Synopsis
Recognise when a person may be entering the last days, test proportionate reversible explanations, communicate uncertainty honestly and replace burdensome routine care with an individual symptom, family, spiritual and practical plan that remains under review.
- 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.
Key red flags
Abrupt reduced consciousness after opioid escalation or kidney decline suggests toxicity rather than inevitable dying.
New focal weakness, severe back pain or sphincter dysfunction requires the MSCC or stroke pathway when treatment remains wanted.
Active major bleeding, stridor, seizure or uncontrolled pain needs an emergency response even under a comfort-focused plan.
A distended bladder, painful abdomen or overflow can cause severe agitation and is often rapidly treatable.
Hypoglycaemia should be checked promptly in diabetes, poor intake, insulin use or unexplained sudden drowsiness.
Family reports of an abrupt change from a stable baseline should be taken seriously even if observations appear only mildly abnormal.
Conflict about diagnosis, information or treatment should prompt senior and specialist review, not withdrawal from communication.
Abrupt collapse, severe new pain, bleeding, hypoglycaemia or medicine toxicity may be reversible and requires immediate goal-based assessment rather than automatic dying diagnosis.
Investigation priorities
Compare mobility, self-care, wakefulness, intake, swallowing, urine, symptoms and treatment response over recent days and weeks.
Confirm who has been told, information preferences, escalation, preferred place, anticipatory medicines and cultural or spiritual needs.
Management branches
A person with advanced illness shows progressive functional, intake, consciousness, circulation or breathing change.
- Compare the current state with recent baseline and seek nursing, family and disease-team observations, then assess symptom burden and immediate safety.
- Check proportionate reversible explanations such as glucose, medicines, retention, constipation, infection, calcium and bleeding according to goals.
- Seek senior multidisciplinary agreement, document evidence and uncertainty and state when the diagnosis and treatment plan will be reviewed.
The person is likely in the last days and the plan prioritises comfort and chosen relationships.
- Review every medicine, observation, test, device, oxygen, antimicrobial, fluid and nutrition intervention for short-term benefit, burden and withdrawal risk.
- Provide anticipatory symptom prescriptions with a feasible route and continue essential comfort or withdrawal-prevention treatment, plus mouth, skin, bladder and bowel care.
- Coordinate staffing, equipment, family support, overnight access, place of care and care-after-death preferences across all involved services.