Registered Nurses' Association of Ontario

Practice Recommendations for Assessment at the End of Life

Recommendation *Type of Evidence

Nurses identify individuals who are in the last days and hours of life.

IIa - IV

Use clinical expertise, disease specific indicators and validated tools to identify these individuals.

IIa - IV
1.1.2      Understand the end-of-life trajectories. IIa - IV

Nurses understand the common signs and symptoms present during the last days and hours of life.

IIb - IV

Common signs of imminent death, may include, but are not limited to:

  • progressive weakness;
  • bedbound state;
  • sleeping much of the time;
  • decreased intake of food and fluid;
  • darkened and/or decreased urine output;
  • difficulty swallowing (dysphagia);
  • delirium not related to reversible causes;
  • decreased level of consciousness not related to other causes;
  • noisy respiration/ excessive respiratory tract secretion;
  • change in breathing pattern (Cheyne-Stokes respiration, periods of apnea); and
  • mottling and cooling extremities.
IIb - IV

Nurses complete a comprehensive, holistic assessment of individuals and their families based on the Canadian Hospice Palliative Care Association Domains of Care, which include the following:

  • disease management;
  • physical;
  • psychological;
  • spiritual;
  • social;
  • practical;
  • end-of-life care/ death management; and
  • loss, grief.

IIb to IV


Include information from multiple sources to complete an assessment. These may include proxy sources such as the family and other health-care providers.

IIb to IV


Use evidence-informed and validated symptom assessment and screening tools when available and relevant.

IIb to IV


Reassess individuals and families on a regular basis to identify outcomes of care and changes in care needs.

IIb to IV


Communicate assessments to the interprofessional team.

IIb to IV

1.3.5   Document assessments and outcomes.

IIb to IV



  • reflect on and are aware of their own attitudes and feelings about death;
  • assess individuals’ preferences for information;
  • understand and apply the basic principles of communication in end-of-life care;
  • communicate assessment findings to individuals (if possible and desired) and the family on an ongoing basis;
  • educate the family about the signs and symptoms of the last days and hours of life, with attention to their: faith and spiritual practices; age-specific needs; developmental needs; cultural needs; and
  • evaluate the family’s comprehension of what is occurring during this phase.



Clinical Management
End-of-Life Care During the Last Days and Hours
Practice Recommendations