End-of-Life Care: Recognition, Communication, Planning and Care in the Last Phase of Life
Symptom assessment, anticipatory care and medicines in the last phase of life
Anticipatory medicines are prescribed in advance so that symptoms can be treated promptly if they arise, particularly when access to prescribing may be difficult out of hours. NICE recommends an individualised approach, with clear indications and routes, and requires assessment before administration. The presence of a 'just in case' medicine does not...
Learning objectives
• Assess symptoms before treating them and consider reversible contributors consistent with goals of care. • Explain the purpose and limits of anticipatory prescribing and distinguish prescribing from automatic administration. • Apply safe principles for pain, breathlessness, nausea, agitation/delirium and respiratory secretions without using a generic dose table. • Recognise when non-pharmacological care, medicine review or specialist palliative-care/pharmacy input is required.
Anticipatory prescribing is preparation, not automatic treatment
Anticipatory medicines are prescribed in advance so that symptoms can be treated promptly if they arise, particularly when access to prescribing may be difficult out of hours. NICE recommends an individualised approach, with clear indications and routes, and requires assessment before administration. The presence of a 'just in case' medicine does not mean that it should be given routinely or pre-emptively without a current indication.
Each administration should still answer five questions: what symptom is present; what is the likely cause; is this medicine appropriate for this person; what route is feasible; and how will benefit or harm be reviewed? Anticipatory prescribing should therefore be accompanied by an individualised care plan rather than a medicine box alone.
Medicine classes and clinical reasoning
This course deliberately does not provide a universal drug-and-dose table. Dose selection depends on prior opioid exposure, renal/hepatic function, frailty, interaction risk, local formulary, licensing and specialist advice. Learners should know the broad therapeutic aims: analgesia for pain; symptom-relieving treatment for breathlessness; antiemetics selected according to likely mechanism and patient factors; targeted management of anxiety/agitation/delirium; and, where indicated, medicines for distressing respiratory secretions.
The educational goal is safe reasoning, not memorisation of doses. Current local/national palliative-care formularies and prescribing systems remain the point of care source for medicine and dose selection.
Non-pharmacological comfort care remains central
Positioning, mouth care, a calm environment, reassurance, bowel/bladder care, fan or airflow where appropriate, pressure-area care and support for family members can materially improve comfort. Medication should not displace these measures. If distress persists despite first-line assessment and treatment, or if there are unwanted effects such as excessive sedation, NICE advises seeking specialist palliative-care input.
Intention matters: symptom relief is not assisted dying
Clinically appropriate symptom relief aims to alleviate suffering using proportionate treatment and review. GMC guidance is clear that professionals should provide treatment for pain and other distressing symptoms. This is ethically and professionally distinct from an intention to cause death. E9 addresses requests to hasten death separately so that learners do not confuse symptom control with assisted dying.
Applied scenarios
1. A dying patient becomes restless. Before escalating sedatives, the team checks for urinary retention, constipation, pain, delirium and medication toxicity.
2. Anticipatory medicines are available in the home, but carers are told they are only administered after assessment for the relevant symptom and according to the prescription.
3. A patient remains severely breathless despite initial measures and develops unwanted sedation. The team seeks specialist palliative-care advice rather than repeatedly escalating treatment without review.
Practice checklist
- Define each symptom and its likely cause.
- Use non-pharmacological comfort measures alongside medicines.
- Prescribe anticipatory medicines for likely needs, not by rote.
- Assess before every administration.
- Reassess benefit and adverse effects after treatment.
- Use current local/national formularies for medicine and dose details.
- Seek specialist advice when symptoms are refractory or treatment is causing harm.
Official sources
Authoritative Stage 2 source map
- S015 - GMC: Treatment and care towards the end of life: good practice in decision making. https://www.gmc-uk.org/professional-standards/the-professional-standards/treatment-and-care-towards-the-end-of-life
- S022 - NICE: NG31 Care of dying adults in the last days of life - recommendations. https://www.nice.org.uk/guidance/ng31/chapter/Recommendations
- S049 - NHS Wales Performance & Improvement: All Wales Care Decisions for the last days of life - guidance and documents. https://performanceandimprovement.nhs.wales/our-work/peolc/professionals/all-wales-care-decisions-for-the-last-days-of-life-guidance/
- S047 - Welsh Government: Quality statement for palliative and end of life care for Wales. https://www.gov.wales/quality-statement-palliative-and-end-life-care-wales-html
- S051 - Scottish Government: Palliative Care Matters for All: palliative care strategy 2025-2030. https://www.gov.scot/publications/palliative-care-matters-palliative-care-strategy-202530/
This module is educational. Recheck high/very-high update-risk sources immediately before publication and follow current local/national policy for clinical use.
