Continuing care
When a patient enters the dying phase, unhelpful investigations and ineffective treatments should be discontinued, including blood tests, monitoring of vital signs and unnecessary medication.
Pressure sores can develop quickly and cause significant pain, so regular turning and appropriate pressure-relieving mattresses should be used promptly.
Constipation, urinary retention or incontinence can cause distress and agitation, so should be screened for and managed appropriately.
Thirst can cause considerable distress to patients and to their watching relatives. If a patient is awake enough to swallow, they should be offered and supported to take food and drinks, though appetite usually wanes as the dying process progresses. Frequent mouth and lip care with gentle cleaning, moistening, tongue brushing, denture care, sips of water and application of water-based lip gel is essential.
If these measures are insufficient to control thirst, clinically assisted hydration with subcutaneous or intravenous fluids can be considered. NICE recommends advising patients or relatives that this may relieve distressing symptoms, but cause other problems such as pulmonary oedema and that it is unclear if giving hydration extends the dying process, or conversely withholding it hastens death13. A therapeutic trial of clinically assisted hydration may be reasonable if the symptoms or signs of dehydration are distressing, regularly reviewed every 24 hours.
Learning Bite
During the dying phase, the emergency medicine clinician should stop unnecessary investigations, emphasise the need for excellent pressure area and mouth care, and consider if clinically assisted hydration is appropriate.