Background: The care of patients in their last weeks of life is a fundamental palliative care
skill, but few evidence-based reviews have focused on this critical period.
Method: A systematic review of published literature and expert opinion related to care in
the last weeks of life.
Results: The evidence base informing terminal care is largely descriptive, retrospective, or extrapolated.
While home deaths and hospice use are increasing, medical care near death is becoming
more aggressive and hospice lengths of stay remain short. Though the prediction of impending
death remains imprecise, studies have identified several common terminal signs and
symptoms. Decreased communication near death complicates the determination of patient
wishes, and advanced directives prior to the terminal stage are recommended. Anorexia and
cachexia are common in dying patients but there is no evidence that this process is painful or
responsive to intervention. While there is general consensus that artificial nutrition is not beneficial
in dying patients, the use of artificial hydration is controversial, especially in the setting
of delirium. Breathlessness has been shown to benefit from oral and parenteral opioids but not
anxiolytics. Accumulation of respiratory tract secretions (death rattle) is common and usually responds
to antimuscarinics. Physical pain typically decreases toward death but its assessment in
dying patients is difficult. Terminal delirium may occur in up to one-third of patients, may have
a reversible cause, and may respond to antipsychotics or benzodiazepines. Palliative sedation is
controversial but widely used, especially internationally. Caregiver stress and bereavement may
benefit from improved communication and hospice involvement.
Conclusion: While the terminal care literature is characterized by varying quality, numerous
knowledge gaps, and frequent inconsistencies, it supports several common clinical interventions.
More research is needed to resolve controversies, define effective therapies, and
improve the outcomes of dying patients.
