Introduction Care of the dying person begins with the recognition that they are approaching the last days of life (LDOL), but there is no universal definition for ‘dying’. Variations in terminology can be misinterpreted by patients, relatives, and healthcare professionals (HCPs) alike. The main aims of the present study were to: 1) describe the different ways clinicians document in the medical notes when someone is thought to be in the LDOL, and 2) determine the prevalence of explicit phrasing about the LDOL, viz., the use of the term ‘dying’ or some alteration thereof.

Method A list of all inpatients who died at the Queen Elizabeth Hospital Birmingham in August 2019 was obtained from Bereavement Services (N=142). Patients on A&E and ITU, patients admitted for less than 24-hours, or those who died unexpectedly were excluded. Individual patient case notes spanning 7 days prior to death were retrospectively scrutinised for the terminology used in the documentation of LDOL. Data were tabulated and analysed using Microsoft Excel.

Results The records of 66 decedents were analysed. Explicit documentation (i.e. ‘this patient is dying’ or variants) occurred for 15 patients (22.7%). Of the remaining 51 patients, whilst there was no explicit documentation, an estimate of life expectancy was stated for 11 patients (16.7%). For the remaining 40 patients (60.6%), for whom there was no explicit documentation or an estimate of life expectancy provided, the most common terms used to describe LDOL were: ‘prognosis poor’, ‘end of life’, ‘deterioration’ and ‘very unwell’.

Conclusion This project has highlighted a clear disparity amongst clinicians regarding their documentation of dying; explicit documentation occurred infrequently. It is not known what the impact of this is on HCP-patient/relative or HCP-HCP communication. Poor written communication could well reflect poor quality of LDOL care. Further studies are needed.