End of Life Care in Frailty: Last days of life

Clinical guidelines
British Geriatrics Society
Date Published:
12 May 2020
Last updated: 
12 May 2020

The aim of this guidance series is to support clinicians and others to consider the needs of frail older people as they move towards the end of their lives and help them to provide high quality care.

This chapter looks at the final days of life in older people with frailty. Please click here to view the other chapters in this series.

Identifying that someone is in the last hours or days of life is important in order to minimise unnecessary investigations and to offer appropriate communication to patients and families. With no bedside test to confirm or refute this, it is frequently laden with uncertainty. Facilitating an end of life care plan is a holistic, patient-centred process which requires great skills, including confidence in identifying transitions in care, an ability to communicate ‘uncertainty’ in difficult circumstances and proficiency with medical ethics and law.

There are signs and symptoms common to the dying process and recognition of these patterns can be helpful in medical decision making (see Table): 1,2





  • Withdrawal from social interactions and distances him/herself


  • Acceptance that death is imminent
  • Retreats into him/herself
  • May be accompanied by a sense of calm acceptance

Routine care plans can be difficult to deviate from for fear of causing harm, despite an ‘intuition’ that (for example) turning someone in the last hour of their life may be inappropriate. Heuristic decision making is an ‘intuitive, rule-of-thumb’ process of thinking through a given problem that requires immediate attention; it allows practitioners to argue the pros and cons of a decision relating to care, in a simplistic framework that focuses on the information at hand. It has been shown to work well when rapid decision making is required in sub-optimal circumstances (such as when collateral history is unavailable). The evidence suggests that in end of life scenarios where this is the case, deviating from guidelines can positively influence care plans, while working within a transparent framework.

Clearly this does not obviate the need for specialist involvement to manage complex symptoms, and those requiring review over time. This is often the case in the difficult area of hydration and nutrition. An inability to safely eat and drink necessitates a medical review to look for reversible causes, but if no reversible cause is found (in advanced dementia, for example) the need to discuss parenteral options may arise. NICE advocates for a patient-specific approach to hydration, weighing the risk-benefits, and including a trial period of parenteral fluid in appropriate cases.4

Pros of Enteral and Parenteral Hydration

Cons of Enteral and Parenteral Hydration

Relieve thirst

Risk of aspiration and deterioration

Reduce agitation

Increase agitation by:

  • The sensation of putting fluids in the mouth
  • Oedema (pulmonary +/- peripheral)
  • Cannulation

Support better mouth care

  • Overlook other important methods of mouth-care, including saliva replacements and ice chips which may be more acceptable to the individual

Alleviate carer anxieties

  • Place pressure on carers who are uncomfortable with the responsibility of assisting with eating and drinking.
  • Potential to reinforce the wrong message if oral hydration is unlikely to be of benefit.

This approach is applicable across symptoms, allowing simple unmet needs (toileting, positioning) to be recognised and easily and appropriately corrected.

‘Parallel care’ which delivers active interventions alongside palliative symptom control may be entirely appropriate. This is particularly important where a person may have a hypoactive delirium. It is also a common dilemma in stroke care, where outcomes are so variable. In such instances, time to monitor and reassess response to treatment is valuable. In the absence of an Advance Care Plan that dictates otherwise, a presumption to ‘diagnose-treat’ is defensible. For example, cannulation for antibiotic administration and parenteral fluids may be appropriate, until a time when it can be seen that they are either causing harm, or not working. Absolute cut-offs in time are often less helpful than an individualised approach that incorporates joint decision making and close communication with family and carers.

From a medical perspective, end of life care should be the bar by which the delivery of other care is measured; great attention to detail is required monitoring for signs of change, both improvement and deterioration, often based on bedside examination alone. Clinical acumen and experience cannot be underestimated. Senior oversight is therefore of great significance in the last hours or days of life, to uphold high levels of clinical responsiveness and ensure advanced communication with loved ones is achieved, but equally, to ensure opportunities for mentorship and learning for junior colleagues and other team members are not missed.

With only one chance to get this right, open and honest communication with shared decision-making involving appropriately experienced personnel is essential.

  1. Diagnosing Dying; symptoms and signs of End Stage Disease.
  2. Benedetti et al. Support Care Cancer (2013) 21; 1509-1517. International Palliative care Experts’ View on Phenomena Indicating the Last Hours and Days of Life.
  3. Davies et al. BMC. Palliative Care (2016) 15;68. A Co-Design process Developing Heuristics for Practitioners providing End of Life Care for People with Dementia.
  4. Care of Dying Adults in the Last Days of Life. NICE Published December 2015.
  5. Guiding practitioners through end of life care for people with dementia: The use of heurisitics. Plos (14 November 2018). Nathan Davies et al.https://doi.org/10.1371/journal.pone.0206422
  6. NHS England. The 6C’s. www.england.nhs.uk. https://www.england.nhs.uk/6cs/wp-content/uploads/sites/25/2015/03/introducing-the-6cs.pdf

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