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Cancer has a well-defined trajectory (Figure 2.3) and it is usual for physical deterioration to take place over several weeks, with a terminal phase lasting hours to days at the end of life. However, sometimes patients can experience sudden death, either as a result of treatment and its side-effects or from complications of the disease itself, including bleeding, infection, pulmonary embolism or a cardiac event. Those deaths which follow the former pattern will be discussed here.

Figure 2.3 Different death trajectories: y axis = health status, x axis = time. (a) Sudden death. (b) Typical cancer death. (c) Typical death from end-organ failure. (d) Typical death from dementia. From Glare and Christakis (2004).

Care of the dying patient starts with a recognition from the multiprofessional team that the terminal phase has begun. It is perhaps the single most important factor in enabling the achievement of all the factors associated with a ‘good death’ (Faull and Nyatanga 2005). The terminal phase can be difficult to identify, and often there are barriers from healthcare professionals reluctant to make a diagnosis of dying. In an attempt to overcome some of these barriers, four basic criteria for recognizing the terminal phase are widely acknowledged (and are associated with the Liverpool Care Pathway, to be discussed later in this chapter) (Kinder and Ellershaw 2003). The presence of two or more of the following, commonly preceded by a progressive period of decline, and where no other reversible cause is present, is said to denote the terminal phase of life:

the patient is bedbound

the patient is semi-comatose or comatose

the patient is only able to take sips of fluid

the patient is no longer able to take tablets.

Evidence-based approaches

Palliative care is relatively new as a specialty in nursing and medicine and its evidence base is therefore comparatively small, though growing. Nursing care of the dying patient should have as its main priority meeting personal needs which will allow the patient to have a ‘good’ death. It has been suggested that the following characteristics are central to a ‘good’ death from medical, nursing and patient perspectives: (1) control, (2) comfort, (3) closure, (4) trust in healthcare providers, (5) recognition of impending death, and (6) an honouring of personal beliefs and values (Kehl 2006).

The WHO (2002) suggests that palliative care:

provides relief from pain and other distressing symptoms

affirms life and regards dying as a normal process

intends neither to hasten nor postpone death

integrates the psychological and spiritual aspects of patient care

offers a support system to help patients live as actively as possible until death

offers a support system to help the family cope during the patient’s illness and in their own bereavement

uses a team approach to address the needs of patients and their families, including bereavement counselling if indicated

enhances quality of life and may also positively influence the course of an illness

is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy and radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.

Legal and professional issues

Advance directives

Advance directives, formerly known as ‘living wills’, allow people to make a legal decision to refuse, in advance, a proposed treatment, or the continuation of that treatment, if at the necessary time the person lacks the capacity to consent to it. Advance directives can only be made by those who are deemed to have the mental capacity to do so, and allow only for the refusal of treatments – they cannot enforce the provision of specified treatments in the same circumstances (Mental Capacity Act 2005, sections 24–26).

Decisions to refuse life-sustaining treatments must be made in writing, be signed and witnessed, and must expressly state that the decision stands even if the person’s life is at risk. Advance directives