This summary is about care at the end of life, including common symptoms and questions about treatment that may come up. It may help people with cancer and their families understand what to expect during this time.
The last weeks and days of life will be different for each person. The signs and symptoms people have may change as the end of life nears, as will their needs for information and support. Some people may wish to continue with chemotherapy and other treatments until the last days of life, and some may wish to end all treatments earlier. Having these decisions in writing early in the cancer diagnosis can make the patient's wishes clear to both the family and the health care team. If a person becomes too sick before they have put their final wishes in writing, it is helpful for family to know what type of care their loved one would want to receive.
For information on end-of-life planning, including advance directives, palliative care, and hospice care, see the PDQ summary on Planning the Transition to End-of-Life Care in Advanced Cancer.
Decisions about whether to continue or stop chemotherapy and immunotherapy are made based on the patient's goals of care.
Decisions about whether to continue or stop chemotherapy are made based on the patient's goals of care. About one-third of patients with advanced cancer continue to receive chemotherapy near the end of life.
Treatment with chemotherapy at this time can result in the following:
However, some patients with cancer choose to continue chemotherapy because they feel it helps them to live in the present. Other patients choose palliative or comfort care to treat pain and other symptoms. These decisions are based on the patient's goals of care and the likely risks and benefits of treatment.
Decisions about whether to continue or stop immunotherapy depend on the patient's response to the drugs. Many patients taking these drugs are older or are no longer helped by chemotherapy. Patients may still have side effects with these drugs. The decision to stop treatment and begin supportive care or hospice services may be unclear.
Hospice care is an important end-of-life option for patients with advanced cancer.
Many patients and caregivers feel they receive important benefits from hospice care. Hospice is a program that gives care to people who are near the end of life and have stopped treatment to cure or control their cancer. It is usually given at home but may also be given in a hospice center, hospital, or nursing home. Hospice care focuses on quality of life rather than length of life.
Hospice-related services include:
Patients who receive hospice care seem to have the following:
Some patients may feel that beginning hospice care means they have given up or they may fear losing the relationship with their oncologist. Having depression may affect a patient's decision about hospice.
When hospice benefits are covered by Medicare, physicians are required to certify that patients are not expected to live more than 6 months and that patients are not being treated to be cured. Other policies may be different, depending on the state.
Doctors, patients, and caregivers should discuss hospice care and when it should begin.
A patient's religious and spiritual beliefs may play a role in treatment decisions.
A spiritual assessment is a method or tool used by doctors to understand the role that religious and spiritual beliefs have in the patient's life. This may help the doctor understand how these beliefs affect the way the patient copes with cancer and makes decisions about cancer treatment.
Serious illnesses like cancer may cause patients or family caregivers to have doubts about their beliefs or religious values and cause spiritual distress. Some patients with cancer may feel anger at God or may have a loss of faith after being diagnosed. Other patients may have feelings of spiritual distress when coping with cancer. Spiritual distress may affect end-of-life decisions and increase depression.
Doctors and nurses, together with social workers, chaplains, and psychologists, may be able to offer care that supports a patient's spiritual health. This may improve patients' quality of life and ability to cope.
See the PDQ summary on Spirituality in Cancer Care for more information.
Patients and family members are faced with making decisions about when to end all treatments.
Decisions about whether to use life-sustaining treatments that may extend life in the final weeks or days cause a great deal of confusion and anxiety. Some of these treatments are ventilator use, parenteral nutrition, and dialysis.
Patients may be guided by their oncologist but have the right to make their own choices about life-sustaining treatments. The following are some of the questions to consider when making these choices:
Choices about care and treatment at the end of life should be made while the patient is able to make them.
A patient may wish to receive all possible treatments, only some treatments, or no treatment at all in the last days of life. These decisions may be written down ahead of time in an advance directive, such as a living will. Advance directive is the general term for different types of legal documents that describe the treatment or care a patient wishes to receive or not receive when he or she is no longer able to speak their wishes.
Studies have shown that cancer patients who have end-of-life discussions with their doctors choose to have fewer procedures, such as resuscitation or the use of a ventilator. They are also less likely to be in intensive care.
See the PDQ summary on Planning the Transition to End-of-Life Care in Advanced Cancer for more information.
The goals of giving fluids at the end of life should be discussed by patient, family, and doctors.
Fluids may be given when the patient can no longer eat or drink normally. Fluids may be given with an intravenous (IV) catheter or through a needle under the skin.
Decisions about giving fluids should be based on the patient's goals of care. Giving fluids has not been shown to help patients live longer or to improve quality of life. However, the harms are minor and the family may feel there are benefits if the patient is less fatigued and more alert.
The family may also be able to swab the patient's mouth and lips to keep them moist or give the patient sips of water or ice chips.
The goals of nutrition support for patients at the end of life are different from the goals during cancer treatment.
Nutrition support can improve health and boost healing during cancer treatment. The goals of nutrition therapy for patients during the last days of life are different from the goals for patients in active cancer treatment and recovery. In the final days of life, patients often lose the desire to eat or drink and may not want food that is offered to them. Also, procedures used to put in feeding tubes may be hard on a patient.
If the patient cannot swallow, two types of nutrition support are used if in line with the patient's goals of care:
Each type of nutrition support has benefits and risks. See the PDQ summary on Nutrition in Cancer Care for more information.
Nutrition support may no longer be needed at end of life.
The goal of end-of-life care is to prevent suffering and relieve symptoms. If nutrition support causes the patient more discomfort than help, then nutrition support near the end of life may be stopped. The needs and best interests of each patient guide the decision to give nutrition support.
The benefits of using antibiotics in the last days of life are unclear.
The use of antibiotics and other treatments for infection is common in patients in the last days of life, but it is hard to tell how well they work. It is also hard to tell if there are any benefits of using antibiotics at the end of life.
Overall, doctors want to make the patient comfortable in the last days of life rather than give treatments that may not help them live longer.
The decision to use blood transfusions depends on many factors.
Many patients with advanced cancer have anemia. Patients with advanced blood cancers may have thrombocytopenia (a condition in which there is a lower-than-normal number of platelets in the blood). Deciding whether to use blood transfusions for these conditions is based on the following:
The decision may also depend on the patient's ability to travel to a medical setting to receive the transfusion.
Many patients have received blood transfusions during active treatment or supportive care and may want to continue transfusions to feel better. It has not been shown that transfusions are safe and effective at the end of life.
Patients should decide if they want cardiopulmonary resuscitation (CPR).
An important decision for the patient to make is whether to have cardiopulmonary resuscitation (CPR) (trying to restart the heart and breathing when it stops). It is best if patients talk with their family, doctors, and caregivers about their wishes for CPR as early as possible (for example, when being admitted to the hospital or when active cancer treatment is stopped). If the patient wishes, he or she can ask the doctor to write a do-not-resuscitate (DNR) order. A DNR is written by a doctor to tell other health professionals not to perform CPR at death, so that the natural process of dying occurs. The patient can ask that the DNR order be changed or removed at any time.
The symptoms that are common at the end of life may be treated so the patient is more comfortable. These symptoms include the following:
Most patients have delirium (a lower level of consciousness). They may be withdrawn, be less alert, and have less energy. Some patients may be agitated or restless, and have hallucinations. Delirium may be controlled by finding and treating the cause.
Causes of delirium include the following:
Patients should be protected from hurting themselves when they are confused or agitated.
Depending on the cause of the delirium, doctors may do the following if in line with the patient's goals of care:
For some patients in the last hours of life, the decision may be to treat only the symptoms of delirium and make the patient as comfortable as possible. There are drugs that help to relieve these symptoms. These drugs may make the patient sedated (feel calm and unaware).
Hallucinations that are not related to delirium often occur at the end of life. Some dying patients hallucinate about loved ones who have already died. Family members may feel distressed when these hallucinations occur. Speaking with clergy, the hospital chaplain, or other religious advisors may help.
Fatigue (feeling very tired)
Fatigue (feeling very tired) is a common symptom in the last days of life. A patient's fatigue may become worse every day during this time. Drowsiness, weakness, and sleep problems may occur. Drugs that increase brain activity, alertness, and energy may be helpful in some patients. See the PDQ summary on Fatigue for more information.
Shortness of Breath
Patients may have difficult, painful breathing or shortness of breath at the end of life. Shortness of breath may be treated with the following:
Pain during the final hours of life can usually be controlled. Opioid analgesics work very well to relieve pain and are commonly used at the end of life. Some patients and family members worry that the use of opioids may cause death to occur sooner, but studies have shown no link between opioid use and early death. See the PDQ summary on Cancer Pain for more information about opioids.
Pain medicines can be given in several ways. In the last days of life, a patient may not be able to swallow pain medicine. When patients cannot take medicines by mouth, the pain medicine may be given by an intravenous (IV) catheter or by a needle under the skin, by placing it in the rectum, or by placing a patch on the skin.
Cough at the end of life may add to a patient's discomfort. Repeated coughing can cause pain and loss of sleep, increase tiredness, and worsen shortness of breath. At the end of life, the decision may be to treat the symptoms of the cough rather than to find and treat the cause. The following types of drugs may be used to make the patient as comfortable as possible:
Patients with cancer may have constipation in the last days of life. The use of laxatives for patients at the end of life may not be helpful. If needed, laxatives may be given rectally to treat constipation and make the patient comfortable.
Patients with cancer may have trouble swallowing in the last days of life. Both fluids and food may be hard to swallow, causing a loss of appetite, weight loss and muscle wasting, and weakness. Small amounts of food that the patient enjoys may be given if they want to eat. Food and fluids should not be forced on the patient because this can make them upset or cause choking. The family may give ice chips or swab the mouth and lips to keep them moist. Artificial nutrition does not benefit patients in the last days of life and may increase the risk of aspiration and infections.
When patients need to take medicine but cannot swallow, medicine may be given by injection or infusion, by placing it in the rectum, or by placing a patch on the skin.
Rattle occurs when saliva or other fluids build up in the throat and airways in a patient who is too weak to clear the throat. There are two types of rattle. Death rattle is caused by saliva pooling at the back of the throat or by fluid in the airways from an infection, a tumor, or extra fluid in body tissues.
Drugs may be given to decrease the amount of saliva in the mouth or to dry the upper airway. Since most patients with rattle are unable to swallow, these drugs are usually given by injection or infusion.
Death rattle is a sign that death may occur in hours or days. Rattle can be very upsetting for those at the bedside. It does not seem to be painful for the patient and is not the same as shortness of breath.
Raising the head of the bed, propping the patient up with pillows, or turning the patient to either side may help relieve rattle. If the rattle is caused by fluid at the back of the throat, the fluid may be gently removed from the mouth using a suction tube. If the rattle is caused by fluid in the airways, the fluid is usually not removed by suction, because it causes severe physical and mental stress on the patient.
Muscle Jerks (Myoclonus)
Myoclonic jerks are sudden muscle twitches that cannot be controlled. A hiccup is one type of myoclonic jerk. Brief, shock-like jerks can occur in one or more different muscle groups anywhere in the body. Taking very high doses of an opioid for a long time may cause this side effect, but it can have other causes as well.
Myoclonic jerks may be caused from damage to the nervous system from taking certain opioids. When opioids are the cause of muscle twitches, changing to another opioid may help. Patients respond to opioids in different ways and certain opioids may be more likely than others to cause muscle jerks in some people.
When the patient is very near death, medicine to stop the myoclonic jerking may be given instead of changing the opioid. When the muscle twitching is severe, drugs may be used to calm the patient, relieve anxiety, and help the patient sleep.
Fever may not always need to be treated at the end of life. Treatment of fever in the last days of life depends on whether it causes the patient distress or discomfort. Fever may be caused by infection, medicines, or the cancer itself. While infections may be treated with antibiotics, patients near the end of life may choose not to treat the cause of the fever.
Hemorrhage (heavy bleeding) is rare but may occur in the last hours of life. Sudden hemorrhage may occur in patients who have certain cancers or disorders. Blood vessels may be damaged by certain cancers or treatments. Radiation therapy, for example, can weaken blood vessels in the area that was treated. Patients with the following conditions have an increased risk of hemorrhage:
Making the patient comfortable is the main goal of care during hemorrhage at the end of life. It is hard to know when hemorrhage might occur. When sudden bleeding occurs at the end of life, patients usually become unconscious and die soon afterwards. The main goal of care is to help the patient be comfortable and to provide support for family members as this experience can be very upsetting.
Palliative Sedation to Control Symptoms at the End of Life
Palliative sedation is the use of sedatives to relieve extreme suffering or pain by making a patient feel calm and unaware. When end-of-life symptoms can't be controlled by any other treatment, patients may choose sedation. Delirium and shortness of breath are the most common symptoms treated with palliative sedation.
Palliative sedation may be temporary. A patient's thoughts and feelings about end-of-life sedation depends on his or her own culture and beliefs. Some patients and their families may wish to have a level of sedation that allows them to communicate with each other. Other patients may not want sedation just before death. Patients who become anxious facing the end of life may want to be sedated.
Palliative sedation does not shorten life when used in the last days.
It is important for the patient to tell family members and health care providers of his or her wishes about sedation at the end of life.
Certain physical changes can help family and health care providers know when a person is nearing the end of life.
Knowing when death is about to occur and what to expect will prepare the family and make this time less stressful and confusing. This is a time for family members close to the patient to say "goodbye". Health care providers can give family members information about the changes they see in their loved one in the final hours and how they may help their loved one.
In the final days to hours of life, patients may withdraw and spend more time sleeping and may also lose the desire to eat and drink. They may answer questions slowly or not at all, seem confused, and may not be interested in what's going on around them. Most patients are still able to hear after they are no longer able to speak. It may give some comfort if family members continue to touch and talk to the patient, even if the patient does not respond.
Some of the physical changes that occur when death is near include the following:
These changes don't always occur in everyone.
It is important to discuss the patient's preferred place of death.
It is important for the patient, caregivers, and doctors to discuss where the patient wishes to die and the best way to fulfill the patient's decision.
For children with advanced cancer, families and doctors should discuss preferred place of death. Children who die in the hospital may have more treatments and their parents may have more intense, prolonged grief than those of children who die at home. End-of-life discussions with the child's doctor may reduce the time the child spends in the hospital and help the parents feel more prepared.
Many patients with advanced cancer wish to die at home.
Patients who die at home with hospice services and support seem to have better symptom control and quality of life. They also tend to feel better prepared for death than patients who die in a hospital or intensive care unit. Grieving caregivers may have less trouble adjusting to their loss and feel they have honored the patient's wishes when their loved one dies at home.
Patients may need to be admitted to the hospital at the end of life if they have not made plans to die at home.
Near the end of life, patients with advanced cancer may be admitted to a hospital or intensive care unit (ICU) if they have not made other choices for their care. In the hospital, patients or family members have to make hard decisions about whether to start, continue, or stop aggressive treatments that may make the patient live longer, but do not improve the patient's quality of life. Families may be unsure of their feelings or have trouble deciding whether to limit or avoid treatments.
Sometimes, treatments like dialysis or blood transfusions may be tried for a short time. Patients or families may talk with doctors any time about whether they want to continue with treatments. They may choose instead to change over to comfort care in the final days.
Ventilator use may keep the patient alive after normal breathing stops.
A ventilator is a machine that helps patients breathe. Using a ventilator will not improve the patient's condition, but may keep the patient alive longer. If the goal of care is to help the patient live longer, a ventilator may be used, according to the patient's wishes. If ventilator support stops helping the patient or is no longer what the patient wants, the family, and health care team may decide to turn the ventilator off.
Before a ventilator is turned off, family members will be given information about what to expect.
Family members will be given information about how the patient may respond when the ventilator is removed and about pain relief or sedation to keep the patient comfortable. Family members will be given time to contact other loved ones who wish to be there. Chaplains or social workers may be called to provide support to the family.
Patients and their families may have cultural or religious beliefs and customs that are important at the time of death.
After the patient dies, family members and caregivers may wish to stay with the patient a while. There may be certain customs or rituals that are important to the patient and family at this time. These might include rituals for coping with death, handling the patient's body, making final arrangements for the body, and honoring the death. The patient and family members should let the health care team know about any customs or rituals they want performed after the patient's death.
Health care providers, hospice staff, social workers, or spiritual leaders can explain the steps that need to be taken once death has occurred, including contacting a funeral home.
See the PDQ summary on Spirituality in Cancer Care for more information.
People react to grief in different ways.
Patients and caregivers share the distress of cancer, with the caregiver's distress sometimes being greater than the patient's. Since caregiver suffering can make it harder to adjust to the death of a loved one, early and constant support of the caregiver is important.
Grief is a normal reaction to the loss of a loved one. People who feel unable to cope with their loss may be helped by grief counseling or grief therapy with trained professionals. See the PDQ summary on Grief, Bereavement, and Coping With Loss for more information.
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This PDQ cancer information summary has current information about patient care during the last days to last hours of life. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.
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PDQ® Supportive and Palliative Care Editorial Board. PDQ Last Days of Life. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/about-cancer/advanced-cancer/caregivers/planning/last-days-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389429]
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Last Revised: 2021-01-25
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