The dying patient

Identifying that a person is imminently dying

What it is

Imminent death means that the person’s decline in health is irreversible and they are likely to die in the coming hours, days, or weeks.

This is also referred to as 'actively dying' or 'entering the terminal phase'.

A person’s overall energy and strength declines as their disease advances. The signs that commonly indicate that a person is dying are caused by the body slowing down, the illness and/or treatments.

Why it matters

Everyone's experience of dying is different and it can be difficult to know when a person is reaching the last few days of their life.

Timely recognition that a person may be imminently dying and clear communication of that possibility enables the person to receive the best possible care, and those around them to be prepared and supported.

If a person dies peacefully without needless suffering, the family and carers have the best opportunity to see the death as a good death and have fewer difficulties as they grieve.

In practice

It is common for a person approaching the end of their life to spend increased time in bed and sleep for longer periods of the day. In the last few days of life, some people can change quickly from being reasonably independent to sleeping all of the time.

The signs that a person is entering the terminal phase include:

• deteriorating day by day or hour by hour
• becoming bed-bound for most of the day
• extreme tiredness and weakness
• sleepiness and drowsiness
• being less responsive and less able to communicate
• needing help with all personal care
• little interest in food or drink
• difficulty swallowing food, fluids and oral medication
• reduced urine output
• new urinary or faecal incontinence
• changes in their normal breathing pattern
• noisy chest secretions
• mottled skin and cold skin particularly hands and feet
• delirium
• the person telling you they feel like they're dying.

As a person approaches death, their pattern of breathing will often change, and may include:

• slow or irregular breathing
• periods of rapid, shallow breathing (similar to panting)
• episodes of apnoea with periods of deep, rapid breathing in-between (Cheyne–Stokes respiration)
• excessive but ineffective efforts to breathe deeply, known as agonal breaths
• noisy ‘rattly’ breathing associated with pooling of respiratory secretions.

There may be significant uncertainty about whether a person is entering the last days of life or stabilising or if there is potential for even temporary improvement. This may be due to inconsistent signs or symptoms or the fluctuating course of the person’s condition. Discussing with colleagues with more experience of providing end-of-life care may be helpful.

Nurses can:

• recognise the signs of imminent death
• look for signs that could indicate a reversible cause of decline such as dehydration, infection, opioid toxicity, delirium
• as appropriate, alert the doctor, specialist, and other members of the care team to the person’s deterioration (e.g. signs, rapidity of change, distress, person’s care wishes verbal or documented)
• contact the family and help them understand the dying process (e.g. as the changes to the person’s breathing can be difficult for family and carers to watch or hear, give an explanation, and reassure them that this is part of the normal process of dying and usually not distressing for the dying person)
• respond to family’s concerns with empathy and compassion
• be an important point of contact between the dying person and the family and other care providers
• continue to talk calmly with the person – hearing is believed to be the last sense to be lost
• provide terminal care in line with the person’s wishes.
  
  

Preparing for the last days of life at home

Preparing for the last days of life should happen before active dying starts. This can be part of advance care planning, care planning and/or triggered when signs of deterioration are recognised.

Preparing for the last days of life includes discussions around preferred place of care and of death.