Researchers at The University of Texas MD Anderson Cancer Center have identified eight highly specific physical and cognitive signs associated with imminent death in cancer patients. The findings, published in the journal Cancer, could offer clinicians the ability to better communicate with patients and families. They may also guide both the medical team and caregivers on complex decision making, such as discontinuation of tests and therapy, plans for hospital discharge and hospice referral.
Previous studies in end-of-life care have focused on physicians prognosticating better. However, according to David Hui, M.D., assistant professor, Palliative Care and Rehabilitation Medicine, research on how to tell if a patient has entered the final days of life has been minimal. Knowing with a high degree of confidence that death is imminent could have significant implications for clinical practice. It may also help families and caregivers make more informed decisions.
"In the past, studies trying to understand the signs associated with impending death were conducted in people who were recognized as dying, so there's a potential bias built into this model. With our study, we observed a list of signs in patients from the time they were admitted to the palliative care unit. They were observed systematically, twice a day, without knowing if the patient would die or be discharged," says Hui, the study's corresponding author.
The study shows that very simple observations by doctors and care teams can help make a very important diagnosis and may inform both the patient and the family so that they can make difficult personal decisions, he explained.
For the prospective study, Hui and colleagues at MD Anderson and Barretos Cancer Hospital (an MD Anderson Sister Institution in Brazil) observed 357 cancer patients admitted to the respective palliative care units, of which 57 percent ultimately died. The researchers systematically observed 52 physical and cognitive signs -- identified by Hui and colleagues in previous research -- twice a day from the patient's admission to discharge or death. Of those 52 signs, the researchers identified the eight most highly associated with impending death within three days. Signs include: nonreactive pupils; decreased response to verbal stimuli; decreased response to visual stimuli; inability to close eyelids; drooping of the nasolabial fold; neck hyperextension; grunting of vocal cords; and upper gastrointestinal bleeding.
"When cancer patients reach the last days of life, this is an extremely emotional time for families -- their stress levels cannot be understated," says Hui. "Knowing when death is imminent would provide more information so caregivers can plan appropriately. For clinicians, having this information could help reassure families that we are providing the best care possible."
Hui stresses that this research is not yet practice-changing, but is an important step in understanding these eight signs and their relation to impending death. Also, says Hui, the findings are only representative of imminent cancer death and should not be generalized to other causes of death.
Follow up studies in different settings are planned: Hui and colleagues will look at the reliability of the identified signs, as well as evaluate this research in other countries and in the hospice setting.
In addition to Hui, other authors on the study include: from MD Anderson, Eduardo Bruera, M.D., professor and chair, and Swati Bansal, both of Palliative Care and Rehabilitation Medicine; and Gary Chisholm, Biostatistics. From Barretos Cancer Hospital, authors include: Renata dos Santos, M.D., and Camila Souza Crovador.
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