The World Health Organization estimates that tens of millions of people need palliative care every year, and that only a small proportion receive it, with the largest gaps in low- and middle-income countries. Most people die in hospitals or at home, cared for by nurses who may have had little training in end-of-life care. Done well, it allows a person to die comfortably and with dignity, and helps the family through one of the hardest times of their lives.
What palliative care is
WHO defines palliative care as an approach that improves the quality of life of patients and families facing life-threatening illness, through the prevention and relief of suffering, physical, psychosocial and spiritual. It is not only for the last days: it can start at diagnosis alongside treatment, for people with cancer, heart failure, kidney failure, COPD, dementia, HIV and many other conditions.
Recognising the last days of life
- Increasing weakness and sleepiness; spending most of the day in bed.
- Little interest in food and drink; difficulty swallowing.
- Changes in breathing: pauses, irregular breathing, or noisy “rattly” breathing.
- Cool, mottled hands, feet and knees; reduced urine.
- Confusion or restlessness in some people.
When the team agrees someone may be dying, it should be discussed with the patient (if possible) and the family, and the plan of care should change: stop unnecessary tests, observations and medicines, and focus on comfort. Check for any advance decisions, and the patient’s resuscitation status.
Anticipatory medicines
In many countries, “just in case” medicines are prescribed in advance for the five common symptoms, usually given subcutaneously when the person can no longer swallow, or via a syringe driver:
| Symptom | Common drug groups (as prescribed) | Nursing measures |
|---|---|---|
| Pain | Opioids (e.g. morphine; oxycodone or alfentanil in kidney failure) | Regular assessment (including non-verbal signs), repositioning, gentle touch |
| Breathlessness | Low-dose opioids, benzodiazepines for anxiety | Sit upright, a fan towards the face, calm presence, open window |
| Nausea and vomiting | Antiemetics (e.g. haloperidol, levomepromazine, cyclizine) | Mouth care, small sips, remove strong smells |
| Agitation or restlessness | Midazolam; antipsychotics if delirium | Check for reversible causes: pain, full bladder, constipation; familiar faces and voices |
| Respiratory secretions (“death rattle”) | Antimuscarinics (e.g. hyoscine butylbromide, glycopyrronium) | Reposition on side; explain to family that it usually doesn’t distress the patient |
Opioids, used correctly and titrated to symptoms, do not hasten death. Fear of opioids, among families and staff, and restrictive national regulations are major barriers to pain relief worldwide. WHO includes oral morphine on its essential medicines list and encourages countries to make it available for palliative care.
Comfort care
- Mouth care every 1–2 hours: moisten lips and mouth, a dry mouth is one of the most distressing symptoms. Families can help.
- Food and fluids: offer sips and mouthfuls for pleasure if the person can swallow safely. Decisions about clinically assisted hydration are made individually and discussed with the family.
- Skin and pressure care, but turning frequency may be reduced if it causes distress.
- Bladder and bowel care: check for urinary retention and constipation.
- Eye care with moist swabs.
- A calm, peaceful environment: privacy, dimmed lights, quiet; let family stay as much as possible.
Talking with families
- Use clear words: “dying” rather than euphemisms that can confuse.
- Explain what to expect: changes in breathing, colour, consciousness.
- Reassure them that hearing may continue; encourage them to talk to and touch their loved one.
- Ask what matters to them, and who else should be called.
- Check their own needs: food, rest, a place to sit, spiritual support.
Culture and faith
Death is surrounded by deeply held beliefs. Ask the family about religious and cultural practices: prayers, presence of a faith leader, positioning, who may touch the body, and timing of burial. For example, many Muslim and Jewish families seek burial as soon as possible; many Christian families may want a priest or pastor for prayers; Hindu families may wish to place holy water or basil leaves. Never assume: ask, and accommodate as far as possible.
Care after death
- Record the time of death, and ensure verification and certification are done according to law and policy.
- Inform the family with compassion if they were not present, and give them time.
- Perform last offices with dignity, respecting cultural and religious wishes and infection control requirements.
- Return personal belongings carefully and document them.
- Give information about next steps (death certificate, mortuary, registration).
- Look after yourself and your team. A brief pause, a moment of silence, or a debrief helps.
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Based on WHO palliative care guidance and NICE guideline NG31 (Care of dying adults in the last days of life). Medicines and doses must follow your local palliative care formulary and prescription.