Care of dying adults in the last days of life

Managing pain and other symptoms

Although not everyone has symptoms, some are common in the last days of life, such as pain, dehydration, nausea and vomiting, breathlessness, feelings of anxiety, agitation and delirium (when a person can be confused or struggle to understand or remember, or their personality may change).

If someone has any of these symptoms they should be offered treatment to help them to stay as comfortable as possible. The care team should check for possible causes of the symptoms and explain which treatments might help. The best treatment might involve taking a medicine, but other types of treatment may be tried too. For example, sometimes simple things like using a fan or opening a window might help with breathlessness, or changing a person's position might help with noisy breathing or to relieve pain. Sometimes a treatment will help with whatever is causing the symptom. Other treatments might be given just to help relieve the symptom and make the person more comfortable.

Pain relief

Not everyone is in pain in the last days of their life, but if someone is they should be offered help to relieve it quickly. Sometimes things like a full bladder can cause pain, and this should be relieved as soon as possible.

Painkillers can often help to relieve pain. To decide on the best type of painkillers for the person, an assessment should be carried to find out how much pain they are in, and they should be asked how they would like to take their painkillers.

Managing breathlessness

Sometimes breathlessness is caused by problems that can be treated, such as fluid in the lungs, and treatment should be offered to help. However, even if a particular cause is not found, help should be given to relieve breathlessness, and the person may sometimes be offered medicine for this.

Oxygen won't usually be given to help with symptoms of breathlessness, unless the person also has low levels of oxygen in their blood, for example from a lung condition.

Managing nausea and vomiting

If the person has nausea or vomiting their doctor should check for possible causes, such as stomach or bowel problems or side effects of treatments, and discuss the different treatment options with them. Medicine may sometimes help, although some medicines may have side effects, such as drowsiness. When deciding on the best treatment, the doctor should check for possible problems with other medicines being taken and discuss with the person any possible side effects.

Managing anxiety, delirium and agitation

People often feel anxious in the last days of their life, and may feel agitated or become delirious (when a person can be confused or struggle to understand or remember, or their personality may change). The doctor should check for possible causes, such as psychological problems or physical problems (for example sometimes agitation is caused by pain or a full bladder) and discuss the possible treatments with the person.

For some people a medicine may be offered to see if that will help. If that doesn't work or if it causes unwanted drowsiness, the doctor should ask for advice from a specialist.

Treating noisy breathing

Sometimes saliva or mucus builds up in the person's throat or chest and can't be cleared, making a noise during breathing (which is sometimes known as a 'death rattle'). This is unlikely to cause any discomfort to the person, but it might be upsetting, particularly for the people who are important to them. There should be a chance for them to talk about any fears or concerns with the care team, and any treatments that might help should be explained.

The doctor might suggest trying a medicine if noisy breathing is upsetting to the person who is dying. Checks should be made often (ideally every 4 hours and at least every 12 hours) to see if it is helping and to detect any problems caused by the medicine, such as a dry mouth, delirium or drowsiness. If there are problems or it isn't working after 12 hours it might be stopped or a different medicine may be tried.

Keeping people hydrated

If someone becomes dehydrated it can make them feel very dry and uncomfortable, and can sometimes make them confused or delirious, which can be very upsetting. It is important to avoid this and keep people comfortable, so signs of dehydration should be checked for every day and help should be given help to keep their mouth and lips moist.

However, some people may not want to drink in the last days of their life, and swallowing may become difficult. People who do want to drink should be given help to carry on drinking if they can still swallow. While they are drinking it is important that they are checked for problems with swallowing or drinks going down the wrong way.

If someone has problems swallowing or can't manage to drink enough, they can become dehydrated. Their doctor might suggest giving them fluids through a drip or tube to see if this helps. This might help make them more comfortable, but for a person who is already at the end of their life, it won't necessarily help them live longer and it might not be the best option for everyone. The doctor should explain that it is not known for sure whether the person might take longer to die if they are given fluids in this way, or if dying might happen sooner without them.

There are also some possible side effects that might affect people when they are given fluids in this way (such as too much fluid in the body tissues). These should be explained and there should be the opportunity to talk about any concerns or worries.

When someone is getting extra fluid through a tube or drip, they should be checked every 12 hours. The amount of fluid might be reduced or stopped if the side effects are causing any problems, or if they decide they don't want it anymore.