• 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.
• Become progressively weak and fatigued without an apparent cause (e.g. hypercalcaemia).
• 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.
• For further details, see the CKS topic on Palliative cancer care - general issues.

• Make sure the person has access to a large bowl, tissues, and water.
• The sight and smell of food or drink may provoke nausea:
• Provide a calm environment away from where food is usually prepared or consumed.
• If the person is usually responsible for cooking, make alternative arrangements.
• Make sure that meals are small and palatable.
• Carbohydrate meals are often better tolerated.
• Offer cool, fizzy drinks (citrus flavours are often preferred).
• Consider parenteral hydration if appropriate.
• Consider relaxation and acupressure bands to relieve symptoms.
• Consider cognitive behavioural therapy for anticipatory nausea or vomiting.
• In general, avoid nasogastric suction.

In depth

• Try simple measures to relieve symptoms.
• If an anti-emetic already controls symptoms well:
• Continue with the same drug.
• Give the same drug by syringe driver if the person becomes unable to take oral medication. If an injectable form is not available, use a drug with a similar mode of action.
• For new or uncontrolled nausea and vomiting:
• If appropriate, try to determine the underlying cause of nausea and vomiting and manage accordingly (see Scenario: Nausea and vomiting - management).
• Otherwise give levomepromazine, 6.25 mg once daily by subcutaneous injection. Repeat the dose after 1 hour if needed.
• If a repeat dose is needed, start levomepromazine by continuous subcutaneous injection (CSCI):
• Start at a dose of 12.5 mg in 24 hours by CSCI, plus a 6.25 mg subcutaneous injection as needed.
• If one or more extra doses are needed, increase the dose to 25 mg in 24 hours.
• If symptoms remain uncontrolled, contact the local palliative care team for advice.
• Review the effectiveness of anti-emetic treatment every 24 hours.

In depth