title: International palliative care experts' view on phenomena indicating the last hours and days of life.
abstract: BACKGROUND
  Providing the highest quality care for dying patients should be a core clinical proficiency and an integral part of comprehensive management, as fundamental as diagnosis and treatment. The aim of this study was to provide expert consensus on phenomena for identification and prediction of the last hours or days of a patient's life. This study is part of the OPCARE9 project, funded by the European Commission's Seventh Framework Programme.
  
  
  METHODS
  The phenomena associated with approaching death were generated using Delphi technique. The Delphi process was set up in three cycles to collate a set of useful and relevant phenomena that identify and predict the last hours and days of life. Each cycle included: (1) development of the questionnaire, (2) distribution of the Delphi questionnaire and (3) review and synthesis of findings.
  
  
  RESULTS
  The first Delphi cycle of 252 participants (health care professionals, volunteers, public) generated 194 different phenomena, perceptions and observations. In the second cycle, these phenomena were checked for their specific ability to diagnose the last hours/days of life. Fifty-eight phenomena achieved more than 80% expert consensus and were grouped into nine categories. In the third cycle, these 58 phenomena were ranked by a group of palliative care experts (78 professionals, including physicians, nurses, psycho-social-spiritual support; response rate 72%, see Table 1) in terms of clinical relevance to the prediction that a person will die within the next few hours/days. Twenty-one phenomena were determined to have "high relevance" by more than 50% of the experts. Based on these findings, the changes in the following categories (each consisting of up to three phenomena) were considered highly relevant to clinicians in identifying and predicting a patient's last hours/days of life: "breathing", "general deterioration", "consciousness/cognition", "skin", "intake of fluid, food, others", "emotional state" and "non-observations/expressed opinions/other".
  
  
  CONCLUSIONS
  Experts from different professional backgrounds identified a set of categories describing a structure within which clinical phenomena can be clinically assessed, in order to more accurately predict whether someone will die within the next days or hours. However, these phenomena need further specification for clinical use.
authors.affiliation: Centre of Palliative Care, Cantonal Hospital of St.Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland. franzisca.domeisen@kssg.ch
authors.forename: Franzisca
authors.initials: F
authors.lastname: Domeisen Benedetti
authors.forename: Christoph
authors.initials: C
authors.lastname: Ostgathe
authors.forename: Jean
authors.initials: J
authors.lastname: Clark
authors.forename: Massimo
authors.initials: M
authors.lastname: Costantini
authors.forename: Maria Laura
authors.initials: ML
authors.lastname: Daud
authors.forename: Barbara
authors.initials: B
authors.lastname: Grossenbacher-Gschwend
authors.forename: Richard
authors.initials: R
authors.lastname: Latten
authors.forename: Olav
authors.initials: O
authors.lastname: Lindqvist
authors.forename: Andreja
authors.initials: A
authors.lastname: Peternelj
authors.forename: Stefanie
authors.initials: S
authors.lastname: Schuler
authors.forename: Kali
authors.initials: K
authors.lastname: Tal
authors.forename: Agnes
authors.initials: A
authors.lastname: van der Heide
authors.forename: Steffen
authors.initials: S
authors.lastname: Eychmüller
mesh_terms: D003244:Consciousness Disorders / Q000175:diagnosis*; D032921:Consensus; D019091:Critical Pathways; D003643:Death; D003697:Delphi Technique; D005060:Europe; D006801:Humans; D038622:Internationality; D010166:Palliative Care / Q000379:methods* / Q000458:organization & administration; D011237:Predictive Value of Tests; D012135:Respiratory Sounds / Q000175:diagnosis*; D011795:Surveys and Questionnaires; D013727:Terminal Care / Q000379:methods* / Q000458:organization & administration