title: Bedside clinical signs associated with impending death in patients with advanced cancer: preliminary findings of a prospective, longitudinal cohort study.
abstract: BACKGROUND
  Five highly specific physical signs associated with death within 3 days among cancer patients were recently reported that may aid in the diagnosis of impending death. In this study, the frequency and onset of another 52 bedside physical signs and their diagnostic performance for impending death were examined.
  
  
  METHODS
  Three hundred fifty-seven consecutive patients with advanced cancer who had been admitted to acute palliative care units at 2 tertiary care cancer centers were enrolled. Fifty-two physical signs were systematically documented every 12 hours from admission to death or discharge. The frequency and median time of onset of each sign from death backwards were examined, and the likelihood ratios (LRs) associated with death within 3 days were calculated.
  
  
  RESULTS
  Two hundred three of the 357 patients (57%) died at the end of the admission. Eight physical signs that were highly diagnostic of impending death were identified. These signs occurred in 5% to 78% of the patients within the last 3 days of life, had a late onset, and had a high specificity (>95%) and a high positive LR for death within 3 days. They included nonreactive pupils (positive LR, 16.7; 95% confidence interval [CI], 14.9-18.6), a decreased response to verbal stimuli (positive LR, 8.3; 95% CI, 7.7-9), a decreased response to visual stimuli (positive LR, 6.7; 95% CI, 6.3-7.1), an inability to close eyelids (positive LR, 13.6; 95% CI, 11.7-15.5), drooping of the nasolabial fold (positive LR, 8.3; 95% CI, 7.7-8.9), hyperextension of the neck (positive LR, 7.3; 95% CI, 6.7-8), grunting of vocal cords (positive LR, 11.8; 95% CI, 10.3-13.4), and upper gastrointestinal bleeding (positive LR, 10.3; 95% CI, 9.5-11.1).
  
  
  CONCLUSIONS
  Eight highly specific physical signs associated with death within 3 days among cancer patients were identified. These signs may inform the diagnosis of impending death.
authors: Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas.
authors: David
authors: D
authors: Hui
authors: Renata
authors: R
authors: Dos Santos
authors: Gary
authors: G
authors: Chisholm
authors: Swati
authors: S
authors: Bansal
authors: Camila
authors: C
authors: Souza Crovador
authors: Eduardo
authors: E
authors: Bruera
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003643:Death; D005260:Female; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000503:physiopathology* / Q000628:therapy; D010166:Palliative Care; D010808:Physical Examination; D011446:Prospective Studies; D055815:Young Adult
keywords: diagnosis; neoplasms; palliative care; physical examination; sensitivity; signs; specificity