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 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).


CONCLUSIONS
We identified highly specific physical signs associated with death within 3 days among cancer patients.
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 dhui@mdanderson.org.
David
D
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
R
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
G
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
S
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
TB
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
K
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
CS
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
X
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
MD
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
PE
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
Rde A
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
MS
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
S
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
F
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
S
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
CE
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
R
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
S
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
J
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
E
Bruera
D003643:Death; D006801:Humans; D009369:Neoplasms / Q000175:diagnosis / Q000401:mortality* / Q000473:pathology*; D010166:Palliative Care; D010361:Patients; D010808:Physical Examination
Death; Diagnosis; Neoplasms; Palliative care; Physical examination; Sensitivity; Signs; Specificity