Tell-Tale Signs of Impending Death in Advanced Cancer Patients

By Megan Brooks

NEW YORK (Reuters Health) - Researchers have identified eight physical signs of impending death in patients with advanced cancer, which could help with end-of-life decision-making.

"Given the paucity of literature on this important topic, clinicians may consider incorporating these 'tell-tale' physical signs in their practice; however, more research is needed to further confirm our findings, particularly in non-cancer populations and in other settings such as hospice," said Dr. David Hui, from the Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center in Houston, in an email to Reuters Health.

Currently, the diagnosis of impending death is based on clinicians' overall impression, Dr. Hui explained. "This impression is often based on a variable number of factors including disease trajectory as well as some physical signs (e.g. unresponsiveness, being completely bed bound, death rattle); however, the diagnostic utility of many of these signs has not been systematically examined until our study. Thus, each clinician may have variable interpretation of these physical signs, and it has been difficult to tell with confidence that a patient has entered the last days of life," he noted.

In an earlier study, Dr. Hui and colleagues identified five signs (among 10 investigated) seen only in the last days of life that were highly predictive of dying within three days among advanced cancer patients - namely, pulselessness of the radial artery, decreased urine output, Cheyne-Stokes breathing, respiration with mandibular movement, and death rattle.

In their latest study, online February 9 in the journal Cancer, they examined the frequency and onset of another 52 bedside physical signs and their diagnostic performance for impending death in 352 consecutive patients with advanced cancer.

All had been admitted to the acute palliative care unit at MD Anderson or Barretos Cancer Hospital in Brazil. The average age was 58, 55% were women, and 28% had gastrointestinal cancers.

They documented the presence or absence of these 52 signs every 12 hours from unit admission to death or discharge. The median time spent in the unit was six days; 203 patients (57%) died at the end of the admission.

The researchers say eight physical signs were highly diagnostic of impending death. They occurred in 5% to 78% of the patients within the last three days of life, had a late onset, and a high specificity (>95%) and positive likelihood ratio (LR >5) for death within three days. They are:

- nonreactive pupils (positive LR 16.7)

- decreased response to verbal stimuli (positive LR, 8.3)

- decreased response to visual stimuli (positive LR 6.7)

- inability to close eyelids (positive LR 13.6)

- drooping of the nasolabial fold (positive LR 8.3)

- hyperextension of the neck (positive LR 7.3)

- grunting of vocal cords (positive LR 11.8)

- upper gastrointestinal bleeding (positive LR 10.3)

"Our study, for the first time, provides likelihood ratios for a wide array of physical signs, which could help clinicians identify the high yield 'tell-tale' signs to aid in the diagnosis of impending death, while at the same time, recognize that some physical signs are of limited utility (e.g. cool extremities)," Dr. Hui said.

"Our study showed that any individual 'tell-tale' sign could be useful for the diagnosis of impending death in three days (i.e. significantly increases the post-test probability of death in three days). We are currently conducting further research to examine if a combination of these physical signs can be more useful for diagnostic purposes," he added.

The ability to make the diagnosis of impending death with confidence is important for talking with families and making end-of-life decisions such as stopping aggressive treatments, the researchers note in their article.

Because the study investigated a large number of clinical signs in a relatively small number of patients, the findings should be considered preliminary until they are validated in future studies, they say.

"The physical signs reported here, in conjunction with those reported previously, may pave the way toward the development and validation of a bedside diagnostic tool for impending death," the researchers conclude.

Reached for comment, John Mastrojohn III, executive vice president and CEO of the National Hospice and Palliative Care Organization (NHPCO), said this is an important study.

"The findings can be helpful to clinicians to better prepare families for the death of a loved one and also to help them honor the wishes of patients who are no longer able to make decisions on their own," he said.

"Our hope would be this study could be replicated in other settings and also with patients with advanced non-cancer diagnoses." he added. "To do so would provide opportunities for the development of bedside tools that would assist clinicians to enhance the care of patients near the end of life, as well as their families."

The study had no commercial funding and the authors have no disclosures.

SOURCE: https://bit.ly/1DcuXF8

Cancer 2015.

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