People at the End of Life

End-of-life care is a core GP competency and a regular source of AKT questions. The focus is on symptom management in the community, advance care planning, and the legal and ethical framework around end-of-life decisions.

Symptom management in the last days of life commonly involves pain, nausea, breathlessness, agitation, and respiratory secretions. First-line medications include morphine for pain and breathlessness, midazolam for agitation and seizures, haloperidol or levomepromazine for nausea, and hyoscine butylbromide for respiratory secretions. These are often delivered via a syringe driver (continuous subcutaneous infusion) when the patient can no longer take oral medications.

Anticipatory prescribing means having injectable medications available in the patient's home before they are needed. The typical anticipatory medications kit includes morphine, midazolam, haloperidol, levomepromazine, and hyoscine butylbromide. Doses should be prescribed with clear instructions for use.

Advance care planning involves discussions about the patient's wishes for future care, including preferred place of death, treatment escalation decisions, and advance decisions to refuse treatment (ADRTs). An ADRT is legally binding if it is valid (made voluntarily by a competent adult) and applicable to the circumstances. If it involves refusing life-sustaining treatment, it must be in writing, signed, witnessed, and include a statement that it applies even if life is at risk.

DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) decisions are clinical decisions, not patient requests. A clinician can make a DNACPR decision if CPR would not be successful. If CPR might work but the patient does not want it, a DNACPR can be completed with the patient's agreement. The decision should be communicated sensitively and documented clearly. ReSPECT forms are increasingly used as a broader framework for emergency treatment preferences.

Bereavement support in primary care includes recognising normal grief, identifying complicated grief, and knowing when to refer. The Kubler-Ross model (denial, anger, bargaining, depression, acceptance) describes common grief responses but is not a rigid sequence. Prolonged grief disorder is recognised when grief symptoms persist beyond 12 months and significantly impair functioning.

Certification of death, cremation forms, and referral to the coroner are practical tasks that GPs perform. You should know when death must be referred to the coroner, including deaths within 14 days of surgery, deaths related to an industrial disease, and deaths where the cause is unknown.