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Hui D, dos Santos R, Chisholm G, Bansal S, Silva TB, Kilgore K, Crovador CS, Yu X, Swartz MD, Perez-Cruz PE, Leite RDA, Nascimento MSDA, Reddy S, Seriaco F, Yennu S, Paiva CE, Dev R, Hall S, Fajardo J, Bruera E. Clinical signs of impending death in cancer patients. Oncologist 2014; 19:681-7. [PMID: 24760709 DOI: 10.1634/theoncologist.2013-0457] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The physical signs of impending death have not been well characterized in cancer patients. A better understanding of these signs may improve the ability of clinicians to diagnose impending death. We examined the frequency and onset of 10 bedside physical signs and their diagnostic performance for impending death. METHODS We systematically documented 10 physical signs every 12 hours from admission to death or discharge in 357 consecutive patients with advanced cancer admitted to two acute palliative care units. We examined the frequency and median onset of each sign from death backward and calculated their likelihood ratios (LRs) associated with death within 3 days. RESULTS In total, 203 of 357 patients (52 of 151 in the U.S., 151 of 206 in Brazil) died. Decreased level of consciousness, Palliative Performance Scale ≤20%, and dysphagia of liquids appeared at high frequency and >3 days before death and had low specificity (<90%) and positive LR (<5) for impending death. In contrast, apnea periods, Cheyne-Stokes breathing, death rattle, peripheral cyanosis, pulselessness of radial artery, respiration with mandibular movement, and decreased urine output occurred mostly in the last 3 days of life and at lower frequency. Five of these signs had high specificity (>95%) and positive LRs for death within 3 days, including pulselessness of radial artery (positive LR: 15.6; 95% confidence interval [CI]: 13.7-17.4), respiration with mandibular movement (positive LR: 10; 95% CI: 9.1-10.9), decreased urine output (positive LR: 15.2; 95% CI: 13.4-17.1), Cheyne-Stokes breathing (positive LR: 12.4; 95% CI: 10.8-13.9), and death rattle (positive LR: 9; 95% CI: 8.1-9.8). CONCLUSION We identified highly specific physical signs associated with death within 3 days among cancer patients.
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Affiliation(s)
- David Hui
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Renata dos Santos
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Gary Chisholm
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Swati Bansal
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Thiago Buosi Silva
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Kelly Kilgore
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Camila Souza Crovador
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Xiaoying Yu
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Michael D Swartz
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Pedro Emilio Perez-Cruz
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Raphael de Almeida Leite
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Maria Salete de Angelis Nascimento
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Suresh Reddy
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Fabiola Seriaco
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Sriram Yennu
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Carlos Eduardo Paiva
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Rony Dev
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Stacy Hall
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Julieta Fajardo
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Eduardo Bruera
- Departments of Palliative Care and Rehabilitation Medicine and Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil; Division of Biostatistics, University of Texas Health Science Center at Houston, Houston, Texas, USA; Programa Medicina Paliativa, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
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