Recognising the last days of life


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?


  1. 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.
  2. 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.
  3. 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.

  1. 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.



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:


7. Bayés R. Morir en paz: evaluación de los factores implicados. Med Clin (Barc).2004;122(14):539-41. DOI:10.1016/S0025-7753(04)74299-2.

22. National Institute for Health and Care Excellence. Care of dying adults in the last days of life. London: National Institute for Health and Care Excellence; 2015. [accessed 12 Oct 2018]. Available from: www.nice.org.uk/guidance/ng31.

23. Baik D, Russell D, Jordan L, Dooley F, Bowles KH, Masterson Creber R. Using the Palliative Performance Scale to estimate survival for patients at the end of life: a systematic review of the literature. J Palliat Med. 2018;21(11):1651-61. DOI: 10.1089/jpm.2018.0141.

24. Ellershaw J, Ward care of the dying patient: the last hours or days of life. BMJ. 2003;326(7379):30-4.

25. Kennedy C, Brooks-Young P, Brunton Gray C, Larkin P, Connolly M, Wilde-Larsson B, et al. Diagnosing dying: an integrative literature review. BMJ Support Palliat Care. 2014;4(3):263- DOI: 10.1136/bmjspcare-2013-000621.

26. Christakis NA, Lamont EB. Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study. BMJ. 2000;320(7233):469-72. DOI: 10.1136/bmj.320.7233.469.

27. Middlewood S, Gardner G, Gardner Dying in hospital: medical failure or natural outcome? J Pain Symptom Manage. 2001;22(6):1035-41. DOI: 10.1016/s0885-3924(01)00362-1.

28. Fins JJ, Miller FG, Acres CA, Bacchetta MD, Huzzard LL, Rapkin BD. End-of-life decision-making in the hospital: current practice and future. J Pain Symptom Manage. 1999;17(1):6-15. DOI: 10.1016/s0885-3924(98)00109-2.

29. Toscani F, Di Giulio P, Brunelli C, Miccinesi G, Laquintana D. How people die in hospital general wards: a descriptive study. J Pain Symptom Manage. 2005;30(1):33-40. DOI: 10.1016/j.jpainsymman.2005.01.013.

30. Neuberger J, Guthrie C, Aaronovitch D, Hameed K, Bonser T, Harries R, et al. More care, less pathway: a review of the Liverpool Care Pathway. Liverpool: Independent Review of the Liverpool Care Pathway; 2013.

31. Chiang JK, Lai NS, Wang MH, Chen SC, Kao YH. A proposed prognostic 7-day survival formula for patients with terminal cancer. BMC Public Health. 2009;9:365. DOI: 10.1186/1471-2458-9-365.

32. Kao YH, Chen CN, Chiang JK, Chen SS, Huang WW. Predicting factors in the last week of survival in elderly patients with terminal cancer: a prospective study in southern Taiwan. J Formos Med 2009;108(3):231-9. DOI: 10.1016/s0929-6646(09)60057-7.

33. Escalante CP, Martin CG, Elting LS, Price KJ, Manzullo EF, Weiser MA, et al. Identifying risk factors for imminent death in cancer patients with acute dyspnea. J Pain Symptom Manage. 2000;20(5):318-25.

34. Hui D, dos Santos R, Chisholm G, Bansal S, Silva TB, Kilgore K, et al. Clinical signs of impending death in cancer patients. Oncologist. 2014;19(6):681-7. DOI: 10.1634/theoncologist.2013-0457.

35. Loekito E, Bailey J, Bellomo R, Hart GK, Hegarty C, Davey P, et al. Common laboratory tests predict imminent death in ward patients. Resuscitation. 2013;84(3):280-5. DOI: 10.1016/j. resuscitation.2012.07.025.

36. Loekito E, Bailey J, Bellomo R, Hart GK, Hegarty C, Davey P, et al. Common laboratory tests predict imminent medical emergency team calls, intensive care unit admission or death in emergency department patients. Emerg Med Australas. 2013;25(2):132-9. DOI: 10.1111/1742-6723.12040.

37. Matsunuma R, Tanbo Y, Asai N, Ohkuni Y, Watanabe S, Murakami S, et al. Prognostic factors in patients with terminal stage lung cancer. J Palliat Med. 2014;17(2):189-94. DOI: 10.1089/jpm.2013.0448.

38. Hui D, Dos Santos R, Chisholm G, Bansal S, Souza Crovador C, Bruera E. Bedside clinical signs associated with impending death in patients with advanced cancer: preliminary findings of a prospective, longitudinal cohort study. Cancer. 2015;121(6):960-7. DOI: 10.1002/cncr.29048.

39. Johnson DC, Kutner JS, Armstrong JD, 2nd. Would you be surprised if this patient died?: Preliminary exploration of first and second year residents’ approach to care decisions in critically ill patients. BMC Palliat Care. 2003;2(1):1.

40. Dendaas NR. Prognostication in advance cancer: nurses’ perceptions of the dying process. Oncol Nurs 2002;29(3):493-9. DOI: 10.1188/02.onf.493-499.

41. van der Werff GF, Paans W, Nieweg RM. Hospital nurses’ views of the signs and symptoms that herald the onset of the dying phase in oncology patients. Int J Palliat Nurs. 2012;18(3):143-9. DOI: 10.12968/ijpn.2012.18.3.143.

42. Abarshi E, Echteld M, Donker G, Van den Block L, Onwuteaka-Philipsen B, Deliens L. Discussing end-of-life issues in the last months of life: a nationwide study among general practitioners. J Palliat Med. 2011;14(3):323-30. DOI: 10.1089/jpm.2010.0312.

43. Domeisen BF, Ostgathe C, Clark J, Costantini M, Daud ML, Grossenbacher-Gschwend B, et al. International palliative care experts’ view on phenomena indicating the last hours and days of life. Support Care Cancer. 2013;21(6):1509-17.

44. Brandt HE, Deliens L, Ooms ME, van der Steen JT, van der Wal G, Ribbe MW. Symptoms, signs, problems, and diseases of terminally ill nursing home patients: a nationwide observational study in the Netherlands. Arch Intern Med. 2005;165(3):314-20. DOI: 10.1001/archinte.165.3.314.

45. Christakis NA, Lamont EB. Extent and determinants of error in physicians’ prognoses in terminally ill patients: prospective cohort West J Med. 2000;172(5):310-3. DOI: 10.1136/ ewjm.172.5.310.

46. Kumagai Y, Maekawa A, Abe M. Prognostic items for the last 10 and 3 days of life of cancer patients at home. Cancer Nurs. 2012;35(5):390-6. DOI: 10.1097/NCC.0b013e318235287d.

47. Fosse A, Zuidema S, Boersma F, Malterud K, Schaufel MA, Ruths S. Nursing home physicians’ assessments of barriers and strategies for end-of-life care in Norway and The Netherlands. J Am Med Dir Assoc. 2017;18(8):713-8. DOI: 10.1016/j.jamda.2017.03.005.

48. Hui D, Bansal S, Park M, Reddy A, Cortes J, Fossella F, et al. Differences in attitudes and beliefs toward end-of-life care between hematologic and solid tumor oncology specialists. Ann Oncol. 2015;26(7):1440-6. DOI: 10.1093/annonc/mdv028.