The dying patient, symptoms and carers

Recognise decline and agree goals

Palliative care addresses physical, psychological, social and spiritual needs in serious illness and can coexist with disease-directed treatment. It is not restricted to cancer or the last hours. Assess the trajectory, function, symptom burden and potentially reversible contributors to deterioration. Discuss what the patient understands and values, their preferred decision participants and place of care, and what treatments might achieve. A prediction of dying is uncertain; explain that uncertainty and review rather than promising an exact time or treating every deterioration as inevitable.

Assess capacity for the current decision, review a relevant advance care directive and identify the lawful substitute decision maker if necessary. A family request cannot override a competent patient's wishes. An order limiting CPR does not automatically prohibit antibiotics, fluids, oxygen or symptom treatment; specify the goals and escalation plan. Explain likely benefits and burdens of hospital transfer, ICU or invasive treatment in the person's circumstances. Record the plan clearly and hand it over across services so carers are not forced to retell a difficult discussion at every transition.

Pain and breathlessness

Characterise pain and seek treatable causes, using an assessment suited to communication ability. Use appropriate non-drug and drug treatment, with opioids selected and titrated to effect when indicated. Consider prior exposure, frailty, kidney/liver function, interactions, constipation and sedation. Routes change when swallowing fails; conversions require a current reference and independent checking where appropriate. Never assume different opioids are interchangeable milligram for milligram. Treat breakthrough symptoms and review the baseline regimen rather than repeatedly giving rescue doses without reassessment.

Breathlessness may improve with positioning, a fan, reassurance and treatment of reversible causes consistent with goals. Oxygen is useful for appropriate hypoxaemia but does not reliably relieve all non-hypoxaemic breathlessness. In selected palliative circumstances, low-dose opioid therapy can reduce distress, with monitoring and a plan suited to renal function and previous opioid use. It is not the same as unmonitored sedation of a person with an untreated acute reversible respiratory illness. Anxiety and family distress also deserve attention without assuming the symptom is purely psychological.

Delirium, secretions and other symptoms

New confusion prompts assessment for pain, retention, constipation, infection, medicines and metabolic illness, balancing investigations with goals. Provide a calm environment and familiar support. Medicines for severe distress or danger are individualised; routine chemical restraint is inappropriate. Terminal agitation can be multifactorial and may need specialist review. Nausea treatment follows likely causes and drug risks. Bowel care, mouth care, skin protection and pressure relief remain meaningful even when other preventive medicines are deprescribed.

Noisy respiratory secretions near death can distress relatives more than the unconscious patient. Explain the mechanism, use repositioning and avoid burdensome suction where unsuitable. Antisecretory treatment is selected under the symptom protocol; it does not remove secretions already present or guarantee silence. Reduced eating/drinking often accompanies dying. Offer comfort mouth care and small intake when safe and desired. Artificial hydration or tube feeding is not automatically beneficial or mandatory in every dying person; discuss possible benefit, overload, aspiration and burden individually.

Treatment limits and assisted dying

Withholding or withdrawing a treatment judged burdensome or declined differs from intentionally causing death. Continue comfort care and explain that stopping an ineffective intervention is not abandonment. Proportionate symptom treatment is selected to relieve suffering with clinical monitoring. Refractory symptoms may require specialist consideration of palliative sedation, with appropriate consent, documentation and governance; this is not a shortcut around difficult assessment. A patient asking to die deserves exploration of pain, depression, fear, coercion and unmet needs.

Voluntary assisted dying has jurisdiction-specific eligibility, assessments, safeguards and clinician duties. Do not import one state's process as an Australia-wide rule. Assess requests respectfully, explain the relevant lawful pathway within competence and obtain local expert advice. A request is not itself proof of incapacity or a mandate for immediate involuntary psychiatric treatment. Conversely, depression, delirium and coercion can affect capacity and voluntariness. Palliative care remains available regardless of a patient's interest in assisted dying.

Carers and cultural needs

Ask carers about exhaustion, practical tasks, sleep, finances and available support, with the patient's permission where applicable. Give clear medication instructions and emergency contacts, including whom to call after hours. Assess whether a home plan is realistic and arrange nursing, respite or inpatient support when needed. Grief can begin before death; offer bereavement support. Ask about religious, cultural and family practices without assuming everyone in a community wants the same rituals or decision structure.

For example, a dying patient with advanced cancer and renal impairment who cannot swallow needs a reviewed symptom regimen and route, not continuation of an unsafe oral prescription. A family distressed by secretions benefits from explanation and appropriate comfort measures. A patient with a no-CPR order who develops painful urinary retention still needs assessment and relief. These decisions test whether goals guide care specifically instead of turning a limitation order into a blanket refusal of treatment.

NSW last-days-of-life resources.

Review checkpoints

• Palliative care can accompany disease-directed treatment.
• Distinguish proportionate symptom relief from treatment intended to cause death.
• Voluntary assisted dying eligibility and processes depend on jurisdiction.