In the last few weeks

You’re likely to experience a range of physical and emotional changes in the last few weeks of your life. These are normal. But it may be hard for you, and the people around you, as they happen. Knowing what to expect can help you cope.

Your healthcare team can help you deal with any physical symptoms you develop. They may prescribe new medication to deal with symptoms such as pain, sickness and vomiting. They can show you techniques to help with problems such as difficulty sleeping, tiredness and lack of energy, breathlessness, difficulty eating or a sore mouth. If it is too hard to manage your symptoms at home, it may help to spend a few days in a hospice.

You may also feel lots of different emotions, such as worry or anger. Talking honestly about how you feel can help. You may want to talk to family, friends, professionals looking after you, or with a counsellor or support organisation.

Becoming more withdrawn as you get close to death is normal. Your carers may need extra support as this happens.

What will happen in the last few weeks of life?

During the last few weeks of life, you may experience a number of emotional and physical changes and symptoms. Even though these changes and symptoms are normal, they can be upsetting for both you and the people around you. Being prepared for what may happen can make the situation a little easier to cope with.


Emotional changes in the last few weeks of life

You may have a lot of different emotions that can include worry, anxiety, panic, anger, resentment, sadness and depression. It’s natural to be worried or anxious when you’re facing death. You may also feel the decline in your health and worry about the loss of your role in your family or with friends.

Talking about how you’re feeling can help. If you’re at home and have a nurse, you can talk to them about any specific concerns that you have. You may find that once you’ve shared your concerns you feel much better, especially if you’ve been worrying about something. Some people prefer to talk to a person they don’t know, such as a trained counsellor.

If you’d like to see a trained counsellor, your GP can refer you. You may also want to search for some helpful organisations who offer support and have some useful helplines. Talking to a religious or spiritual adviser can also help to reduce your fear and anxiety, even if you’ve not attended religious services or had contact with spiritual leaders before.

It’s not uncommon for people to become withdrawn. For some this may be due to depression, which your doctor or nurse can help with. For others, it’s a natural part of gradually withdrawing from the world and you may find yourself losing interest in the things and the people around you, even close family. Family, friends and others caring for you may need more support or someone to talk to as this happens. We have more information for people caring for someone with cancer at the end of life.


Coping with physical changes and symptoms in the last few weeks of life

The physical changes and symptoms that occur vary with the type of illness a person has. Here, we describe physical changes that generally happen in the last few weeks of life and the specific changes that may occur with some types of cancer.

As someone becomes more ill, their medicines may be reviewed by their doctor or nurse. Some medicines may be stopped if they’re no longer needed. If someone has symptoms such as pain, feeling sick or breathlessness, the doctor or nurse may prescribe new medicines to control them. Medicines can be changed and tailored to what you need. Complementary therapies may improve quality of life and well-being, and can also sometimes help to reduce symptoms.


Tiredness and lack of energy

It’s normal to gradually lose energy and not be able to do things for yourself. Tiredness and weakness can make it harder for you to concentrate or take part in what’s going on around you. You may need to rest a lot during the day, either in a chair or in bed. If you’re not moving around much, you may get sore areas, for example on your bottom or heels. Your district nurse can organise equipment, such as a pressure-relieving cushion for your chair or a mattress for your bed, to help prevent soreness. You can also help by changing your position as often as you can.

Helpful hints for managing tiredness

  • Pace yourself and save your energy for the things that matter to you and that you enjoy.
  • Cut down on any unnecessary tasks, such as cooking, cleaning or making the bed. You could ask your friends and family to help you with these.
  • Ask a carer to help with washing and dressing if these tire you out.
  • Accept and use equipment (such as a raised toilet seat, bath board, walking frame) that helps you with daily tasks and avoids you getting so tired.
  • If you have important things that you want to do, such as sorting out your financial affairs, do them at a time of day when you have more energy.
  • If you’re struggling with eating, try to eat little and often to keep your energy levels up.


Sleep Disturbance

Some people find they can’t sleep well at night. There may be many reasons for this. These include:

  • some medicines such as steroids, can keep you awake
  • psychological factors such as anxiety and depression, or perhaps a fear of dying in the night
  • symptoms that aren’t controlled such as pain, breathlessness or incontinence
  • other factors such as light, noise and sleeping during the day.

It’s important to tell your doctor or nurse if you’re not sleeping well. Once the causes of your sleeplessness are known, your sleep can often be improved. Let your doctor or nurse know if you have any specific anxieties or symptoms, such as pain, breathlessness or incontinence, that are affecting your sleep. For example, if pain is causing sleeplessness, this can be controlled by adjusting your dose of painkillers at night.

Your nurse can advise you about this.

Helpful hints for helping you sleep

  • If your mattress is uncomfortable, ask your nurse for advice on a more comfortable one.
  • Try to reduce light and noise at night.
  • Have a hot drink before going to bed, but avoid caffeine and alcohol at night time.
  • Keep your bedroom for sleeping. If you wake up during the night, go to another room in the house. If you need to sleep during the day, go to your bed and sleep.
  • If you wake at night, don’t toss and turn. Get up and go to another room. Have a hot drink if you like. When you feel sleepy, go back to bed again.
  • Avoid using any screen, such as a TV screen or computer screen, for an hour before going to bed.
  • Keep a ‘worry book’ so that if you wake up during the night you can write down the things you’re worried about. You can then work through your list of worries during the day and get support and advice from your carers or your doctor or nurse.
  • Try using relaxation techniques at night. You may find it helpful to use a relaxation tape or to listen to some soothing music.
  • If you find touch and massage helpful, you could ask your carer to give your hands or feet a gentle massage.
  • If you find that, despite following these hints, you aren’t sleeping enough, talk to your doctor or specialist nurse. They may advise you to try taking sleeping tablets. You may only need to take sleeping tablets for a limited amount of time or on an ‘as required’ basis.


Pain

Not everyone who is terminally ill gets pain, but if you do, it can be reassuring to know there can be effective ways of controlling it. If you have pain, it’s important to let your doctor or nurse know exactly where your pain is, how it feels, and how it affects you so they can treat it effectively.

Painkillers

Everyone feels pain differently and there are several types of painkillers for different types of pain. They include:

  • simple painkillers such as paracetamol
  • moderately strong painkillers such as codeine and tramadol
  • strong painkillers such as morphine, oxycodone, fentanyl and diamorphine
  • anti-inflammatory drugs such as ibuprofen and diclofenac
  • painkillers for nerve pain such as gabapentin, pregabalin, amitriptyline and dosulepin. Some of the drugs for nerve pain are also used for depression and epilepsy.
  • Painkillers are usually given as tablets, liquid medicines, or patches stuck on to the skin. If you’re unable to swallow or are being sick, your nurse or doctor can give you painkillers such as morphine, diamorphine and oxycodone as an injection or by using a syringe driver.

Syringe driver

This is a small portable pump, which is set up by your nurse or doctor.

A syringe containing enough drug(s) for usually 24 hours is attached to the pump. The pump delivers a continuous dose of the drug(s) from the syringe through a small needle or tube that is inserted just under the skin of your tummy (abdomen) or arm. Your nurses will change the syringe each day or when needed. Painkillers, anti-sickness, anti-anxiety and several other medicines can be given by a syringe driver.

Many people worry that their pain will get worse as they near the end of their life and they’ll need to take increasing doses of strong painkillers such as morphine. It’s important to remember that there’s no such thing as a ‘right’ dose of morphine. The ‘right’ dose is the dose that gets rid of your pain.

Side effects of painkillers

Painkillers containing codeine and strong painkillers have three common side effects: drowsiness, sickness and constipation. Drowsiness usually wears off after a few days, so you should be pain-free and still alert enough to do all that you want to do. If you feel sick, anti-sickness medicines (anti-emetics) can help, and this usually settles gradually over a few days. Constipation is such a common side effect that everyone taking strong painkillers usually needs to take a laxative regularly. Your doctor, nurse or pharmacist can advise you about this.

Helpful hints for controlling your pain with painkillers

  • Always take your painkillers regularly and as prescribed by your doctor or nurse.
  • Let your doctor or nurse know as soon as possible if your pain isn’t controlled.
  • Keep a pain diary if you can. Ask your district nurse or specialist nurse if they can give you one.
  • Be aware of the side effects of some painkillers and take medicines if needed to keep them controlled.
  • If you get side effects that aren’t being treated or responding to treatment, let your doctor or nurse know.
  • Other ways of controlling pain
  • There are a number of other ways to control pain that can be used alongside painkillers.

Helpful hints for using other ways to control your pain

  • Find a comfortable position to sit or lie in.
  • Use warmth or cold on the area of pain.
  • Use relaxation techniques such as deep breathing or meditation.
  • Try to distract your attention away from the pain, for example by playing music or watching a film you enjoy.
  • Talk to your doctor or nurse about Transcutaneous Electrical Nerve Stimulation (TENS) and acupuncture, which are more specialised ways of controlling pain. They will let you know if these are suitable for you.
  • If you know of methods that have helped control your pain in the past, try them to see if they help now.


Feeling sick and vomiting

Your illness, or your medicines, may make you feel sick (nausea) or be sick (vomit). If this happens, your doctor or nurse can prescribe anti-sickness drugs (anti-emetics), which usually control sickness effectively. These may be taken as tablets. If you can’t swallow tablets, they can also be given as suppositories that are inserted into your back passage, as injections or by a syringe driver.

Helpful hints for reducing sickness

  • If you’ve been given anti-sickness medicines, take them regularly to prevent the sickness returning.
  • Have warm or cold food, as this doesn’t smell as strong as hot food.
  • Eat dry foods such as crackers.
  • Food or drink containing ginger can help. Try crystalised ginger, ginger tea, ginger beer or ginger biscuits.
  • Sip fizzy drinks.
  • Eat little and often.


Weight loss and loss of appetite

You may lose weight, even if you’re eating well, and this can be upsetting. Gradually you’ll find that your appetite reduces due to your illness or the medicines you’re taking. It’s also common to be put off eating by the sight and smell of food.

Medicines, such as steroids, can sometimes help to boost your appetite. Your doctor can prescribe these if they are suitable for you.

Helpful hints for boosting your appetite

  • Eat small frequent meals.
  • Put smaller portions on your plate rather than being put off by larger portions.
  • Make your food look attractive.
  • Get someone else to cook your food if you find yourself put off by the smell of cooking and avoid foods with a strong smell.
  • Have a glass of sherry, brandy or your favourite alcoholic drink about 30 minutes before eating. But remember that the effects of alcohol may increase if you’re ill or taking particular medicines, so it’s best to check this with your doctor or nurse.
  • Have snacks handy to nibble.
  • Have nourishing drinks.
  • Avoid filling your stomach with fluid before meals as this may cause you to eat less.
  • Eat slowly.

As you near the end of your life, your metabolism slows down and your body no longer needs food as it can’t digest it well or absorb the nutrients from it. At this stage, it’s important not to force yourself to eat and it’s okay if you don’t.

You may want to try liquid meals when you don’t feel able to eat a proper meal. There are many different types of complete meals in liquid form such as Build-up® or Complan®. Your doctor or nurse can advise which is the best for you. They can often arrange a supply on prescription.

As a carer, you might feel anxious or upset because your relative or friend no longer wants or enjoys food. Although this can be hard to accept, it’s important that you don’t try to force them to eat. You may want to try giving them drinks they like instead.


Constipation

Many people find that they get constipated more easily because they aren’t moving around or eating and drinking as much. There are also a number of medicines, such as strong painkillers, that can cause constipation.

Helpful hints for managing constipation

  • If you’ve been prescribed laxatives to help with constipation, take them as prescribed. 
  • Let your GP or nurse know as soon as possible if you’re constipated. You should also let them know if your laxatives aren’t working. 
  • Drink as much fluid as possible. 
  • Add high-fibre foods to your diet, such as fruit and vegetables, brown rice, bread or pasta if you’re able to eat them.


Breathlessness

Some people may feel breathless. There can be many reasons for this, such as cancer in the lung, chronic lung problems, general weakness, fluid inside the lung (pulmonary oedema), fluid around the lungs (pleural effusion) or anaemia (low red blood cell count).

Breathlessness can be very frightening but there are various ways of treating it, depending on the cause. It’s important to let your doctors and nurses know if you’re breathless so they can help you as soon as possible.

Nurses can show you and your carers the best positions for you to sit or stand to help with your breathing. You can also be taught how to breathe more effectively, pace your activity and save your energy. Anxiety is very common in patients with breathlessness and this can make your breathing feel even more difficult. Your nurse or physiotherapist can teach you ways to relax, so that you feel less anxious and breathless.

Helpful hints for managing breathlessness

  • Think about ways to arrange your home to make tasks easier. For example, a chair in the hallway or a chair at the top and bottom of the stairs could be used to take a rest when walking between rooms or climbing up and down the stairs.
  • Sit down to carry out everyday tasks like washing and dressing.
  • If you feel breathless, try using a cool fan to blow air on to your face or sitting by an open window.
  • If you need to talk to someone in another room without getting up or shouting, try using a baby monitor or alarm.
  • If you’re breathless in bed, try using a V-shaped pillow to help you sit in an upright position.
  • If you have difficulty getting to the toilet, use a commode or urine bottle.

There are several medicines that can be used for breathlessness, such as a very low dose of morphine.

Your GP or nurse can also arrange for you to have oxygen at home if you need this.

If breathlessness is caused by a build-up of fluid around your lungs (pleural effusion), the fluid can be drained off. If it’s caused by anaemia (a low red blood cell count), then your doctor may arrange for you to have a blood transfusion.


Mouth problems

You may develop problems with your mouth such as dryness, ulcers or an infection. These problems can sometimes be made worse by the medication you’re taking. You will also be more at risk of mouth problems if you find it difficult to maintain good mouth care. It’s important to let your nurse or doctor know if you develop any mouth problems so that they can help.

Helpful hints for preventing mouth problems

  • Brush your teeth twice a day using a fluoride toothpaste. Use a soft children’s toothbrush if your mouth is sore. Rinse your mouth with fresh water after brushing.
  • Rinse your mouth three or four times a day to remove debris and keep it clean. You can use water or a salt-water rinse (1 teaspoon of salt to 1 pint of cold or warm water). You should rinse your mouth with cold or warm water after using a salt-water rinse.
  • If you have false teeth, clean these as usual and soak them overnight.
  • Use any mouthwashes that have been prescribed for you, and follow the instructions.
  • Cut down on substances that can dry or irritate the mouth, such as caffeine, alcohol or smoking.
  • If you have a dry mouth, sip tonic water or lemonade, or try sucking ice lollies, ice cubes or chewing sugar-free gum.

Marie Curie has produced a video on how to cope with mouth problems. You might find it helpful to watch this video.


Cough and wheezing

You may have a cough or feel wheezy, which can be upsetting. Your GP can prescribe medicines to help with these symptoms. Sitting as upright as possible while supported on pillows can reduce a cough and help you breathe more easily.


Fluid build-up (oedema)

Some people have a build-up of fluid in a part of their body. This is known as oedema. You may have swollen legs and ankles if you’re not able to move around much. Water tablets (diuretics) can sometimes help. If the fluid build-up is in your legs and ankles, your doctor may prescribe special pressure stockings to help reduce this. Using a footstool to keep your feet up when sitting can also help, as can gently exercising your legs.

A nurse or physiotherapist can show you some exercises to do. It may be harder to move around if your legs are swollen, and this can be frustrating. It may help to talk to your carers about how you feel. Your nurses can help you find ways of moving around.


Changes in appearance

You may find it upsetting if your appearance has changed, for example if you’ve lost weight or put some on. It can help to talk through your feelings with your carers or your nurses. They may be able to find ways to help you look and feel better.


Infection

If you’re not moving around much and aren’t eating or drinking well, you may be more at risk of infection, such as a chest or urine infection. Let your doctor know immediately if you develop a high temperature or start to feel shivery, shaky or unwell. They may prescribe antibiotics to treat the infection.


Anaemia (low red blood cell levels

Anaemia can make you very tired and breathless. If you’re anaemic, your doctor or nurse may recommend that you have a blood transfusion. You’ll usually have this as a day patient in a hospital or hospice. However, in some areas it may be possible to have it done at home.

A blood transfusion may help you feel better very quickly and can be repeated if it’s needed and has helped you before.


Bladder problems

If you have problems emptying your bladder or can’t control it, a thin, flexible tube (catheter) can be put into your bladder to drain the urine. Having a catheter saves you from the discomfort of trying to use a bedpan or bottle if you can’t get out of bed.


Swollen tummy (ascites)

With some types of cancer, fluid may sometimes build up in the tummy (abdomen) so that it becomes swollen, tight and uncomfortable. This is known as ascites. It can often be relieved by inserting a tube into the abdomen to drain off the extra fluid. This is done under local anaesthetic and can be repeated, if needed. Ascites can also be managed by taking water tablets (diuretics), which your GP or specialist palliative care nurse will discuss with you.


High calcium levels (hypercalcaemia)

Some types of cancer can cause high calcium levels in the blood. This can make you feel drowsy or sick and can cause confusion or constipation. It may also make pain more difficult to cope with. If you develop these symptoms, let your nurse or doctor know so they can take a blood test to check your calcium levels. If your calcium level is high, a few days of treatment in hospital or a hospice with medicine (bisphosphonates) given through a drip will help to bring your calcium levels down.


Managing difficult symptoms

Usually, it’s possible to manage your symptoms at home, but sometimes it can help to spend a few days or weeks in a hospice having them treated. Your community palliative care team or GP will discuss this with you if they think it would be helpful. In the hospice, the doctors and nurses will be able to assess your symptoms. They can adjust the dose of your medicines or add in new ones to control your symptoms more quickly than if you were at home. Once your symptoms are controlled, you can go home again to the care of your GP with the support of your community palliative care team and district nurses.


Complementary therapies

Although complementary therapies can’t cure illnesses, many people find they can help them feel stronger and more confident about coping with dying. They may also improve their quality of life and reduce symptoms.

Many hospices and hospitals offer complementary therapies alongside conventional care. These may include:

  • acupuncture
  • homeopathy
  • relaxation, visualisation, or guided imagery techniques
  • aromatherapy
  • reflexology
  • reiki.

You might like to try some complementary therapies, such as relaxation and visualisation, to reduce anxiety. It may also be possible for hospital or hospice staff trained in complementary therapies to teach your carers how to give you a massage.

Many hospices and hospitals also offer free complementary therapies to carers. You can ask your nurse about which therapies are available in your local area.


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