Palliative & End of Life Care

Pain

• WHO analgesic ladder — step up, not straight to strong
• Paracetamol and NSAIDs useful alongside stronger drugs
• Morphine is first-line strong opioid; start low, titrate
• Co-prescribe laxative and antiemetic with opioids
• Breakthrough dose = 1/6th of total 24-hour dose
• Neuropathic: amitriptyline, gabapentin, or pregabalin
• Non-pharmacological: repositioning, heat, massage, TENS

Nausea & vomiting

• Match antiemetic to cause
• Cyclizine for vestibular or raised ICP
• Metoclopramide for gastric stasis (not bowel obstruction)
• Haloperidol for chemical and metabolic causes
• Levomepromazine if cause unclear
• SC route if vomiting persists

Breathlessness

• Low-dose oral morphine (2.5–5 mg) reduces the sensation
• Fan blowing cool air across the face — evidence-based
• Position: upright, leaning forward, or patient preference
• Oxygen only helps if hypoxic
• Midazolam for anxiety-driven breathlessness

Constipation & mouth

• Start laxatives when opioids are started
• Softener + stimulant combination (docusate + senna)
• Macrogols for impaction
• Mouth care every 2–4 hours
• Moisten lips with water-based balm
• Check for oral thrush

Recognising dying

• Increasing drowsiness and withdrawal
• Reduced oral intake
• Mottled skin, peripheral cyanosis
• Cheyne-Stokes breathing
• Reduced urine output
• General withdrawal from surroundings

Medication review

• Stop non-essential medications
• Convert essentials to SC route
• Set up syringe driver if multiple drugs needed
• Anticipatory prescribing for pain, nausea, breathlessness, agitation, secretions

Comfort care

• Mouth care every 2–4 hours
• Repositioning for comfort
• Continence care with dignity
• Pressure area care continues
• Gentle hygiene

Environment & family

• Side room if possible
• Reduce noise and bright lights
• Allow personal items, photos, music
• Flexible visiting
• Keep family informed of changes
• Reassure about what is normal

Setting up

• "I'd like to talk about what's ahead. Is now okay?"
• Find a private space — not a corridor
• Sit down, eye level, phone on silent
• Ask who they'd like present
• Have tissues and water available

During the conversation

• "What is your understanding of where things are?"
• "I wish I had better news."
• "What matters most to you right now?"
• "We will make sure you are comfortable"
• "You don't have to decide anything today"
• Be clear — say "dying" when that is what you mean

Advance care planning

• ADRT is legally binding
• Lasting Power of Attorney for Health
• "Have you thought about what you'd want if you couldn't speak for yourself?"
• Document and share with GP, hospital, ambulance

Supporting relatives

• "If you need a break, that is okay"
• "It is normal for breathing to change like this"
• "There is no right or wrong way to grieve"
• Offer tea. Show them the bathroom.
• Small kindnesses matter enormously

Home

• Often the patient's preference
• District nursing support needed
• Anticipatory medications at home
• Equipment: hospital bed, syringe driver
• Clear out-of-hours plan
• GP and palliative team involved

Hospice

• Specialist palliative care, calm environment
• Expert symptom management
• Family support and bereavement services
• Referral via GP or hospital palliative team

Hospital

• May be needed for complex symptoms
• Aim for a side room
• Palliative care team involved
• Flexible visiting, reduce clinical clutter

Care home

• Many residents die in care homes
• Staff need palliative care training
• Access to anticipatory medications
• GP and community palliative team closely involved

Verification

• Can be performed by RN or doctor
• Check heart sounds, breath sounds, pupils for 5+ min
• Document time, who verified, who present

Last offices

• Wash and prepare with dignity
• Remove non-essential lines
• Respect cultural and religious wishes
• Offer family the chance to help

Documentation

• Complete nursing notes and notification forms
• Property documented carefully
• Handle belongings sensitively — a carrier bag of possessions handled badly stays with families forever

Bereavement

• Give written information about next steps
• Cruse Bereavement Care, Macmillan, Marie Curie
• Some wards send a follow-up card
• Staff debrief and wellbeing support

Spiritual needs

• Ask about religious or spiritual needs
• Offer chaplaincy
• Some patients want prayer, readings, or rituals
• Some want nothing — respect that too

Cultural practices

• Some families wish to wash the body themselves
• Specific requirements about who handles the body
• Timing of burial may be important
• Ask — do not assume based on appearance or name

Ethical decisions

• DNACPR: not restarting the heart, not withdrawing care
• Best interests decisions if patient lacks capacity
• Withdrawing treatment is ethically equal to withholding
• Mental Capacity Act applies

Student nurse role

• Be present — sitting with someone matters
• Offer practical help: tea, blankets, directions
• Ask your mentor what you can do
• It is okay to feel emotional
• Write a reflective account
• Debrief with someone you trust