Clinical Learning
Clinical 10: Advance care planning and care towards the end of life
Identifying people approaching the end of life, planning ahead, communicating uncertainty and applying NICE guidance for the last days of life.
Clinical safety: Use current guidance, local policy and patient-specific judgement.
Learning objectives
• Recognise when advance care planning may be appropriate • Explore goals, preferences and people important to the patient • Distinguish broader end-of-life planning from care in the last days of life • Communicate uncertainty and review plans as condition changes • Apply person-centred principles to symptom-focused care and treatment review
Clinical safety note
End-of-life decisions are highly individual and legally sensitive. Follow applicable mental-capacity law, consent guidance, local advance-care-planning policy and current palliative-care prescribing guidance. Seek specialist advice for complex symptoms or significant uncertainty.
Planning before the last days
End-of-life care can extend over weeks, months or longer. NICE NG142 supports systems that identify people who may be approaching the end of life so that discussions, coordination and advance care planning can happen before a crisis. Planning should explore the person's priorities, what matters to them, preferred place of care where appropriate, people they want involved, and how decisions will be revisited as circumstances change.
Communication and uncertainty
Prognosis is uncertain. Avoid presenting estimates as certainties. Share information sensitively, check understanding and involve those important to the person with consent or appropriate legal authority. Advance care planning is a process, not a one-off form. Review preferences when health, capacity, treatment options or circumstances change.
The last days of life
NICE NG31 addresses people thought to be in the last 2 to 3 days of life. Gather information about physiological, psychological, social and spiritual needs, clinical signs, the wider context, goals and wishes. Be alert to the possibility that the person may stabilise or improve. Avoid investigations unlikely to change care. Review medicines and interventions for continuing benefit, burden and alignment with goals.
Comfort, dignity and escalation
Good care includes symptom assessment, anticipatory planning, communication, hydration discussions, and access to appropriate palliative-care expertise. Exact medicines and doses should follow current local palliative-care and prescribing guidance. When there is significant uncertainty or complex symptom burden, seek advice from colleagues with appropriate experience rather than forcing certainty.
