title: Frequency and factors associated with unexpected death in an acute palliative care unit: expect the unexpected.
abstract: BACKGROUND
  Few studies have examined the frequency of unexpected death and its associated factors in a palliative care setting.
  
  
  OBJECTIVE
  To determine the frequency of unexpected death in two acute palliative care units (APCUs); to compare the frequency of signs of impending death between expected and unexpected deaths; and to determine the predictors associated with unexpected death.
  
  
  METHODS
  In this prospective, longitudinal, observational study, consecutive patients admitted to two APCUs were enrolled and physical signs of impending death were documented twice daily until discharge or death. Physicians were asked to complete a survey within 24 hours of APCU death. The death was considered unexpected if the physician answered "yes" to the question "Were you surprised by the timing of the death?"
  
  
  RESULTS
  In total, 193 of 203 after-death assessments (95%) were collected for analysis. Nineteen of 193 patients died unexpectedly (10%). Signs of impending death, including non-reactive pupils, inability to close eyelids, decreased response to verbal stimuli, drooping of nasolabial folds, peripheral cyanosis, pulselessness of the radial artery, and respiration with mandibular movement, were documented more frequently in expected deaths than unexpected deaths (P < 0.05). Longer disease duration was associated with unexpected death (33 months vs. 12 months, P = 0.009).
  
  
  CONCLUSIONS
  Unexpected death occurred in an unexpectedly high proportion of patients in the APCU setting and was associated with fewer signs of impending death. Our findings highlight the need for palliative care teams to be prepared for the unexpected.
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Bruera
authors.affiliation: Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
authors.forename: Gary
authors.initials: G
authors.lastname: Chisholm
authors.affiliation: Barretos Cancer Hospital, Barretos, Brazil.
authors.forename: Renata
authors.initials: R
authors.lastname: Dos Santos
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Bruera
authors.affiliation: Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA. Electronic address: dhui@mdanderson.org.
authors.forename: David
authors.initials: D
authors.lastname: Hui
mesh_terms: D001291:Attitude of Health Personnel; D003422:Critical Care / Q000706:statistics & numerical data*; D016638:Critical Illness / Q000401:mortality / Q000628:therapy; D003645:Death, Sudden / Q000453:epidemiology*; D005260:Female; D006801:Humans; D015994:Incidence; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009026:Mortality; D009369:Neoplasms / Q000401:mortality* / Q000628:therapy*; D010166:Palliative Care / Q000706:statistics & numerical data*; D012307:Risk Factors; D015996:Survival Rate; D013727:Terminal Care / Q000706:statistics & numerical data; D013781:Texas / Q000453:epidemiology
keywords: Cohort studies; death; epidemiology; neoplasms; palliative care; prognosis