Care of the person who has reached the final stage of their life is a key aspect of maintaining human dignity and is enormously important for relatives and friends who will remember this period perhaps better than any other during the cancer journey. Unrelieved suffering of patients at the end of life is associated with increased relative distress and can unnecessarily complicate the already difficult period of bereavement. Nursing care during this period does not simply represent a continuation of previously given care, nor necessarily the complete cessation of all ‘active treatment’ measures that may previously have been undertaken. As with all aspects of nursing care, assessment of the individual patient and their relatives, exceptional communication and good multiprofessional working will help to determine the appropriate next steps for each individual.

Cancer has a well‐defined trajectory (illustrated in Figure 28.1) 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 (see Chapter c26 for Acute oncology). Those deaths that follow the former pattern will be discussed here.

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 [12]). The last days/hours of life can be difficult to identify, and often there are barriers from healthcare professionals reluctant to make a diagnosis of dying.

Much of the current literature advocates identification as early as possible of patients who may be reaching the end of their life to help plan their ongoing care and to ensure they and their families have the opportunity to discuss what is of importance to them; in some cases this includes preferences regarding who they want to be with them when they die and preferences around place of care and death (DH [8], NICE [40]). Considerations such as the surprise question ‘Would you be surprised if this patient were to die in the next 12 months?’ can be a useful starting point for clinicians (DH [8]). The use of tools such as the Supportive and Palliative Care Indicator Tool (SPICT) supports a more in‐depth flow diagram to aid clinicians in the identification process (Boyd and Murray [3]). For patients, cancer booklets such as Your Life, and Your Choices, Plan Ahead can help steer them through issues that may need to be considered when faced with a life‐limiting illness (Macmillan Cancer Support [32]).

Recognizing dying in the last days to hours of life in patients with cancer is not easy and is a skill that develops over time. In a patient who is approaching the end of their life, clinical signs that may help us know the patient's prognosis is hours to days include reduced consciousness level and respiratory changes such as Cheyne–Stokes breathing. In the majority of cases there is a progressive physical decline, frailty and a deterioration in mobility coupled with reduced oral intake including food, fluid and oral medications (Sleeman [52]).

Following on from recognizing that a patient may be dying it is important to consider several issues (Collis [5]):