Care of the Imminently Dying Patient and Hospice Care
Recognizing the dying phase
Signs of the last days include declining performance status, decreased oral intake, dysphagia, oliguria, cool or mottled extremities, Cheyne-Stokes breathing, terminal secretions, and agitated delirium. These are expected and not automatically treated as emergencies. The death rattle is caused by pooled secretions and is generally not distressing to the patient, though it distresses families; reposition and use glycopyrrolate or scopolamine rather than deep suctioning.
Medication and care changes
Discontinue nonessential medications such as statins, anticoagulants, antihypertensives, and glucose-lowering agents. Continue symptom medications, switching to subcutaneous, buccal, rectal, or transdermal routes when swallowing fails. Provide meticulous mouth care, skin care, positioning, and urinary catheterization only for retention or comfort. Do not stop opioids because the patient is dying; untreated pain and dyspnea are common. Consider palliative sedation only for refractory symptoms with informed consent and documented process.
Hospice
In the US, hospice eligibility requires a prognosis of six months or less if the disease follows its usual course, plus a comfort-focused plan. Medicare hospice includes routine home care, continuous care, general inpatient care, respite, and bereavement support. Patients may revoke the benefit. Children may receive concurrent disease-directed treatment.
Traps
Do not assume stopping artificial nutrition or hydration causes suffering; explain the physiology. Do not forget family support and spiritual care. Do not confuse hospice with a place.
Rule of thumb
When swallowing fails, convert essential medications to alternative routes and stop everything that does not improve comfort.