Clinical signs for impending death in cancer patients identified

While many would rather not think about when someone might die, knowing how much longer a seriously ill person has left to live can be very useful for managing how they spend their final days. Researchers have now revealed eight signs in patients with advanced cancer associated with death within 3 days.

The ability to accurately diagnose impending death in patients would be beneficial to clinicians, patients and their families.

Diagnosis of an impending death can help clinicians, patients and their friends and family to make important decisions. Doctors can spare time and resources by stopping daily bloodwork and medication that will not make a short-term difference. Families will know if they still have time to visit their relatives.

This study shows that simple bedside observations can potentially help us to recognize if a patient has entered the final days of life.

"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."

The study, published in Cancer, follows on from the Investigating the Process of Dying Study - a longitudinal observational study that documented the clinical signs of patients admitted to an acute palliative care unit (APCU). During the study, the researchers identified five signs that were highly predictive of an impending death within 3 days.

For the new study, the researchers again observed the physical changes in cancer patients admitted to two APCUs - at the MD Anderson Cancer Center in Houston, TX, and the Barretos Cancer Hospital in Brazil.

Eight highly-specific physical signs were identified

A total of 357 cancer patients participated in the study. The researchers observed them and documented 52 physical signs every 12 hours following their admission to the APCUs. The patients were observed until they died or were discharged from the hospitals, with 57% dying during the study.

The researchers found eight highly-specific physical signs identifiable at the bedside that strongly suggested that a patient would die within the following 3 days if they were present. The signs identified were:

• Decreased response to verbal stimuli
• Decreased response to visual stimuli
• Drooping of "smile lines"
• Grunting of vocal cords
• Hyperextension of neck
• Inability to close eyelids
• Non-reactive pupils
• Upper gastrointestinal bleeding.

With the exception of upper gastrointestinal bleeding, all of these signs are related to deterioration in neurocognitive and neuromuscular function.

Neurological decline strongly associated with death

"The high specificity suggests that few patients who did not die within 3 days were observed to have these signs," the authors write. "These signs were commonly observed in the last 3 days of life with a frequency in patients between 38% and 78%. Our findings highlight that the progressive decline in neurological function is associated with the dying process."

As the study is limited by only examining cancer patients admitted to APCUs, it is not known whether these findings will apply to patients with different types of illness. The findings are currently being evaluated in other clinical settings such as inpatient hospices.

On account of the relatively small number of patients observed for this study, the authors also suggest that their findings should be regarded as preliminary until validated by further research.

In the meantime, the authors of the study are working to develop a diagnostic tool to assist clinical decision-making and educational materials for both health care professionals and patients' families.

"Upon further validation, the presence of these telltale signs would suggest that patients [...] are actively dying," they conclude. "Taken together with the five physical signs identified earlier, these objective bedside signs may assist clinicians, family members, and researchers in recognizing when the patient has entered the final days of life."

References:

1.  Bedside clinical signs associated with impending death in patients with advanced cancer: preliminary findings of a prospective, longitudinal cohort study, David Hui, et al., Cancer, doi: 10.1002/cncr.29048, published online 9 February 2015, abstract.
2.  Cancer news release, accessed 6 February 2015 via Wiley.