29th December 2024

Prognosis and the dying patient

Accurately estimating prognosis can be difficult, and some patients surprise us with their trajectories. Reflecting on the time frame over which changes are happening can be an effective way of explaining their prognosis – e.g. if they have found that they have become worse each month, week or day, they may have in the region of months, weeks or days left respectively.

At the very end of life, there are patterns to dying, and recognising these can be helpful to allow us to care for our patients at the end of their lives:

• Day-to-day changes
• Reduced physical activity – reduced mobility, becoming weaker and more fatigued, sleeping more, bed bound
• Reduced mental activity – reduced cognition, communication, reduced consciousness
• Reduced intake – food, fluids, and medications
• Terminal agitation
• Peripheral cyanosis, mottled skin, cool to touch
• Breathing changes – apnoea or cheynes-stokes breathing

Anticipatory medications are often prescribed to manage some of the symptoms that we can predict may arise in the last days of life. These are subcutaneous medications to tackle pain (e.g. morphine), agitation (e.g. midazolam), secretions (e.g. glycopyrronium bromide), and nausea (e.g. haloperidol), and are prescribed or provided in advance to minimise any delays if they are needed. They are not to hasten the journey to death but are to make it as comfortable as possible.

References

• Mannix K. With the end in mind: how to live and die well. London: William Collins; 2019
• National Institute for Health and Care Excellence. Scenario: Terminal phase [Internet]. NICE. 2021 [cited 2022 Feb 13]. Available from: https://cks.nice.org.uk/topics/palliative-care-general-issues/management/terminal-phase/