# Care in the last days of life: recognising dying, hydration, symptom control and anticipatory medicines

Source: https://onco.cc/protocols/care-in-the-last-days-of-life/  
OnCo record `care-in-the-last-days-of-life` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

When someone may be in their last days, the team should say so honestly, plan care with them and their family, stop medicines that no longer help, keep their mouth moist and offer drinks if they want them, and prescribe 'just in case' medicines for pain, breathlessness, sickness, agitation and noisy breathing so that help is at hand without delay, including at home.

## Summary

NICE NG31 (2015) sets out the process: gather and document the person's needs, signs and wishes when dying is suspected; look for the signs that suggest it (agitation, Cheyne-Stokes breathing, falling consciousness, mottled skin, noisy secretions) while staying alert to recovery; reassess at least every 24 hours; discuss the prognosis honestly unless the person does not want to know; name a lead professional; and make an individualised care plan. Hydration is supported by mouth, with frequent mouth care; clinically assisted hydration is an individual decision, with a therapeutic trial considered for distressing signs of dehydration, monitored at least every 12 hours. MASCC (2024) adds that anyone with a prognosis of a week or more and insufficient intake should be considered for assisted hydration, and that a blanket policy either way is not justifiable. NICE gives no named doses; it advises the lowest effective dose, a syringe pump when more than 2 or 3 as-needed doses are given in 24 hours, no intramuscular injections, no routine oxygen, and specialist advice when symptoms do not settle. The drug classes it names are opioids or benzodiazepines for breathlessness, benzodiazepines for anxiety and agitation, antipsychotics for delirium, hyoscine butylbromide then octreotide for nausea from bowel obstruction, and atropine, glycopyrronium or hyoscine for distressing noisy secretions. Anticipatory medicines are prescribed early and individually, with indications and doses stated. The Korean guideline (2020) grades its parallel recommendations, for example opioids for dyspnoea B IIa and antipsychotics for delirium B IIb. One randomised trial (SILENCE, 2021) found that giving scopolamine butylbromide prophylactically once dying was recognised halved the rate of death rattle; no guideline read recommends prophylaxis.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: end of life care; last days of life; care of the dying; just in case medicines; anticipatory prescribing; anticipatory medicines; death rattle; noisy respiratory secretions; terminal agitation; terminal delirium; dying phase

## Connected records

- protocols: [Indwelling pleural catheter: draining fluid from the chest at home](https://onco.cc/protocols/indwelling-pleural-catheter-drainage-at-home/), [Malignant ascites: paracentesis and indwelling peritoneal catheter drainage](https://onco.cc/protocols/malignant-ascites-drainage/), [Palliative sedation for refractory suffering at the end of life](https://onco.cc/protocols/palliative-sedation-for-refractory-suffering/), [Strong opioids for cancer pain: starting, titrating, rescue doses and preventing constipation](https://onco.cc/protocols/strong-opioids-for-cancer-pain/), [Syringe driver (syringe pump): setting up and checking a continuous subcutaneous infusion in palliative care](https://onco.cc/protocols/syringe-driver-continuous-subcutaneous-infusion/)
- technologies: [Early integrated palliative care](https://onco.cc/technologies/palliative-care/), [Syringe pumps and subcutaneous syringe drivers](https://onco.cc/technologies/syringe-drivers/)
- terms: [Advance care planning](https://onco.cc/terms/advance-care-planning/), [Care of dying adults in the last days of life](https://onco.cc/terms/last-days-of-life-care/), [Palliative sedation](https://onco.cc/terms/palliative-sedation/), [ReSPECT (Recommended Summary Plan for Emergency Care and Treatment)](https://onco.cc/terms/respect-process/)
- ideas: [An antimuscarinic started when dying is recognised, to prevent the death rattle rather than treat it](https://onco.cc/ideas/idea-upgrade-prophylactic-antimuscarinic-when-dying-recognised/)

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