Study identifies clinical signs suggestive of impending death in patients with advanced cancer 
 
 09 Feb 2015 
 
 While the 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 early online in Cancer, has revealed eight highly specific physical signs associated with death within three 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 healthcare professionals to make a diagnosis with confidence and to communicate this with the family. 
 
 To address this, David Hui, MD, MSc, of the MD Anderson Cancer Center, 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 percent of the patients died. 
 
 The researchers identified eight bedside physical signs that, if present, strongly suggest that a patient will die within three days. 
 
 The signs include non-reactive 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 recognise if a patient has entered the final days of life,” said Dr Hui. 
 
 “Upon further confirmation of the usefulness of these ‘tell-tale’ signs, we will be able to help doctors, nurses, and families to better recognise 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, Dr Hui and his team are now creating some educational materials to help healthcare professionals and families recognise 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’s unclear whether they also translate outside of cancer centres. 
 
 Therefore, the investigators are in the process of validating their results in other healthcare settings, such as home and inpatient hospice. 
 
 Reference 
 
 David Hui, Renata dos Santos, Gary Chisholm et al., Bedside clinical signs associated with impending death in patients with advanced cancer: Preliminary findings of a prospective longitudinal cohort study. Cancer, published Online: February 9, 2015 
 
 Source: Wiley 

 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. 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," says study author Dr. David 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." 
 
 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." 
 
 Recently, Medical News Today reported on a study finding that colorectal cancer survivors who smoke have more than twice the risk of death compared to those that do not smoke.
– It's possible to know when a cancer patient's death is imminent, according to a new study that has identified eight "tell-tale" signs that indicate that the end is nigh. A researcher involved in the study, published in Cancer, explains why the findings are so novel: Previous studies focused on "people who were recognized as dying, so there's a potential bias built into this model." In this instance, researchers at the University of Texas MD Anderson Cancer Center instead observed their subjects twice daily—noting 52 physical and cognitive signs—from the moment they were admitted to one of two acute palliative care units, "without knowing if the patient would die or be discharged," explains Dr. David Hui. Of the 357 patients they studied, 57% died, and eight of the 52 signs were deemed most associated with death coming within three days. Write the authors, "These signs were commonly observed in the last three days of life with a frequency in patients between 38% and 78%." They are: nonreactive pupils decreased response to verbal stimuli decreased response to visual stimuli inability to close eyelids drooping of the nasolabial fold (the skin fold that runs from the corner of the nose to the mouth, ie, "smile lines") neck hyperextension grunting of vocal cords upper gastrointestinal bleeding "Knowing when death is imminent would provide more information so caregivers can plan appropriately," explains Hui—for instance, remaining in the hospital overnight so as not to miss a loved one's passing. From a clinical standpoint, "time and resources" can be conserved by, for instance, ending daily blood tests, reports Medical News Today. The researchers next plan to review whether the results hold in settings other than cancer centers, such as home hospice, notes ecancernews. (A recent UK cancer study came to a staggering conclusion.)