, and the last-days plan must be revised if the trajectory no longer fits.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
The person becomes bedbound, needs complete care, communicates less and no longer recovers after sleep or minor exertion.
Interest in food and drink falls, swallowing becomes effortful and oral tablets, large sips or forced feeding create coughing or distress.
Longer sleep, reduced attention, intermittent agitation and diminishing response become more prominent as cerebral perfusion and metabolism change.
Falling urine output, weak peripheral pulse, cooling, mottling and lower blood pressure reflect reduced perfusion but vary between individuals.
Irregular rate, shallow breaths, apnoeic pauses, Cheyne–Stokes pattern and pooled upper-airway secretions often appear near death.
Abrupt collapse, severe new pain, bleeding, hypoglycaemia or medicine toxicity may be reversible and requires immediate goal-based assessment rather than automatic dying diagnosis.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
First-line trajectory assessmentFirst stepFirst line - Why
- Compare mobility, self-care, wakefulness, intake, swallowing, urine, symptoms and treatment response over recent days and weeks.
- Interpretation and limitations
- Concordant progressive decline across domains supports dying more than one isolated sign or abnormal observation.
- 02
Focused bedside examination - Why
- Assess comfort, consciousness, breathing pattern, perfusion, mouth, bladder, bowel, skin and focal neurological or infective features.
- Interpretation and limitations
- Findings guide immediate relief and identify a reversible problem without automatically triggering burdensome full-system examination.
- 03
Bedside glucose and targeted tests - Why
- Use glucose, bladder scan, oxygen measurement or selected blood tests only when a plausible result could change goal-concordant care.
- Interpretation and limitations
- A rapidly correctable abnormality may reverse decline; normal tests cannot provide a gold-standard confirmation of dying.
- 04
Medicine and route reconciliation - Why
- Review every prescription, recent dose, kidney and liver change, withdrawal risk and ability to swallow or absorb treatment.
- Interpretation and limitations
- Accumulation or abrupt cessation may mimic dying; route failure also predicts loss of symptom control unless an alternative is planned.
- 05
Senior multidisciplinary clinical review - Why
- Combine disease trajectory, specialist knowledge, bedside changes, nursing observation, family report and patient preference.
- Interpretation and limitations
- This repeated clinical synthesis is the practical reference standard; prognostic tools can inform but never prove the last days.
- 06
Communication and plan auditPreferred - Why
- Confirm who has been told, information preferences, escalation, preferred place, anticipatory medicines and cultural or spiritual needs.
- Interpretation and limitations
- Gaps create avoidable crisis even when recognition is correct and should be repaired during the same review.
04Treatment approachPreparation, options, escalation and aftercare.
01RecognitionSynthesize trajectory and reversible causesFirst stepA person with advanced illness shows progressive functional, intake, consciousness, circulation or breathing change.+
- 1Compare the current state with recent baseline and seek nursing, family and disease-team observations, then assess symptom burden and immediate safety.
- 2Check proportionate reversible explanations such as glucose, medicines, retention, constipation, infection, calcium and bleeding according to goals.
- 3Seek senior multidisciplinary agreement, document evidence and uncertainty and state when the diagnosis and treatment plan will be reviewed.
02ConversationExplain that time may be shortThe clinical team believes the person may be dying and information can support decisions and preparation.+
- 1Ask what the person knows and wants to know and who should join; use an interpreter and assess capacity for the decisions at hand.
- 2Explain plainly that the changes suggest dying, acknowledge uncertainty about timing, pause and address concerns about symptoms, food and family roles.
- 3PreferredConfirm priorities, preferred place, spiritual or cultural needs and emergency contacts and document what was said and who should receive updates.
03Individual planReplace low-value routine with comfort-focused careThe person is likely in the last days and the plan prioritises comfort and chosen relationships.+
- 1Review every medicine, observation, test, device, oxygen, antimicrobial, fluid and nutrition intervention for short-term benefit, burden and withdrawal risk.
- 2Provide anticipatory symptom prescriptions with a feasible route and continue essential comfort or withdrawal-prevention treatment, plus mouth, skin, bladder and bowel care.
- 3Coordinate staffing, equipment, family support, overnight access, place of care and care-after-death preferences across all involved services.
04ReassessmentChange the plan when the trajectory changesThe person improves, develops a new symptom, survives longer than expected or patient and family understanding changes.+
- 1Repeat symptom, function, intake, consciousness and reversible-cause assessment at least daily and after any material change.
- 2If the person stabilises, say so, reconsider medicines and investigations and revise prognostic language without framing earlier uncertainty as failure.
- 3If deterioration continues, adjust doses and routes, update family and place-of-care support and anticipate practical and bereavement needs.
05Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- Review pain, breathlessness, agitation, nausea, secretions, mouth, bladder, bowel and skin at every care contact appropriate to the setting.
- Assess swallowing before each oral medicine round and switch route before repeated missed doses cause withdrawal or symptom recurrence.
- Reassess function, alertness, intake, urine, breathing and reversible explanations at least daily and whenever change is reported.
- Record anticipatory medicine use, effect and adverse effects and seek specialist advice when repeated rescue doses fail.
- Ask family what they are seeing and whether explanations, contact routes and participation in care remain clear and acceptable.
- Review whether preferred place remains safe and achievable as dependency, night needs and caregiver capacity change.
- After death ensure verification, certification referral, device and property processes and cultural or spiritual wishes are followed respectfully.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Recognition is iterative
A careful diagnosis can still change; reassessment and honest revision are signs of good practice rather than failure.
Uncertainty can be shared
Saying that someone may be dying conveys seriousness while preserving truth when exact timing cannot be known.
Swallow failure predicts route failure
Waiting for complete inability to take tablets creates avoidable withdrawal, seizure or pain before alternative medicines are ready.
Reduced intake is not neglect
Explaining the physiological loss of appetite helps families replace pressure to eat with mouth care, touch and chosen tastes.
Observation can become burden
Routine blood pressure or blood tests add little when they cannot change treatment and interrupt sleep or family time.
Culture is personally defined
Ask about rituals and modesty directly; membership of a group does not reliably predict an individual's wishes.
07Common pitfallsFrequent interpretation and management errors.
- 01
Using one sign or prognostic score as proof that death is imminent.
- 02
Missing opioid toxicity, hypoglycaemia, retention or infection because the patient has advanced disease.
- 03
Telling family with certainty that death will occur within a precise time unsupported by the clinical picture.
- 04
Avoiding the word dying and leaving relatives unable to prepare.
- 05
Stopping every medicine without checking withdrawal, seizure, steroid and symptom consequences.
- 06
Continuing routine observations, blood tests and tablets after they cease to provide benefit.
- 07
Waiting for severe symptoms before prescribing a feasible non-oral rescue route.
- 08
Assuming reduced intake requires forced feeding or automatic intravenous fluid.
- 09
Making cultural assumptions rather than asking the person and family.
- 10
Failing to reverse the plan when the person stabilises or improves.