Knowing what to expect in the final days or hours helps comfort the family.

Most people don't know the signs that show death is near. Knowing what to expect can help them get ready for the death of their loved one and make this time less stressful and confusing. Health care providers can give family members information about the changes they may see in their loved one in the final hours and how they may help their loved one through this.

People may not want to eat or drink in the final days or hours.

In the final days to hours of life, people often lose the desire to eat or drink, and may not want food and fluids that are offered to them. The family may give ice chips or swab the mouth and lips to keep them moist. Food and fluids should not be forced on the person because it can cause discomfort or choking.

People near death may not respond to others.

People may withdraw and spend more time sleeping. They may answer questions slowly or not at all, seem confused, and may not be interested in what's going on around them. Most people 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 person, even if they do not respond.

A number of physical changes are common when a person is near death.

Certain physical changes may occur in a person at the end of life:

• They may feel tired or weak.
• They may pass less urine, and it may be dark in color.
• Their hands and feet may become blotchy, cold, or blue. Caregivers can use blankets to keep the person warm. Electric blankets or heating pads should not be used.
• Their heart rate may go up or down and become irregular.
• Blood pressure usually goes down.
• Breathing may become irregular, with very shallow breathing, short periods of not breathing, or deep, rapid breathing.

However, these signs and changes don't always occur in everyone. For this reason, it may be hard to know when a person is near death.

Cultural or religious beliefs and customs may be important at the time of death.

After a person dies, family members and caregivers may wish to stay with them awhile. There may be certain customs or rituals that are important to the person and family at this time. These might include rituals for coping with death, handling the person's body, making final arrangements for the body, and honoring the death. It’s important to let the health care team know what customs or rituals are important to the person and their family after the person’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.

For more information, see Spirituality in Cancer Care.

Delirium

Fatigue

Shortness of Breath

Pain

Cough

Constipation

Trouble Swallowing

Death Rattle

Myoclonic Jerking

Fever

Hemorrhage

Decisions about Chemotherapy

Decisions about whether to continue or stop chemotherapy are made by the patient and doctor together. About one-third of people with advanced cancer continue to receive chemotherapy or other treatment near the end of life.

Treatment with chemotherapy at this time can result in the following:

• serious side effects
• spending more days in the hospital
• spending the last days of life in an intensive care unit

However, some people with cancer choose to continue chemotherapy because they feel it helps them to live in the present and focus on active treatment. Other people choose palliative or comfort care to treat pain and other symptoms. These decisions are based on the person's goals of care and the likely risks and benefits of treatment.

Decisions about Targeted Therapy

Decisions about whether to continue or stop targeted therapy are made by the patient and doctor together. Targeted therapies may help people with tumors that have spread to other areas in the body.

Treatment with targeted therapy at the end of life can result in the following:

• spending the last days of life in a hospital
• poor awareness of prognosis
• less time to prepare for the end of life

Decisions about Immunotherapy

Decisions about whether to continue or stop immunotherapy are made by the patient and doctor together. Many people taking immunotherapy are older or are no longer helped by chemotherapy, but these drugs may still have unwanted side effects.

Treatment with immunotherapy at the end of life can result in the following:

• being less likely to use hospice services
• spending the last days of life in the hospital
• having problems related to medical costs (financial toxicity)

Decisions about Hospice

Hospice care is an important end-of-life option for people with advanced cancer. People may feel that beginning hospice care means they have given up. Some people fear losing the relationship with their oncologist. However, many patients and caregivers feel they receive important benefits from hospice care.

People who receive hospice care seem to have the following:

• better mental outlook
• better relief of symptoms
• better communication
• better end-of-life care
• more days spent at home
• less stressful death (without causing death to happen sooner)

Hospice-related services include:

• visiting nurse
• chaplain
• counselor
• home health aide
• respite care

Doctors, patients, and caregivers should discuss hospice care and when it should begin.

When hospice benefits are covered by Medicare, physicians are required to certify that the person is not expected to live more than 6 months and is not being treated to be cured. Other policies may be different, depending on the hospice and the state.

Decisions about Place of Death

Many people with advanced cancer wish to die at home. People who die at home with hospice services and support seem to have better symptom control and quality of life. They also feel better prepared for death than people who die in a hospital or intensive care unit. Grieving caregivers have less trouble adjusting to their loss and feel they have honored the person's wishes when their loved one dies at home.

People who get hospice care are more likely to be able to die at home. Hospice care can help control the person's symptoms and give the caregiver the help they need.

However, not all people choose to die at home. It is important for the person, caregivers, and doctors to discuss where the person wants to die and the best way to fulfill the person's decision.

For children with advanced cancer, families and doctors should discuss wishes for the place of death early in the course of the disease. Children who die in the hospital may have more intense treatments and their parents may have more complicated grief than those of children who die at home.

In the last days of life, patients and family members will have to make decisions about treatments to keep the person alive.

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.

People near death may be guided by their oncologist, but they have the right to make their own choices about life-sustaining treatments. The following are some of the questions to discuss:

• What are the person’s goals of care?
• How would the possible benefits of life-sustaining treatments help reach the person's goals of care, and how likely is the desired outcome?
• How would the possible harms of life-sustaining treatments affect the person's goals of care? Is the possible benefit worth the possible harm?
• Besides possible benefits and harms of life-sustaining treatments, what else can affect the decision?
• Are there other resources, such as palliative care, a chaplain, or a medical ethicist, that could help the person or family make decisions about life-sustaining treatments?

Choices about care and treatment at the end of life should be made while the person is able to make them.

A person 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.

Without knowing a person's wishes, the health care team will do everything medically possible to keep the person alive, such as cardiopulmonary resuscitation (CPR) and the use of a ventilator (breathing machine).

Studies have shown that people with cancer 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, and the cost of their health care is lower during their final week of life. Reports from their caregivers show that these people live just as long as those who choose to have more procedures, and have a better quality of life in their last days.

Care that supports a person's spiritual health may improve quality of life.

A spiritual assessment is a method or tool used by doctors to understand the role that religious and spiritual beliefs have in the person's life. This may help the doctor understand how these beliefs affect the way the person copes with cancer and makes decisions about cancer treatment.

Serious illnesses like cancer may cause people or family caregivers to have doubts about their beliefs or religious values and cause spiritual distress. Some studies show that people with cancer may feel anger at God or may have a loss of faith after being diagnosed. Other people 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 and psychologists, may be able to offer care that supports a person's spiritual health. They may encourage the person to meet with their spiritual or religious leaders or join a spiritual support group. This may improve a person's quality of life and ability to cope. When people with advanced cancer receive spiritual support from the medical team, they are more likely to choose hospice care and less aggressive treatment at the end of life.

For more information, see Spirituality in Cancer Care.

Fluids

Nutrition Support

Antibiotics

Transfusions

Resuscitation

Choices about whether to use intensive care should be discussed.

Near the end of life, people 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 ICU, patients or family members have to make hard decisions about whether to start, continue, or stop aggressive treatments that may make the person live longer but harm their 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. However, at any time, patients or families may talk with doctors about whether they want to continue with ICU care. They may choose instead to change over to comfort care in the final days.

Ventilator use may keep a person alive after normal breathing stops.

A ventilator is a machine that helps people breathe. Sometimes, using a ventilator will not improve the person's condition but will keep them alive longer. If the goal of care is to help the person live longer, a ventilator may be used, according to the person's wishes. If ventilator support stops helping or is no longer what the person wants, the person, their family, and the health care team may decide to turn the ventilator off.

The emotions of patients and caregivers are closely connected.

Patients and caregivers share the distress of cancer, with the caregiver's distress sometimes being greater than the patient's distress. Since caregiver suffering can affect the person's well-being and the caregiver's adjustment to loss, early and constant support of the caregiver is very important.

Palliative sedation lowers the level of consciousness and relieves extreme pain and suffering.

Palliative sedation uses drugs called sedatives to relieve extreme suffering by making a person calm and unaware.

The decision whether to sedate a person at the end of life is a hard one. Sedation may be considered for a person's comfort or for a physical condition such as uncontrolled pain. Palliative sedation may be given on and off, or until death. A person's thoughts and feelings about end-of-life sedation may depend greatly on his or her own culture and beliefs. Some people who become anxious facing the end of life may want to be sedated. Some people and their families may wish to have a level of sedation that allows them to communicate with each other. Other people may wish to have no procedures, including sedation, just before death.

Studies have not shown that palliative sedation shortens life when used in the last days.

It is important for the person to tell family members and health care providers of their wishes about sedation at the end of life. When a person makes their wishes about sedation known ahead of time, doctors and family members can be sure they are doing what the person would want. Families may need support from the health care team and mental health counselors while palliative sedation is used.

About PDQ

Physician Data Query (PDQ) is the National Cancer Institute's (NCI's) comprehensive cancer information database. The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries come in two versions. The health professional versions have detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions have cancer information that is accurate and up to date and most versions are also available in Spanish.

PDQ is a service of the NCI. The NCI is part of the National Institutes of Health (NIH). NIH is the federal government’s center of biomedical research. The PDQ summaries are based on an independent review of the medical literature. They are not policy statements of the NCI or the NIH.

Purpose of This Summary

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.

Reviewers and Updates

Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary ("Updated") is the date of the most recent change.

The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Supportive and Palliative Care Editorial Board.

Clinical Trial Information

A clinical trial is a study to answer a scientific question, such as whether one treatment is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. During treatment clinical trials, information is collected about the effects of a new treatment and how well it works. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become "standard." Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Clinical trials can be found online at NCI's website. For more information, call the Cancer Information Service (CIS), NCI's contact center, at 1-800-4-CANCER (1-800-422-6237).

Permission to Use This Summary

PDQ is a registered trademark. The content of PDQ documents can be used freely as text. It cannot be identified as an NCI PDQ cancer information summary unless the whole summary is shown and it is updated regularly. However, a user would be allowed to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks in the following way: [include excerpt from the summary].”

The best way to cite this PDQ summary is:

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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