title: Symptom Expression in the Last Seven Days of Life Among Cancer Patients Admitted to Acute Palliative Care Units.
abstract: BACKGROUND
  The symptom burden in the last week of life of patients with advanced cancer has not been well characterized.
  
  
  OBJECTIVE
  To examine the frequency, intensity, and predictors for symptoms in the last seven days of life among patients who were able to communicate and died in an acute palliative care unit (APCU).
  
  
  METHODS
  We systematically documented the Edmonton Symptom Assessment System (ESAS) daily and 15 symptoms twice daily on consecutive advanced cancer patients admitted to APCUs at MD Anderson Cancer Center (U.S.) and Barretos Cancer Hospital (Brazil) from admission to death or discharge in 2010/2011. We examined the frequency and intensity of the symptoms from death backward.
  
  
  RESULTS
  A total of 203 of 357 patients died. The proportion of patients able to communicate decreased from 80% to 39% over the last seven days of life. ESAS anorexia (P = 0.001 in longitudinal analyses), drowsiness (P < 0.0001), fatigue (P < 0.0001), poor well-being (P = 0.01), and dyspnea (P < 0.0001) increased in intensity closer to death. In contrast, ESAS depression (P = 0.008) decreased over time. Dysphagia to solids (P = 0.01) and liquids (P = 0.005) as well as urinary incontinence (P = 0.0002) also were present in an increasing proportion of patients in the last few days of life. In multivariate analyses, female sex, non-Hispanic race, and lung cancer were significantly associated with higher ESAS symptom expression (odds ratio > 1).
  
  
  CONCLUSIONS
  Despite intensive management in APCUs, some cancer patients continue to experience high symptom burden as they approached death.
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA. Electronic address: dhui@mdanderson.org.
authors.forename: David
authors.initials: D
authors.lastname: Hui
authors.affiliation: Department of Palliative Care, Barretos Cancer Hospital, Barretos, Brazil.
authors.forename: Renata
authors.initials: R
authors.lastname: dos Santos
authors.affiliation: Department of Biostatistics, M. D. Anderson Cancer Center, Houston, Texas, USA; Division of Bioinformatics and Computational Biology, M. D. Anderson Cancer Center, Houston, Texas, USA.
authors.forename: Gary B
authors.initials: GB
authors.lastname: Chisholm
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, M. D. Anderson Cancer Center, Houston, Texas, USA.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Bruera
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018450:Disease Progression; D005260:Female; D006801:Humans; D016014:Linear Models; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000401:mortality / Q000503:physiopathology* / Q000628:therapy*; D010166:Palliative Care; D012720:Severity of Illness Index; D013727:Terminal Care; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
keywords: Anorexia; death; deglutition disorders; depression; dyspnea; neoplasms; pain; palliative care; symptom assessment; urinary incontinence