Clinical Signs of Impending Death in Cancer Patients

Background.The physical signs of impending death have not been well characterized in cancer patients. A better understanding of these signs may improve the abilityofcliniciansto 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 medianonsetofeachsignfromdeathbackwardandcalculated theirlikelihoodratios(LRs)associatedwithdeathwithin3days. Results. Intotal,203of357patients(52of151intheU.S.,151 of 206 in Brazil) died. Decreased level of consciousness, Palliative Performance Scale #20%, and dysphagia of liquids appearedathighfrequencyand.3daysbeforedeathandhad low specificity (,90%) and positive LR (,5) for impending death. In contrast, apnea periods, Cheyne-Stokes breathing, deathrattle,peripheralcyanosis,pulselessnessofradialartery, respiration with mandibular movement, and decreased urine output occurred mostly in the last 3 days of life and at lower frequency. Fiveof these signshadhigh specificity (.95%)and positiveLRsfordeathwithin3days,includingpulselessnessof 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),decreasedurineoutput(positiveLR: 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. The Oncologist 2014;19:681–687