Recognising the last days of life

Publicado 22 mayo, 2024

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Clinical practice guideline on palliative care for adults in the last days of life

Resumida HTML

Introduction Recognising the last days of life Communication and information Shared decision-making and development of a care plan Hydration Management of symptoms Palliative sedation

Question

What signs and symptoms should be evaluated when it is suspected that an adult patient with an advanced chronic condition may be in the last days of life?

Recommendations

When caring for people with progressive disease, at a very advanced stage, always establish their prognosis and identify whether they are in the last days of life (clinical status assessment) and record this in their medical record.
Support clinical judgement (the cornerstone for identifying the last days of life) by the following:
- Assessment of possible reversible causes of deterioration, especially when symptoms that appear are not consistent with the expected clinical trajectory.
- Monitoring of changes in patients’ physical, psychosocial and spiritual needs.
- Assessment of functional status and speed of decline. If considering the use of instruments for supporting this assessment, we suggest the Palliative Performance Scale (PPS) or the Eastern Cooperative Oncology Group (ECOG) Performance Status.
- Consideration of the opinions of other members of the multidisciplinary team, and if in doubt, consultation with experts.
Thoroughly investigate, in a proportionate manner and considering patients’ and relatives’ values and preferences, possible reversible causes of deterioration, such as dehydration, infection, opioid toxicity, steroid withdrawal, acute renal failure, and metabolic disturbances, to rule them out or initiate appropriate treatment, if applicable.

Look for the following:
- Cardiovascular changes:
  - Reduction in blood pressure
  - Oliguria
  - Motting of the skin
- Respiratory changes:
  - Noisy breathing (rattling)
  - Changes in breathing pattern: Cheyne-Stokes breathing, apnoea
  - Diyspnoea
  - Mandibular breathing
- Changes in physical condition:
  - Severe and progressive weakness
  - Loss of abbility to close eyes
  - Loss of interest in eating and drinking
  - Swallowing difficulties
  - Urinary incontinence or retention
- Cognitive and neurological changes:
  - Reduced level of consciousness (from somnolence to coma)
  - Hypoactive delirium or hyperactive delirium (characterised by agitation)
- Psychosocial and emotional changes:
  - Isolation
  - Changes in mood
- Changes in spiritual experience.

Rationale

We have made a weak recommendation in favour of assessing various signs and symptoms in patients with advanced progressive conditions, and a series of good clinical practice recommendations which aim to promote systematised assessment and the recording of the needs and preferences of patients and their relatives. The guideline development group (GDG) has taken into account the good benefit-risk balance, the importance for patients, and that such assessment might not imply significantly higher costs than usual clinical practice.

Complete clinical question

Full information on this question (available in Spanish), see:
http://portal.guiasalud.es/guia-en-capas/gpc_612_atencion_paliativa_sud-2/#question-1

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