Study identifies signs suggesting impending death in patients with advanced cancer

Although a diagnosis of an impending death is always sad, it can be important for patients, families, and clinicians as they make decisions related to hospital discharge, hospice referral, and treatments. Now a new study published in CANCER (2015; doi:10.1002/cncr.29048), has revealed eight highly specific physical signs associated with death within 3 days in cancer patients.

When a patient has entered the final days of life, it makes sense to stop daily bloodwork and potentially futile medications, and to focus on comfort care. Knowing whether the patient is imminently dying can also inform many personal decisions for family caregivers, such as whether a wife wants to stay overnight in the hospital and whether a son still has time to fly in to see his father.

Unfortunately, very few studies have examined the signs of impending death, making it difficult for health care professionals to make a diagnosis with confidence and to communicate this with the family.

David Hui, MD, MSc, of the MD Anderson Cancer Center in Houston, Texas, and his colleagues recorded the physical changes in the final days of life in 357 cancer patients who were admitted to acute palliative care units in two cancer centers: MD Anderson Cancer Center in Houston and Barretos Cancer Hospital in Brazil. The investigators systematically documented 52 physical signs every 12 hours from admission to death or discharge.

During the study, 57% of the patients died. The researchers identified eight bedside physical signs that, if present, strongly suggest that a patient will die within 3 days. The signs include nonreactive pupils, decreased response to verbal stimuli, decreased response to visual stimuli, inability to close eyelids, drooping of the nasolabial fold (which makes the face appear more relaxed), hyperextension of the neck (in which the head tilts back when the patient is lying down), grunting of vocal cords, and upper gastrointestinal bleed. These signs may help doctors and nurses to make the diagnosis of impending death.

“This study shows that simple bedside observations can potentially help us to recognize if a patient has entered the final days of life,” said Hui. “Upon further confirmation of the usefulness of these ‘tell-tale' signs, we will be able to help doctors, nurses, and families to better recognize the dying process, and in turn, to provide better care for the patients in the final days of life.”

Based on the study's findings, Hui and his team are now creating some educational materials to help health care professionals and families recognize when a patient has entered the final days of life, and they are developing a diagnostic tool of impending death based on these physical signs to support clinical decision making.

While the findings are relevant for clinicians who care for dying cancer patients, it is unclear whether they also translate outside of cancer centers. Therefore, the investigators are in the process of validating their results in other health care settings, such as home and inpatient hospice.

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