title: Change in physiological variables in the last 2 weeks of life: an observational study of hospital in-patients with cancer.
abstract: BACKGROUND
  Recognising dying remains a difficult clinical skill which has gained increasing importance in the United Kingdom since the Neuberger review. Clinical and research methods exist to aid recognition of dying but do not exhibit the level of accuracy required for such an important decision.
  
  
  OBJECTIVE
  To explore change in key clinical parameters as cancer patients near the end of life.
  
  
  METHODS
  This is a retrospective cohort study of terminally ill patients. Data were collected from hospital case-notes. Case-note data were analysed using multilevel modelling to explore absolute values and rates of change of given variables.
  
  
  METHODS
  Hospital in-patients who died from solid-tumour malignancies within a 3-month period in 2009 formed the cohort. The setting was an acute hospital trust in the North of England.
  
  
  RESULTS
  A total of 15,337 data points from the case-notes of 102 patients were analysed. There was a clinically and statistically significant deterioration in respiratory function and renal function over the last 2 weeks of life. Heart rate and serum sodium also changed but did not vary greatly from normal limits. White cell parameters, haemoglobin and albumin showed evidence for change over longer periods.
  
  
  CONCLUSIONS
  Results demonstrate statistically and clinically significant change in routinely measured respiratory and renal function variables during the final 2 weeks of life in people dying with cancer. Although useful in acute early warning scores, in a terminally ill patient, relative haemodynamic stability should not be interpreted as reassuring. Further work is needed to understand how these findings apply to the individual or inform other prognostic work.
authors.affiliation: St Benedict's Hospice, Sunderland, UK drpaulmtaylor@gmail.com.
authors.forename: Paul
authors.initials: P
authors.lastname: Taylor
authors.affiliation: University of York, York, UK.
authors.forename: Simon
authors.initials: S
authors.lastname: Crouch
authors.affiliation: University of York, York, UK.
authors.forename: Debra A
authors.initials: DA
authors.lastname: Howell
authors.affiliation: Columbia University School of Nursing and Visiting Nurse Service of New York, New York, USA.
authors.forename: Dawn W
authors.initials: DW
authors.lastname: Dowding
authors.affiliation: Hull and York Medical School, Hull, UK.
authors.forename: Miriam J
authors.initials: MJ
authors.lastname: Johnson
mesh_terms: D015331:Cohort Studies; D004739:England / Q000453:epidemiology; D006339:Heart Rate / Q000502:physiology; D006801:Humans; D000860:Hypoxia / Q000503:physiopathology; D007297:Inpatients; D009369:Neoplasms / Q000401:mortality* / Q000503:physiopathology*; D064887:Observational Studies as Topic; D011379:Prognosis; D051437:Renal Insufficiency / Q000503:physiopathology; D056152:Respiratory Rate / Q000502:physiology; D012189:Retrospective Studies; D013727:Terminal Care / Q000706:statistics & numerical data*; D006113:United Kingdom
keywords: Palliative; cancer; dying; observation; prognosis; terminal