Terminal Care

Source: eTG.

Recognising when death is approaching

A period of deterioration often occurs in the weeks leading up to the terminal phase: accelerating disease progression; progressive loss of strength/energy (the patient spends most of their time in bed); increasing periods of sleep; and declining interest in food, with oral intake mostly fluids.

The terminal phase is the last days of life, when the patient is actively dying: totally bed-bound; poorly responsive or unconscious; unable to swallow; minimal/no urine output; changing breathing pattern; peripheral shutdown (pale, mottled skin).

During the deterioration period, discuss with family/carers what may happen around the time of death, and make sure there’s a clear plan for the patient’s preferred place of death — ideally documented earlier through advance care planning, not first raised at this stage.

Place of care

Most, but not all, patients wish to die at home — though this may not be possible depending on the level of support required. If a patient is going to die at home, make sure carers know: how to recognise death; who to call (GP or another authorised person to certify death); and the need to contact a funeral director.

Medication review and anticipatory prescribing

Stop unnecessary medication and transition off oral medications for symptom control as swallowing becomes unreliable. Complete resuscitation planning in consultation with the patient and family, including a not-for-resuscitation order.

Prescribe anticipatory (subcutaneous/buccal) medications ahead of need, and coordinate with the patient’s regular pharmacy to ensure timely availability. Australia’s National Core Community Palliative Care Medicines List (2025) standardises four medications for community symptom control in the terminal phase: clonazepam drops, haloperidol injection, hyoscine butylbromide injection, and morphine injection. This doesn’t replace clinical judgement — complex cases (renal failure, Parkinson’s disease, frail elderly) warrant specialist palliative care consultation rather than relying on the list alone.

Pain

Often expressed as agitation — look for the cause; urinary retention is a commonly missed one. Medication often needs starting anticipatorily.

Opioid-naive patients: morphine 2.5–5 mg SC 4-hourly, or 10–15 mg/24 hours by continuous SC infusion, plus 2.5–5 mg PRN 1-hourly. If 3+ PRN doses are given in a day, increase the background dose.

Dyspnoea

Try non-pharmacological measures first: reposition the patient, provide cool air (open a window or use a fan), maintain a calm environment.

Pharmacological — opioids or benzodiazepines can be used:

• Opioid-naive: morphine 1–2.5 mg SC 1-hourly PRN. If already on regular opioids, give a PRN dose of the existing opioid.
• Benzodiazepine-naive: clonazepam 0.2–0.5 mg SC/SL 2-hourly PRN, or midazolam 0.5–1 mg SC 2-hourly PRN.

Oxygen should not be used routinely in the last days of life — breathlessness here is often driven by metabolic changes rather than hypoxia, so oxygen doesn’t help and can reduce comfort (tethering the patient, drying nasal mucosa).

Respiratory tract secretions (“death rattle”)

Distressing to carers, but unlikely to be uncomfortable for the patient themselves — reassure carers of this. Reposition the patient to allow pooled secretions to drain; suction visible pooled secretions in the oral cavity.

Anticholinergics can be given, though evidence supporting them is limited — start early if they’re going to help, and stop if there’s no benefit after 12–24 hours:

• Glycopyrronium 200 mcg SC 2-hourly
• Hyoscine butylbromide 20 mg SC 2-hourly

Neither crosses the blood-brain barrier, so neither should cause delirium.

Nausea and vomiting

Not usually a new problem in the last days of life — if present earlier, it typically settles during this phase. Regurgitation of stomach contents is common and often mistaken for vomiting by carers; clarify this distinction, since antiemetics won’t help true regurgitation.

If genuinely new N&V: haloperidol 0.5–1 mg SC 4-hourly, or metoclopramide 10 mg SC 8-hourly.

Agitation

Usually multifactorial in the terminal phase. Look for a correctable underlying cause: pain, breathlessness, delirium, medication toxicity, metabolic disturbance.

General measures: calm environment; presence of people familiar to the patient; catheter for urinary retention; laxative suppositories for faecal loading.

If no cause is found, trial haloperidol or a benzodiazepine: clonazepam 0.2–0.5 mg SC/SL 2-hourly PRN, midazolam 2.5 mg SC 1-hourly PRN, or haloperidol 0.5–1 mg SC 4-hourly PRN. If more than 3 doses are needed in 24 hours, consider prescribing regularly.

Palliative sedation

A distinct, third-line intervention — the deliberate reduction of consciousness to relieve refractory and intolerable symptoms (pain, dyspnoea, agitation/terminal restlessness, nausea) in a patient with a predicted prognosis of under 2 weeks, once standard therapy has been exhausted. It differs from ordinary titrated symptom control (which aims to relieve distress without deliberately lowering consciousness) and is ethically and legally distinct from euthanasia or physician-assisted suicide: the intent is symptom relief, not ending life, and success is judged by symptom control rather than death — the doctrine of double effect is the usual ethical framework applied.

Is a symptom refractory? Before considering sedation, confirm: the symptom hasn’t responded to a reasonable, timely trial of standard treatment; further treatment would carry unacceptable side effects or delay; and the symptom is genuinely physical (or has a clearly identified psychological/existential component being addressed in parallel) — rule out reversible contributors like urinary retention, constipation, or medication effects first.

This is not routinely used or initiated in general practice — it’s normally overseen by a specialist palliative care service (inpatient or via consultation into a home/RACF setting), with multidisciplinary planning, informed consent (from the patient or substitute decision-maker), and careful documentation of the indication, prognosis, treatments already tried, and family discussion. A GP’s role is usually recognising when it may be needed and referring early, and supporting the patient/family through the process — not initiating it independently.

Typical drug choices (specialist-guided): midazolam first-line (tolerance/dose escalation over time can occur; rare paradoxical excitation); levomepromazine if there’s significant nausea or delirium (lowers seizure threshold, requires Special Access Scheme paperwork in Australia); phenobarbitone for inadequate response to the above (needs individualised dosing, injection-site necrosis risk); propofol as a last resort in the final days, requiring IV access and specialist input. Opioids for analgesia are continued alongside sedation, with their own toxicity (myoclonus, pinpoint pupils) monitored and dosed accordingly.

Hydration/nutrition decisions are addressed case-by-case, respecting cultural/religious/psychological factors — many patients reaching this point have already stopped oral intake from their underlying decline, and evidence doesn’t support artificial hydration/nutrition improving comfort or survival in this setting. Routine nursing care (bowel/bladder, eye/mouth/ skin) continues throughout.

After the patient has died

Verify death — must be done by an authorised person (doctor, ambulance officer, nurse). In some states (e.g. NSW) this must happen before the body is moved.

Complete the death certificate — requirements vary by state; in some states any medical practitioner with access to the record can complete it, in others it must be the treating practitioner.

Complete a cremation certificate if relevant — particularly important where the patient had implanted devices (pumps, radioisotopes, ICDs, pacemakers).

Report to the coroner if required — regulations vary between states; if uncertain, discuss with the coroner’s office before or after the death.