Care of dying adults

Red Flags

Acute reversible cause of deterioration (sepsis, electrolyte, hypercalcaemia, drug toxicity, urinary retention) — investigate and treat where consistent with care goals^[1]
Severe uncontrolled symptoms (pain, dyspnoea, agitation) — anticipatory medications urgently administered; specialist palliative care^[1]
Distress, family conflict, or unaddressed psychosocial / spiritual concerns — multidisciplinary palliative care input^[1]
Suspected over-sedation or paradoxical agitation — review medication doses; consider switching agent or rotating opioid^[1]

First-line treatment

Interventions

Communication and shared decision making^[1]
Sensitive disclosure of dying phase; ascertain patient and family priorities; agree on goals of care, place of care, and DNACPR status; document; revisit as needed
Anticipatory prescribing (5 essentials)^[1]
Prescribe in advance for: pain (morphine), dyspnoea (morphine), nausea (haloperidol or levomepromazine), agitation/restlessness (midazolam), respiratory secretions (hyoscine butylbromide or glycopyrronium); 4-hourly PRN with breakthrough doses; subcutaneous route preferred when oral not tolerated
Symptom control with continuous subcutaneous infusion (CSCI / syringe driver)^[1]
When PRN doses ≥3 in 24 h or oral route not tolerated; titrate based on prior 24-h requirements; monitor and adjust daily; combine appropriate agents (analgesic + antiemetic + anxiolytic) per local protocol
Hydration and nutrition (individualised)^[1]
Discuss with patient and family; clinically assisted hydration neither routinely beneficial nor harmful in last days; small volumes may improve comfort or worsen secretions; review regularly; avoid forced oral intake
Family and carer support^[1]
Information about expected changes, bereavement support, practical guidance (registration of death, funeral arrangements); involve faith leaders per family preference; access to palliative care helpline 24/7

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Morphine sulfate (pain or dyspnoea)^[1]	Opioid analgesic	Opioid-naive: 2.5–5 mg SC PRN every 4 h; titrate per response. Established opioid: convert oral total dose to SC equivalent (oral:SC = 2:1)	—	First-line for pain and dyspnoea; subcutaneous route via butterfly needle; convert to CSCI for steady control; counsel about constipation, drowsiness, nausea
Midazolam (agitation, restlessness, terminal seizures)^[1]	Benzodiazepine	2.5–5 mg SC PRN every 1 h; CSCI 10–60 mg/24 h titrated	—	First-line for anxiety, restlessness, terminal restlessness, seizures; 1:1 PRN to CSCI titration; sedation expected
Haloperidol (nausea, delirium)^[1]	Typical antipsychotic / antiemetic	0.5–1.5 mg SC every 4 h PRN; CSCI 1.5–5 mg/24 h; max 10 mg/24 h	—	First-line antiemetic and for delirium; lower dose for elderly; QTc consideration; alternative metoclopramide unless complete bowel obstruction
Levomepromazine (multimodal antiemetic + sedation)^[1]	Phenothiazine	6.25–12.5 mg SC every 8 h PRN; CSCI 12.5–25 mg/24 h, titrate to 200 mg	—	Useful when haloperidol insufficient; sedating; multimodal antiemetic effect; postural hypotension
Hyoscine butylbromide or glycopyrronium (secretions)^[1]	Anticholinergic	Hyoscine butylbromide 20 mg SC PRN; CSCI 60–240 mg/24 h. Glycopyrronium 200 µg SC PRN; CSCI 600–1200 µg/24 h	—	For respiratory secretions; positioning and reassurance also help; glycopyrronium does not cross BBB (less sedation/confusion)

Morphine sulfate (pain or dyspnoea)^[1]

Opioid analgesic

Adult: Opioid-naive: 2.5–5 mg SC PRN every 4 h; titrate per response. Established opioid: convert oral total dose to SC equivalent (oral:SC = 2:1)
Paediatric: —

First-line for pain and dyspnoea; subcutaneous route via butterfly needle; convert to CSCI for steady control; counsel about constipation, drowsiness, nausea

Midazolam (agitation, restlessness, terminal seizures)^[1]

Benzodiazepine

Adult: 2.5–5 mg SC PRN every 1 h; CSCI 10–60 mg/24 h titrated
Paediatric: —

First-line for anxiety, restlessness, terminal restlessness, seizures; 1:1 PRN to CSCI titration; sedation expected

Haloperidol (nausea, delirium)^[1]

Typical antipsychotic / antiemetic

Adult: 0.5–1.5 mg SC every 4 h PRN; CSCI 1.5–5 mg/24 h; max 10 mg/24 h
Paediatric: —

First-line antiemetic and for delirium; lower dose for elderly; QTc consideration; alternative metoclopramide unless complete bowel obstruction

Levomepromazine (multimodal antiemetic + sedation)^[1]

Phenothiazine

Adult: 6.25–12.5 mg SC every 8 h PRN; CSCI 12.5–25 mg/24 h, titrate to 200 mg
Paediatric: —

Useful when haloperidol insufficient; sedating; multimodal antiemetic effect; postural hypotension

Hyoscine butylbromide or glycopyrronium (secretions)^[1]

Anticholinergic

Adult: Hyoscine butylbromide 20 mg SC PRN; CSCI 60–240 mg/24 h. Glycopyrronium 200 µg SC PRN; CSCI 600–1200 µg/24 h
Paediatric: —

For respiratory secretions; positioning and reassurance also help; glycopyrronium does not cross BBB (less sedation/confusion)

Safety-net

Anticipatory medications mean we are prepared, not that we expect rapid deterioration; we will reassess regularly and discuss any concerns^[1]
Family contact information for the palliative care team should be visible at home; out-of-hours support exists for urgent symptom control^[1]
Bereavement support and follow-up after death is part of palliative care; ask about local bereavement services^[1]

Referral criteria

Complex symptoms not controlled with anticipatory prescribingSpecialist palliative care^[1]
Existential distress, family conflict, or complex psychosocial needsMultidisciplinary palliative care with social work, chaplaincy^[1]
Death at home and out-of-hours supportLocal palliative care helpline; community nursing^[1]
Bereavement support for familyBereavement service or counselling per local provision^[1]

Clinical summary

Recognising the dying phase, anticipatory prescribing, symptom control, and family support for adults in the last days of life.

References

1.NICE Guideline NG31 — Care of Dying Adults in the Last Days of Life (2015, updated 2021); WHO Palliative Care; Indian Association of Palliative Care Standards (2021)