End-of-Life Care: Recognition, Communication, Planning and Care in the Last Phase of Life
Individualised care in the last days and hours
The central lesson from NICE NG31 is individualisation. Once a person may be entering the last days of life, the team should communicate the uncertainty, identify what matters, assess symptoms and hydration, review medicines and interventions, and keep the plan under active review. A standard form can improve reliability, but it must not replace clinical...
Learning objectives
• Build an individualised plan that integrates recognition, communication, comfort care, medication review, hydration and family support. • Avoid rigid pathway thinking and review each intervention for current benefit and burden. • Recognise improvement or stabilisation as a trigger to revisit the diagnosis of dying and the care plan. • Coordinate care across shifts/settings so that the person and family receive consistent information and support.
A plan is a prompt for thinking, not a licence for automatic withdrawal
The central lesson from NICE NG31 is individualisation. Once a person may be entering the last days of life, the team should communicate the uncertainty, identify what matters, assess symptoms and hydration, review medicines and interventions, and keep the plan under active review. A standard form can improve reliability, but it must not replace clinical judgement.
Automatic cessation of observations, antibiotics, insulin, fluids, oxygen or regular medicines simply because a 'dying pathway' has been started is unsafe. Each intervention should be considered against likely benefit, burden, goals and the person's current condition.
Basic nursing and supportive care are core clinical interventions
Positioning, mouth care, skin and pressure-area care, toileting, continence support, privacy, a calm environment and help with communication are not optional extras. For some people these measures contribute more to comfort than additional medication. Family members may wish to participate in simple care such as mouth care or offering sips and should be supported safely if they choose.
Medication review should be selective, not indiscriminate
Preventive medicines with no plausible near-term benefit may be stopped, while treatments that provide current symptomatic or goal-related benefit may remain important. The correct question is not 'what can we stop?' but 'what is this medicine achieving now, what burden does it impose, and does it still fit the care goals?' This reduces both overtreatment and inappropriate withdrawal.
Communication should be planned and consistent
Families commonly become distressed when different clinicians offer different explanations. The plan should record what has been discussed, what remains uncertain, who is the main contact, and what changes the family should expect. Honest phrases such as 'we are concerned that time may be short, but we will keep reviewing' are safer than false certainty.
Cultural, spiritual and religious needs should be explored as individual preferences, not inferred from group identity. Interpreters and communication support should be used where needed.
Review protects against diagnostic momentum
NICE explicitly recognises that a person may deteriorate, stabilise or improve temporarily. If the clinical picture changes, the plan must change. A person who becomes more alert, drinks, eats or otherwise improves should not remain on an unchanged last-days plan through inertia. Reassessment is therefore a safety intervention, not administrative tidying.
Applied scenarios
1. A standard last-days form is started and every regular medicine is stopped, including one controlling distressing seizures. The team restores individual review.
2. A person thought to be dying becomes more alert and begins eating the next morning. The diagnosis and care plan are reassessed rather than continued automatically.
3. Relatives receive conflicting explanations from different teams. A named communication plan and documented key messages improve continuity.
Practice checklist
- Document the level of prognostic certainty.
- Review each intervention individually.
- Keep basic nursing and comfort care visible in the plan.
- Use medication review rather than blanket discontinuation.
- Plan consistent communication with the person and family.
- Explore cultural/spiritual preferences individually.
- Reassess promptly if the clinical picture changes.
Official sources
Authoritative Stage 2 source map
- 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/
- 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
- 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/
- S056 - Department of Health NI: Advance Care Planning: For Now and For The Future. https://www.health-ni.gov.uk/publications/advance-care-planning-now-and-future
This module is educational. Recheck high/very-high update-risk sources immediately before publication and follow current local/national policy for clinical use.
