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.
Sepsis and reversible illness in palliative care
Palliative and end-of-life care · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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High-risk suspected sepsis
Suspected infection with high-risk physiology, organ dysfunction, neutropenia or rapidly progressive source can cause death within hours. Palliative care status must not delay emergency treatment when reversal and escalation remain consistent with the person's wishes.
Action: Use ABCDE care, calculate NEWS2, check glucose and lactate, obtain cultures and blood tests without delaying antibiotics and give source-appropriate intravenous antimicrobial treatment within the current NICE timeframe. Use reassessed 250 mL crystalloid boluses for hypoperfusion and involve senior, critical-care and source-control teams while confirming ceilings and capacity.
Synopsis
Recognise sepsis and other reversible deterioration without labelling every change as dying, assess urgency and treatment goals in parallel and use antibiotics, fluids, source control or a time-limited trial when benefit remains proportionate.
Palliative status does not exclude reversible illness. New confusion, hypotension, tachypnoea, hypoxia, reduced urine, rigors or functional collapse requires active assessment rather than automatic attribution to dying.
Sepsis is life-threatening organ dysfunction from infection; fever may be absent in older, neutropenic, corticosteroid-treated or dying patients.
First-line assessment combines ABCDE, NEWS2, infection source, perfusion, cognition, urine output, medicines and baseline trajectory with immediate review of the person's goals.
Use the current NICE adult sepsis risk criteria. High-risk suspected sepsis needs urgent bloods, cultures when they do not delay care, intravenous broad-spectrum antibiotics and senior review within the recommended emergency timeframe.
Measure lactate, blood culture, full blood count, renal and liver function, clotting and glucose and image or sample the likely source when results will change treatment.
Give small reassessed crystalloid boluses for sepsis-related hypoperfusion, not automatic litres; heart failure, kidney failure and frailty increase overload risk.
Source control—drainage, catheter change, surgery or relief of obstruction—may determine recovery more than repeated antibiotic escalation.
A DNACPR decision applies to cardiopulmonary resuscitation after arrest and does not itself refuse antibiotics, fluid, oxygen, hospital transfer or intensive care.
When benefit is uncertain, offer a time-limited treatment trial with an agreed target, review time and stopping rule instead of vague treatment 'for now'.
If active treatment is not wanted or cannot achieve recovery, relieve breathlessness, fever discomfort, pain, delirium and secretions and communicate that comfort care remains active treatment.
Key red flags
New confusion, reduced consciousness or a sudden major functional fall can be organ dysfunction even without fever.
Systolic hypotension, rising lactate, mottling, prolonged capillary refill or oliguria suggests impaired perfusion and possible shock.
Marked tachypnoea, new oxygen need, cyanosis or exhaustion indicates respiratory organ dysfunction.
Recent systemic anticancer treatment with fever or deterioration requires immediate neutropenic-sepsis assessment.
Pain out of proportion, rapidly spreading erythema, crepitus or bullae suggests necrotising soft-tissue infection.
Obstructed infected kidney or biliary system will not be cured reliably by antibiotics without urgent drainage review.
DNACPR must not be used as shorthand to withhold reversible treatment that the person would want.
High-risk sepsis
NICE high-risk criteria, marked lactate elevation, severe hypotension, respiratory failure or rapidly progressive infection requires emergency treatment and senior review.
Investigation priorities
01
ABCDE, NEWS2 and bedside glucoseFirst step
Quantify immediate airway, breathing, circulation, cognition and temperature risk and identify hypoglycaemia as a rapid alternative.
Management branches
High-risk sepsisTreat physiology and source immediately
Suspected infection meets current NICE high-risk criteria or causes rapidly progressive organ dysfunction.
Use ABCDE and NEWS2, obtain lactate, cultures and organ bloods, call senior help and confirm any known escalation limits without delaying rescue.
Give source-appropriate intravenous antibiotics within the emergency timeframe and 250 mL reassessed crystalloid boluses for hypoperfusion when safe.
Arrange urgent source control and critical-care review if within goals, then narrow treatment and revise fluid and organ support from response and results.
Key medicines
Empiric intravenous antimicrobial for high-risk sepsisGive the source-specific local broad-spectrum regimen within the NICE emergency timeframe, using allergy, previous microbiology, healthcare exposure, weight and renal and hepatic function to select and dose treatment.Obtain cultures first only if this causes no harmful delay; review daily for narrowing, route and duration and monitor kidney, liver, cytopenia, interaction and Clostridioides difficile risk.
Reassessed isotonic crystalloid bolusFor sepsis-related hypoperfusion in an adult, give 250 mL isotonic crystalloid over about 10 to 15 minutes and reassess before each further bolus, using the current NICE maximum and senior review.Heart failure, renal failure and frailty increase pulmonary-oedema risk; stop and escalate for worsening breathing, oxygenation, crackles or non-responsive shock.
Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
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.