• Attempt to estimate the person's prognosis and discuss this with them if appropriate.
• Estimating the prognosis helps in the planning of appropriate treatment and care — if prognosis is not discussed, or predictions are inaccurate, people may make inappropriate treatment decisions, or inadequately prepare for death.
• The Prognostic Indicator Guidance (pdf) can be used. It is part of the Gold Standards Framework, which aims to optimize the care of people nearing the end of life who are looked after by primary care teams in the community.
• Some people may request not to know their prognosis. This should be respected and they should be given the opportunity to discuss it again at a later date.
• A discussion of prognosis should involve:
• Identifying the person's own thoughts regarding their prognosis.
• Explaining the difficulty of providing an accurate prognosis.
• Providing a rough estimate only (e.g. days, weeks, months, years).

In depth

• It is essential to recognize the signs of dying in order to appropriately care for people at the end of life.
• People are likely to be in the terminal phase of their illness when they:
• Deteriorate day by day or faster because of their underlying condition.
• Express a realization that they are dying.
• Have reduced cognition, and are drowsy or comatose.
• Are bed-bound.
• Take little food or fluid, and have difficulty taking oral medication.
• Are peripherally cyanosed and cold.
• Have an altered breathing pattern.

In depth

• The terminal phase requires a careful discussion with the person, family, and carers regarding the following issues. This may involve discussing and weighing up the benefits, burdens and risks for the person:
• Stopping any unnecessary drug treatments and continuing other drug treatments by an appropriate route.
• Having commonly required medication available in the house (e.g. cyclizine, diamorphine, hyoscine hydrobromide, and midazolam), so that new or developing symptoms can be treated without delay.
• Control of physical symptoms.
• Realistic goals (e.g. in terms of treatment and resuscitation issues).
• Religious and spiritual care.
• Providing an appropriate environment (e.g. one which is comfortable and has an appropriate level of noise and activity for the person).
• If the person is likely to require care out of normal surgery hours, ensure that the local on-call service has been informed and given an effective handover.
• Provide emergency contact numbers and information on what to do when death occurs.

In depth