Bedside clinical signs associated with impending death in patients with advanced cancer: preliminary findings of a prospective, longitudinal cohort study

High specificity clinical signs of impending death: A scoping review

BACKGROUND

Accurate diagnosis of impending death is essential to provide proper care in the last days and hours of life. Recognising the death situation immediately allows adjustment of care goals, ensuring that they suit the patient's condition, as well as tuning the team's and family's expectations.

OBJECTIVE

To map and describe evidence on high specificity clinical signs of impending death in cancer and noncancer hospitalised patients over 18 years of age.

METHODS

A comprehensive search of the published literature was conducted According to Joanna Briggs Institute's methodology for scoping reviews. Online databases, including MEDLINE, CINAHL complete, SCOPUS, WEB OF SCIENCE, and the Cochrane Database of Systematic Reviews, and the search for unpublished studies included OpenGrey, DART-Europe, and RCAAP. Publications in English, French, Portuguese, and Spanish were included, and no period was set. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extensions to scoping review guidelines were used to report the results. The review protocol was registered in Open Science Framework (Simões et al., 2022).

RESULTS

The 15 studies included in this review were published in English between 2013 and 2023. In addition to identifying the clinical signs of impending death, some researchers intend to develop accurate prognostic models for this clinical situation. Only two studies in the noncancer population met the inclusion criteria. Twelve articles were prospective observational studies (seven were multicentre studies), one was a retrospective cohort study, and two were narrative reviews. A clinical sign that is common to studies in both populations is respiration with mandibular movement, particularly in the last 12 h of life.

CONCLUSIONS

Clinical signs of impending death and prediction models can help clinicians identify impending death. However, they should not replace clinical judgement. Further research is required to understand whether the dying process differs among different patient populations and care settings.

Nursing contribution to end-of-life care decision-making in patients with neurological diseases on an acute hospital ward: documentation of signs and symptoms

BACKGROUND

Recognizing impending death in patients with neurological diseases presents challenges for nurses and other healthcare professionals. This study aimed to identify nursing contribution to end-of-life (EOL) care decision-making for patients with neurological diseases in an acute hospital ward and to compare signs and symptoms among subgroups of patients.

METHODS

In this retrospective study, we analyzed data from 209 patient health records using the Neurological End-Of-Life Care Assessment Tool to evaluate the care in the last 3 to 7 days of life. Key aspects included the need for EOL care, EOL care decision-making, signs and symptoms of imminent death, and communication with relatives. The patient records pertain to patients who died in an acute neurological ward between January 2011 and August 2020; 123 with ischemic stroke, 48 with hemorrhagic stroke, 27 with amyotrophic lateral sclerosis [ALS], and 11 with Parkinson's disease or extrapyramidal and movement disorders [PDoed]. Both descriptive and inferential statistical analyses were performed to analyze the data.

RESULTS

Nurses identified the need for EOL care in 36% of cases and contributed to EOL decision-making as information brokers (15%), advocates (6%), and supporters (6%). They identified disease progression in 44% of the cases. The mean number of signs and symptoms in both the acute and progressive disease groups was 6.5 and ranged from 1 to 14. Patients with stroke without a documented EOL decision had more severe symptoms, including respiratory congestion (68%) and dyspnea (37%), than those with EOL decision. A higher frequency of no food intake was documented in patients with stroke receiving EOL care (p = 0.007) compared to those without. Among patients with ALS or PDoed, those with EOL decision showed a trend toward a higher frequency of unconsciousness or limited consciousness than those without EOL decision (p = 0.067). For all groups of patients, conversations with relatives occurred in 85% instances and family meetings in 93%.

CONCLUSIONS

Nurses made substantial contributions to EOL care decision-making for patients with neurological diseases. To improve early identification of imminent death in patients with neurological diseases in acute hospital wards, healthcare professionals must investigate barriers contributing to delayed recognition.

CLINICAL TRIAL NUMBER

Not applicable.

Prediction of Next-Day Survival in Imminently Dying Cancer Patients: A Multicenter Cohort Study

Background: Accurate prediction of next-day survival in imminently dying patients is crucial for facilitating timely end-of-life decisions. Objectives: To develop diagnostic models for predicting next-day survival in cancer patients with a Palliative Performance Scale (PPS) score of ≤20. Design: A multicenter, prospective, observational study. Setting/subjects: We enrolled advanced cancer patients at 23 palliative care units across Japan. Measurements: Clinical signs of impending death were recorded daily after patients' PPS scores decreased to ≤20, continuing until death or for up to 14 days. The developed models included the prediction of one-day survival-decision tree (P1d-Survival-DT), based on recursive partitioning analysis, the P1d-Survival-organ system score, which utilized a scoring system across four clinical systems (nervous/cardiovascular/respiratory/musculoskeletal), and the early signs model that focused on the absence of two early signs (altered consciousness and liquid dysphagia). Results: Of the 1896 patients included in the study, 1396 (74%) reached PPS ≤20. The average age was 73 ± 12 years, with 49% being female. The P1d-Survival-DT model showed next-day survival rates of 91.6% for patients with a response to verbal stimuli and no peripheral cyanosis, and 37.1% for those with no response to verbal stimuli and respiration with mandibular movement. The P1d-Survival-organ system score model revealed a 95.9% survival rate for score = 0, decreasing progressively to 46.7% for score = 4. The early signs model predicted a 95.2% survival rate in patients with normal consciousness and no liquid dysphagia. Conclusions: This study successfully developed three distinct models to predict next-day survival in cancer patients with PPS ≤20, offering vital tools for informed decision making in palliative care settings.

Prognostic factors and development of the practical prediction score for 7-day mortality of palliative patients in the emergency department

Background End-of-life (EOL) care aims to facilitate good death and fulfill the patient's final desires. Despite the known benefits of palliative consultations, emergency physicians encounter challenges in decision-making due to limited palliative resources. Previous studies primarily focus on non-emergency settings; thus, we aimed to develop a practical prediction score for 7-day mortality for palliative patients in the emergency department (ED). Methods This retrospective cohort study, conducted at a tertiary-level university hospital in Thailand between June 2022 and May 2023, evaluated adult palliative patients who declined life-sustaining treatments. Variables associated with 7-day mortality were analyzed using univariable and multivariable logistic regression. Results Of 499 ED visits, 152 patients (30.46%) died within seven days. Six predictors were identified: solid malignancy, respiratory with mandibular movement, systolic blood pressure < 100 mmHg, lymphopenia, thrombocytopenia, and a blood urea nitrogen to creatinine ratio > 20. These factors were used to develop the Ramathibodi End-of-life (RAMA-EOL) score, demonstrating an AuROC curve of 80.46% (95% CI: 76.15-84.77). Patients with a score ≥ 3 had a positive likelihood ratio of 2.92 (95% CI: 2.38-3.57) for 7-day mortality. Conclusion The RAMA-EOL score reliably predicts 7-day mortality in palliative ED patients, facilitating timely palliative care interventions for high-risk individuals.

Upper arm movements in the last days of life: A new possible sign of impending death

One of the most crucial stages of palliative care is the last days and hours of life, which require special attention and knowledgeable identification of clinical signs described as signs of impending death (SID). Our case series of 11 patients receiving home palliative care describes bilateral hypoactive, stereotyped upper arm movements (scratching of the head, forehead, and nose) that were previously unknown or described, often accompanied by SID.

Determining timeframes to death for imminently dying patients: a retrospective cohort study

BACKGROUND

Clinicians are frequently asked 'how long' questions at end-of-life by patients and those important to them, yet predicting timeframes to death remains uncertain, even in the last weeks and days of life. Patients and families wish to know so they can ask questions, plan, make decisions, have time to visit and say their goodbyes, and have holistic care needs met. Consequently, this necessitates a more accurate assessment of empirical data to better inform prognostication and reduce uncertainty around time until death. The aims of this study were to determine the timeframes for palliative care patients (a) between becoming comatose and death, and (b) between being totally dependent and bedfast, and then comatose, or death, using Australia-modified Karnofsky Performance Status (AKPS) scores. The secondary aim was to determine if covariates predicted timeframes.

METHOD

This is a large retrospective cohort study of 2,438 patients, 18 years and over, cared for as hospice inpatients or by community palliative care services, died between January 2017 and December 2021, and who collectively had 49,842 AKPS data points. An Interval-Censored Cox Proportional Hazards regression model was used.

RESULTS

Over 53% (n = 1,306) were comatose (AKPS 10) for longer than one day before death (mean = 2 days, median = 1, SD = 2.0). On average, patients were found to be totally dependent and bedfast (AKPS 20) for 24 days, before progressing to being comatose. A difference in life expectancy was observed at AKPS 20 among people with cancer (mean = 14.4, median = 2, SD = 38.8) and those who did not have cancer (mean = 53.3, median = 5, SD = 157.1).

CONCLUSION

Results provide clinicians with validated data to guide communication when answering 'how long' questions at end-of-life. Knowledge of projected time to death can prompt timely conversations while the patient can understand and engage in meaningful conversations. The importance of considering covariates such as location and diagnosis in determining timeframes has been highlighted. Shared decision-making and essential person-centered end-of-life care can be planned.

A pilot observational study of the association of 24-hour mortality with the subjective assessment of the forearm skin temperature and moisture compared to other bedside indicators of illness severity

Background

Although the association of peripheral skin temperature with infection, serious illness and death have been recognised for centuries, few studies have explicitly compared this finding with other bedside indicators of illness severity. This study compared subjectively assessed dorsal forearm skin temperature and moisture with other indicators of illness severity.

Methods

Non-interventional observational study of acutely ill medical patients admitted to a low-resource Ugandan hospital, which examined the association of subjectively assessed dorsal forearm skin temperature and other bedside findings with death within 24 h.

Results

While in hospital 653 patients had 2,104 observations; the dorsal forearm skin was subjectively felt to be abnormally hot or cold at 239 observations, and this finding was associated with 24-hour mortality (odds ratio 4.48, 95% CI 1.89-10.46); this increased risk of death was comparable to the increased mortality risk associated with tachypnoea, hypoxia, and a Shock Index >1.0, but considerably lower than that associated with a Kitovu Fast Triage score >0. When stratified according to both temperature and wetness, 'cold and wet' and 'hot and wet' skin were associated with higher early warning scores. Cold or hot forearm skin had a specificity for 24-hour mortality of 0.83, but a sensitivity of only 0.34; therefore, its absence does not rule-out the chance of imminent death.

Conclusion

Touching and feeling the skin temperature and moisture is a valuable clinical sign, which can be rapidly determined at the bedside. However, although it has high specificity, its sensitivity for imminent death is low.

Registered nurses' experiences of communication with patients after the end-of-life breakpoint communication: A pilot interview study

Purpose

Effective nurse-patient communication is demanding and essential when patients' treatment changes from curative to palliative approach. We aimed to illustrate nurses' experiences communicating with patients who have undergone end-of-life breakpoint communication.

Method

Six nurses from both haematology and oncology wards at a hospital in southern Sweden were interviewed. The data were analysed using content analysis.

Result

Three themes with a total of eight categories were identified: Nurses were excluded from the end-of-life breakpoint communication, which impacted the following communication and the dialogue between nurses and patients afterwards; the importance of communication, where the experience of following-up patients, supporting patients and having existential conversations was highlighted; the nurses' strategies in the communication, included experience of using tools, the need for more information and education, and to be human.

Conclusion

Nurses in today's healthcare system need education to provide the care and the communication that patients ask for and are obligated to receive regarding support and information. In the results, nurses suggest and relate their strategies for effective patient communication, which would also aid nurses working in areas other than palliative care. For example, they propose collaborating more with physicians to facilitate better information flow and patient contact. Moreover, reflective tutorials, including spiritual leaders to aid patients' existential concerns, are beneficial. The need for further research in this area is crucial for the growth and development of nurse-patient communication.

Recognising dying in motor neurone disease: A scoping review

INTRODUCTION

Timely identification of dying in motor neurone disease enables optimal care, yet we know that healthcare professionals can fail to recognise when death is approaching. Clinical factors help predict the end of life in other terminal conditions. Examining these principles in motor neurone disease would help guide more accurate recognition of this critical phase.

AIM

To examine and map out what is known about dying in patients with motor neurone disease, and the recognition of dying by healthcare professionals.

DESIGN

A scoping review was conducted following the Arksey and O'Malley methodological framework.

DATA SOURCES

Four electronic databases (MEDLINE, Scopus, PsycINFO and CINAHL) and grey literature were searched on the 10th May 2023. Reference lists and citations were also reviewed.

RESULTS

From 1512 articles, 13 studies were included. Dyspnoea, anxiety and pain were the most common symptoms associated with the dying phase. Worsening respiratory function, the development of specific new symptoms and deteriorating symptom control suggested approaching death. No studies reported changes in vital signs or biomarkers associated with dying. Barriers to the recognition of dying by healthcare professionals included a rapid and unpredictable terminal decline.

CONCLUSIONS

Dying in motor neurone disease is associated with patterns of symptoms and signs, however evidence is limited compared with other terminal conditions and requires further exploration. The characteristic sudden and unpredictable terminal decline is a key barrier to recognition of dying by healthcare professionals. Optimising advance care planning is one approach to navigate these complex, unpredictable clinical situations.

Talking about dying and death: Essentials of communicating about approaching death from the perspective of major stakeholders

OBJECTIVES

Although caring for dying patients and their family caregivers (FC) is integral to patient care, training in communication about approaching death is almost inexistent in medical and nursing curricula. Consequently, many health professionals have insufficient knowledge about conducting these conversations. In order to gain a broader insight into essential aspects of this communication from different perspectives, we conducted focus groups with key stakeholders.

METHODS

Medical specialists, nurses, medical students, bereaved FC and patient representatives participated in five focus groups (n = 30). Following a focus group schedule, we elicited relevant aspects of communication about approaching death, associated emotions, and appropriate communication frameworks. We analyzed data thematically.

RESULTS

Four main themes were central to conversations about approaching death: (1) embracing care within medical expertise, (2) preparing the conversation while remaining open to the unexpected, (3) recognizing and reflecting on own emotions and reactions, and (4) establishing a meaningful connection with others.

SIGNIFICANCE OF RESULTS

Communicating about approaching death with dying patients and their FC can be complex and challenging at a professional and personal level. With the recognition of the dying phase, a process is initiated for which health professionals need solid clinical knowledge about but also effective communication skills, constant self-reflection and self-care strategies. Comprehensive training and supervision while dealing with the challenges of communicating approaching death to dying patients and their FC are key, particularly for trainees, less experienced physicians and nurses. The essential components identified in this study can help health professionals to master these conversations.

Can We Make More Accurate Prognoses During Last Days of Life?

Background: Life expectancy prediction is important for end-of-life planning. Established methods (Palliative Performance Scale [PPS], Palliative Prognostic Index [PPI]) have been validated for intermediate- to long-term prognoses, but last-weeks-of-life prognosis has not been well studied. Patients admitted to a palliative care facility often have a life expectancy of less than three weeks. Reliable last-weeks-of-life prognostic tools are needed. Objective: To improve short-term survival prediction in terminally ill patients. Method: This prospective study included all patients admitted to a palliative care facility in Montreal, Canada, over one year. PPS and PPI were assessed until patients' death. Seven prognostic clinical signs of impending death (Short-Term Prognosis Signs [SPS]) were documented daily. Results: The analyses included 273 patients (76% cancer). The median survival time for a PPS ≤20% was 2.5 days, while for a PPS ≥50% it was 44.5 days, for a PPI >8 the median survival was 3.5 days and for a PPI ≤4 it was 38.5 days. Receiver operating characteristic curves showed a high accuracy in predicting survival. Median survival after the first occurrence of any SPS was below one week. Conclusions: This study demonstrated that the PPS and PPI perform well between one week and three months extending their usefulness to shorter term survival prediction. SPS items provided survival information during the last week of life. Using SPS along with PPS and PPI during the last weeks of life could enable a more precise short-term survival prediction across various end-of-life diagnoses. The translation of this research into clinical practice could lead to a better adapted treatment, the identification of a most appropriate care setting for patients, and improved communication of prognosis with patients and families.

Pharmacologic Management of End-of-Life Delirium: Translating Evidence into Practice

End-of-life delirium affects a vast majority of patients before death. It is highly distressing and often associated with restlessness or agitation. Unlike delirium in other settings, it is considered irreversible, and non-pharmacologic measures may be less feasible. The objective of this review is to provide an in-depth discussion of the clinical trials on delirium in the palliative care setting, with a particular focus on studies investigating pharmacologic interventions for end-of-life delirium. To date, only six randomized trials have examined pharmacologic options in palliative care populations, and only two have focused on end-of-life delirium. These studies suggest that neuroleptics and benzodiazepines may be beneficial for the control of the terminal restlessness or agitation associated with end-of-life delirium. However, existing studies have significant methodologic limitations. Further studies are needed to confirm these findings and examine novel therapeutic options to manage this distressing syndrome.

'How long do you think?' Unresponsive dying patients in a specialist palliative care service: A consecutive cohort study

BACKGROUND

Predicting length of time to death once the person is unresponsive and deemed to be dying remains uncertain. Knowing approximately how many hours or days dying loved ones have left is crucial for families and clinicians to guide decision-making and plan end-of-life care.

AIM

To determine the length of time between becoming unresponsive and death, and whether age, gender, diagnosis or location-of-care predicted length of time to death.

DESIGN

Retrospective cohort study. Time from allocation of an Australia-modified Karnofsky Performance Status (AKPS) 10 to death was analysed using descriptive narrative. Interval-censored survival analysis was used to determine the duration of patient's final phase of life, taking into account variation across age, gender, diagnosis and location of death.

SETTING/PARTICIPANTS

A total of 786 patients, 18 years of age or over, who received specialist palliative care: as hospice in-patients, in the community and in aged care homes, between January 1st and October 31st, 2022.

RESULTS

The time to death after a change to AKPS 10 is 2 days (n = 382; mean = 2.1; median = 1). Having adjusted for age, cancer, gender, the standard deviation of AKPS for the 7-day period prior to death, the likelihood of death within 2 days is 47%, with 84% of patients dying within 4 days.

CONCLUSION

This study provides valuable new knowledge to support clinicians' confidence when responding to the 'how long' question and can inform decision-making at end-of-life. Further research using the AKPS could provide greater certainty for answering 'how long' questions across the illness trajectory.

[Comfort Terminal Care in the intensive care unit: recommendations for practice]

BACKGROUND AND OBJECTIVE

The Working Group on Ethics in Anesthesia and Intensive Care Medicine of the Austrian Society for Anesthesiology Resuscitation and Intensive Care Medicine (ÖGARI) already developed documentation tools for the adaption of therapeutic goals 10 years ago. Since then the practical implementation of Comfort Terminal Care in the daily routine in particular has raised numerous questions, which are discussed in this follow-up paper and answered in an evidence-based manner whenever possible.

RESULTS

The practical implementation of pain therapy and reduction of anxiety, stress and respiratory distress that are indicated in the context of Comfort Terminal Care are described in more detail. The measures that are not (or no longer) indicated, such as oxygen administration and ventilation as well as the administration of fluids and nutrition, are also commented on. Furthermore, recommendations are given regarding monitoring, (laboratory) findings and drug treatment and the importance of nursing actions in the context of Comfort Terminal Care is mentioned. Finally, the support for the next of kin and the procedure in the time after death are presented.

DISCUSSION

A change in treatment goals with a timely switch to Comfort Terminal Care enables good and humane care for seriously ill patients and their relatives at the end of life and the appreciation of their previous life with the possibility of positive experiences until the end.

Factors Associated with Antimicrobial Use at the End-Of-Life Among Hospitalized Cancer Patients

Background: Antimicrobials are frequently administered at end-of-life (EOL) and their non-beneficial use may subject patients to unnecessary harms. Studies analyzing factors for antimicrobial prescribing in solid tumor cancer patients at the EOL are lacking. Thus, we aimed to identify factors and patterns associated with antimicrobial use in hospitalized adults with cancer at EOL. Methods: We used a retrospective cohort design to review electronic medical records of terminal hospitalized patients ≥18 years with solid tumors admitted to non-intensive care units in a metropolitan comprehensive cancer center during 2019 and assessed antimicrobial use in the last 7 days of life. Results: Among 633 cancer patients, 59% (n = 376) received antimicrobials (AM+) within the last 7 days of life. AM + patients were older (P = .012), mostly of male gender (55%), and non-Hispanic ethnicity (87%). AM + patients were significantly more likely to have a foreign device, suspected signs of infection, neutropenia, positive blood culture result, documented advance directive; receive laboratory or radiologic testing, and a palliative care or infectious disease consultation (all P < .05). No statistically significant differences were observed in the presence of documented goals of care discussions, or EOL discussions/EOL care orders. Conclusion: Antimicrobial use at the EOL is common in solid tumor cancer patients at the EOL and is associated with increased utilization of invasive interventions. There is an opportunity for infectious disease specialists to build primary palliative care skills and partner with antimicrobial stewardship programs to better advise patients, decision makers, and primary teams on the use of antimicrobials at the EOL.

Top Ten Tips Palliative Care Clinicians Should Know About Cachexia

Cachexia is a multifactorial syndrome that is common in cancer and chronic disease. It is often underdiagnosed and therefore goes untreated or undertreated. Cachexia causes suffering across biopsychosocial domains and affects patients and their loved ones. In this article, a group of clinicians and researchers across cancer care, nutrition, and exercise offers tips about assessment, classification, and management of cachexia, with attention to its stage. The required multimodal management of cachexia mirrors well the interprofessional collaboration that is the mainstay of interdisciplinary palliative care and attention to screening, diagnosis, and management of cachexia is critical to maximize patients' quality of life.

Factitious Disorder Imposed on Another in Palliative Care: A Case Report

In palliative care, many end-of-life (EOL) patients are physically dependent on their caregivers. These patients may also have difficulty expressing their needs because of their underlying disease and are vulnerable to abuse. Factitious disorder imposed on another (FDIA) describes a condition in which an individual intentionally feigns physical or psychological signs or symptoms in another person with the intention of deceiving medical providers. Although FDIA is a form of abuse that palliative care workers must be aware of because of its multiple impacts on EOL care, it has never been reported in the palliative care literature. In this case discussion, we highlight a woman with advanced dementia who was subjected to FDIA. We discuss the impact of FDIA on EOL care and the management of FDIA in palliative care.

Developing and testing inter-rater reliability of a data collection tool for patient health records on end-of-life care of neurological patients in an acute hospital ward

AIM

Develop and test a data collection tool-Neurological End-Of-Life Care Assessment Tool (NEOLCAT)-for extracting data from patient health records (PHRs) on end-of-life care of neurological patients in an acute hospital ward.

DESIGN

Instrument development and inter-rater reliability (IRR) assessment.

METHOD

NEOLCAT was constructed from patient care items obtained from clinical guidelines and literature on end-of-life care. Expert clinicians reviewed the items. Using percentage agreement and Fleiss' kappa we calculated IRR on 32 nominal items, out of 76 items.

RESULTS

IRR of NEOLCAT showed 89% (range 83%-95%) overall categorical percentage agreement. The Fleiss' kappa categorical coefficient was 0.84 (range 0.71-0.91). There was fair or moderate agreement on six items, and moderate or almost perfect agreement on 26 items.

CONCLUSION

The NEOLCAT shows promising psychometric properties for studying clinical components of care of neurological patients at the end-of-life on an acute hospital ward but could be further developed in future studies.

Student nurses' end-of-life and post mortem care self-efficacy: A descriptive study

BACKGROUND

Student nurses providing end-of-life care reported that caring for a person dying created anxiety, fear, and increased stress and reflected low self-efficacy. New nurses felt unprepared academically and emotionally. High self-efficacy is necessary to handle adverse emotional reactions. However, the literature lacks an instrument to evaluate nursing students' self-efficacy in caring for someone who is dying.

OBJECTIVE

The study aims to investigate the reliability and validity of the "End-of-Life and Postmortem Self-Efficacy Scale" and explore nursing students' self-efficacy associated with the nursing duties and responsibilities of caring for individuals during the active phase of dying and immediately after death.

DESIGN

The study was a quantitative descriptive, cross-sectional design.

PARTICIPANTS

National Student Nurses' Association members enrolled in undergraduate registered nurse associate's, bachelor's degree programs, or a nursing diploma program.

METHOD

National Student Nurses' Association members responded to an electronic survey containing 18 items related to end-of-life and post mortem nursing responsibilities.

RESULTS

A total of 498 responses were analyzed. Cronbach's alpha (α = 0.938) showed high reliability of the 18 items on the instrument. The Kaiser-Meyer-Olkin was 0.925 and indicated sampling adequacy. Bartlett's test of sphericity was highly significant (p = .001). The nursing students' mean end-of-life and post mortem self-efficacy score was 62 (scale of 0-100).

CONCLUSION

The "End-of-Life and Postmortem Self-Efficacy Scale" showed high reliability in evaluating the latent concept of end-of-life and post mortem self-efficacy. The low mean self-efficacy score indicated that nursing students might be underprepared to provide EOL and post mortem care as new graduates. Faculty can use the "End-of-Life and Postmortem Self-Efficacy Scale" to assess student readiness and identify gaps in knowledge in the care of someone who is dying. Future research is needed to determine how increasing nursing students' end-of-life and post mortem self-efficacy influences the perception of end-of-life preparedness.

Beyond Last Words: Patterns of Linguistic and Interactional Behavior in a Historical Sample of Dying Hospital Patients

Patterns of linguistic and interactional behavior by people at the very end of their lives are not well described, partly because data is difficult to obtain. This paper analyzes descriptions of 486 deaths gathered from 1900 to 1904 in the first-ever clinical study of dying by noted Canadian physician, Sir William Osler. Only 16 patients were noted speaking, and only four canonical last words were reported. The most frequent observation by medical staff was that the deaths were quiet (n = 30), though range of other behaviors were noted (e.g., moaning, delirium, seeming intention to speak). Osler's problematic study left behind data whose analysis is a small step toward empirically characterizing the linguistic and interactional details of a previously under-described phenomena as well as the importance of the social context in which they occur.

A Review of Clinical Signs and Symptoms of Imminent End-of-Life in Individuals With Advanced Illness

Background: World population is not only aging but suffering from serious chronic illnesses, requiring an increasing need for end-of-life care. However, studies show that many healthcare providers involved in the care of dying patients sometimes express challenges in knowing when to stop non-beneficial investigations and futile treatments that tend to prolong undue suffering for the dying person. Objective: To evaluate the clinical signs and symptoms that show end-of-life is imminent in individuals with advanced illness. Design: Narrative review. Methods: Computerized databases, including PubMed, Embase, Medline,CINAHL, PsycInfo, and Google Scholar were searched from 1992 to 2022 for relevant original papers written in or translated into English language that investigated clinical signs and symptoms of imminent death in individuals with advanced illness. Results: 185 articles identified were carefully reviewed and only those that met the inclusion criteria were included for review. Conclusion: While it is often difficult to predict the timing of death, the ability of healthcare providers to recognize the clinical signs and symptoms of imminent death in terminally-ill individuals may lead to earlier anticipation of care needs and better planning to provide care that is tailored to individual's needs, and ultimately results in better end-of-life care, as well as a better bereavement adjustment experience for the families.

The impact of palliative care consultation on reducing antibiotic overuse in hospitalized patients with terminal cancer at the end of life: a propensity score-weighting study

OBJECTIVES

A substantial number of hospitalized patients with terminal cancer at the end-of-life phase receive antibiotics, even with imminent death. We evaluated the impact of palliative care consultation on antibiotic use in hospitalized patients with terminal cancer during the end-of-life phase.

METHODS

We identified adult patients with metastatic solid cancer who died at a tertiary medical centre in Seoul, Republic of Korea, following at least 4 days of hospitalization (January 2018-December 2020). Patients were divided into palliative and non-palliative care consultation groups. Propensity score-weighted, multivariable logistic regression analysis was used to compare the proportion of patients receiving antibiotics within 3 days before death between the two groups.

RESULTS

Among 1143 patients analysed, 940 (82.2%) received antibiotics within 3 days before death. The proportion of patients receiving antibiotics was significantly lower (propensity score-weighted P < 0.001) in the palliative care consultation group (344/468; 73.5%) than in the non-palliative care consultation group (596/675; 88.3%). The decrease in the proportion of patients receiving antibiotics in the palliative care consultation group was significant for a carbapenem (42.4% versus 22.4%; P < 0.001), a glycopeptide (23.3% versus 11.1%; P < 0.001) and a quinolone (30.5% versus 19.4%; P = 0.012). In the multivariable logistic regression analysis, receiving palliative care consultation (adjusted OR 0.46, 95% CI 0.33-0.65; P < 0.001) was independently associated with reduced antibiotic use during the end-of-life phase.

CONCLUSIONS

Palliative care consultation may reduce aggressive antibiotic use in hospitalized patients with terminal cancer during the end-of-life phase.

Perceptible Signs of End of Life in Pediatric Intensive Care Patients

Background: How children die in pediatric intensive care units (PICUs) has been poorly described, and support for parents during this traumatic experience could be improved. Better information on perceptible signs of the end of life (EOL) in children may help mitigate the trauma. Objective: To describe the most common perceptible EOL signs in PICU patients. Methods: A prospective study in a PICU. Health care providers observed 28 children expected to die and noted the perceptible signs. Results: The most common perceptible signs were desaturation and bradycardia. Twenty-seven patients had at least one change in physical appearance. Gasping was noted in 12 patients. Conclusion: Perceptible signs of the EOL were different from those reported in children dying in other units or in adults. Sharing information about signs of EOL with parents may prepare them and enable them to better support their child.

Prognostication of the last days of life: Review article

Accurate prediction of impending death (i.e., last few days of life) is essential for terminally-ill cancer patients and their families. International guidelines state that clinicians should identify patients with impending death, communicate the prognosis with patients and families, help them with their end-of-life decision-making, and provide sufficient symptom palliation. Over the past decade, several national and international studies have been conducted that systematically investigated signs and symptoms of impending death as well as how to communicate such a prognosis effectively with patients and families. In this article, we summarize the current evidence on prognostication and communication regarding the last days of life of patients with cancer, and future directions of clinical research.

Prevalence and severity of symptoms and signs in patients with advanced cancer in the last days of life: the East Asian collaborative cross-cultural study to elucidate the dying process (EASED)

PURPOSE

Few large-scale studies have focused on the prevalence of symptoms and signs during the last days of patients diagnosed with advanced cancer. Identifying the patterns of specific symptoms according to cancer type is helpful to provide end-of-life care for patients with advanced cancer. We investigated the prevalence and severity of symptoms and signs associated with impending death in patients with advanced cancer.

METHODS

In this secondary analysis of an international multicenter cohort study conducted in three East Asian countries, we compared the severity of symptoms and signs among dying patients in the last 3 days of life according to the type of primary cancer using one-way analysis of variance (ANOVA). Post hoc analysis was conducted for multiple comparisons of each symptom according to the type of primary cancer.

RESULTS

We analyzed 2131 patients from Japan, Korea, and Taiwan. The prevalence of most symptoms and signs were relatively stable from 1 week after admission to the last 3 days of life. According to cancer type, edema of the lower extremities was the most common symptom and fatigue/ ascites were the most severe symptoms in digestive tract cancer. For lung cancer, respiratory secretion was the most prevalent and dyspnea/respiratory secretion were the most severe symptoms.

CONCLUSION

We demonstrated the prevalence and severity of symptoms and signs associated with the impending death of patients with advanced cancer in East Asia. Our study can enable clinicians to recognize the specific symptoms and signs at the very end of life.

Prediction Models for Impending Death Using Physical Signs and Vital Signs in Noncancer Patients: A Prospective Longitudinal Observational Study

Background: Accurate information on the prognosis in the last days of life is essential for providing better end-of-life care; however, few studies have examined the signs of impending death (SID) or developed short-term prediction models in noncancer patients.

Objective: To investigate the prevalence and onset of SID and to develop models that predict death within 7 days, 72 hours, and 24 hours in noncancer patients.

Design: This is a prospective longitudinal observational study.

Setting/Subjects: Subjects were noncancer patients admitted to a hospital in Japan between 2019 and 2020.

Measurements: We investigated 11 physical signs and vital signs every 12 hours until death after confirming a reduced daily oral intake to less than a few mouthfuls.

Results: We analyzed data from 50 noncancer patients. The prediction model “pulselessness of the radial artery OR respiration of mandibular movement OR the shock Index (SI) >1.0” predicted death within 7 days with an accuracy of 83.9%, whereas the models developed to predict death within 72 and 24 hours had an accuracy of 65.0% or less. The median onset of all signs was within 3 days of death. The frequencies of decreased response to verbal stimuli and decreased response to visual stimuli were 76.0% and 74.0%, respectively.

Conclusions: The prediction model using physical signs and SI predicted death within 7 days in noncancer patients with high accuracy. The prediction of death within 72 and 24 hours in noncancer patients requires investigation of physical signs not examined in this study.

The conscious state of the dying patient: An integrative review

OBJECTIVES

The cognitive state of the dying in the last days of life may deteriorate, resulting in a reduced ability to communicate their care needs. Distressing symptoms, physical and existential, may go unrecognized and untreated. The objectives of this integrative review were to systematically interrogate the literature to determine the changing conscious state of dying adults and to identify changes in their care needs.

METHODS

An integrative review protocol was registered with PROSPERO (CRD42020160475). The World Health Organization definition of palliative care informed the review. CINAHL, MEDLINE (OVID), Scopus, PsycINFO, Cochrane Library, and PubMed were searched from inception to October 2019 using search strategies for each database. Inclusion and exclusion criteria were applied. Methodological quality was appraised using the Joanna Briggs Institute Checklist for the Case Series appraisal tool. Extracted data were synthesized using a narrative approach.

RESULTS

Of 5,136 papers identified, 11 quantitative case series studies were included. Six themes were identified: conscious state and change over time, awareness, pain, absence of holistic care, the voiceless patient, and signs and symptoms of dying.

SIGNIFICANCE OF RESULTS

In the last days of life, the physical and conscious state of the dying patient declines, resulting in an inability to express their care needs. Dignity in dying and freedom from pain and suffering are both an imperative and a human right; and unvoiced care needs can result in unnecessary suffering and distress. This review revealed that little is known about how healthcare professionals assess holistic care needs at this vulnerable time. Although much has been written about palliative and end-of-life care, the assessment of care needs when patients are no longer able to voice their own needs has largely been ignored, with little attention from clinical, educational, or research perspectives. This gap in evidence has important implications for the dying and their families.

Diagnostic models for impending death in terminally ill cancer patients: A multicenter cohort study

Background

Accurately predicting impending death is essential for clinicians to clarify goals of care. We aimed to develop diagnostic models to predict death ≤3 days in cancer patients.

Methods

In this multicenter cohort study, we consecutively enrolled advanced cancer patients admitted to 23 inpatient hospices in 2017. Fifteen clinical signs related to impending death were documented daily from the day when the Palliative Performance Scale (PPS) declined to ≤20–14 days later. We conducted recursive partitioning analysis using the entire data set and performed cross‐validation to develop the model (prediction of 3‐day impending death‐decision tree [P3did‐DT]). Then, we summed the number of systems (nervous/cardiovascular/respiratory/musculoskeletal), where any sign was present to underpin P3did score (range = 0–4).

Results

Data following PPS ≤20 were obtained from 1396 of 1896 inpatients (74%). The mean age was 73 ± 12 years, and 399 (29%) had gastrointestinal tract cancer. The P3did‐DT was based on three variables and had four terminal leaves: urine output (u/o) ≤200 ml/day and decreased response to verbal stimuli, u/o ≤200 ml/day and no decreased response to verbal stimuli, u/o >200 ml/day and Richmond Agitation‐Sedation Scale (RASS) ≤−2, and u/o >200 ml/day and RASS ≥−1. The 3‐day mortality rates were 80.3%, 53.3%, 39.9%, and 20.6%, respectively (accuracy = 68.3%). In addition, 79.6%, 62.9%, 47.2%, 32.8%, and 17.4% of patients with P3did scores of 4, 3, 2, 1, and 0, respectively, died ≤3 days.

Conclusion

We successfully developed diagnostic models for death ≤3 days. These may further help clinicians predict impending death and help patients/families prepare for their final days.

Factors related to spiritual well-being in the last days of life in three East Asian countries: An international multicenter prospective cohort study

BACKGROUND

Some factors associated with spiritual well-being in dying patients have previously been reported. However, there has been no cross-cultural study comparing factors related to spiritual well-being. The current investigation may shed light on this under-investigated area through a comparison of diverse factors.

AIM

We aimed to (1) examine factors associated with spiritual well-being in the last days and (2) compare those factors across three East Asian countries.

DESIGN

This is an international multicenter prospective cohort study.

SETTING/PARTICIPANTS

Newly admitted inpatients with far advanced cancer in palliative care units in Japan, Korea and Taiwan were enrolled. Each patient was classified into one of two groups based on spiritual well-being score in the last days of life. Univariate and multivariate analyses were performed to identify the factors related to better spiritual well-being score in each country.

RESULTS

A total of 1761 patients treated at 37 palliative care units from January 2017 to September 2018 were analyzed. Seven variables were significant in Japan, three in Korea, and five in Taiwan. "Good death scale [acceptance]," "fatigue" and "expressed wish for hastened death" were unique in Japan. "Visit from a pastoral care worker within 48 h of death" was unique in Korea. "Patient's preferences for place of death," "dyspnea" and "continuous deep sedation" were unique in Taiwan.

CONCLUSIONS

This study found novel factors related to spiritual well-being in the last days of life, several of which differed according to country. Recognition of factors associated with spiritual well-being can improve the quality of palliative care.

Dying Alone during a Pandemic

Background: The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented experience that has had profound impact and consequences for health care providers, visitation policies, and procedures. Hospitals and health care facilities were forced to implement changes to visitation policies, in an effort, to minimize transmission of the virus, which unfortunately had negative impact on patients' and family members' well-being as well as moral distress for the staff. Objectives: We present here a case illustration of the impacts of such a response to the pandemic situation at our institution, including challenges for uniformly implementing such a change along with suggestions to support patients during these difficult times. Conclusion: Health care facilities should make efforts to maintain balance between safety precautions and minimizing potential negative impacts on patients, families, and staff by implementing innovative measures to support ongoing communication and access to family support.

How Successful Is Parenteral Oxycodone for Relieving Terminal Cancer Dyspnea Compared With Morphine? A Multicenter Prospective Observational Study

CONTEXT

Parenteral morphine is widely used for dyspnea of imminently dying cancer patients (terminal dyspnea). However, the efficacy of other opioids such as oxycodone remains largely unknown.

OBJECTIVES

To explore the efficacy of parenteral oxycodone vs. morphine by continuous infusion over 24 hours in cancer patients with terminal dyspnea.

METHODS

This was a pre-planned subgroup analysis of a multicenter prospective observational study. Inclusion criteria were advanced cancer patients admitted to palliative care units, Eastern Cooperative Oncology Group performance status = 3-4, and a dyspnea intensity ≥2 on the Integrated Palliative care Outcome Scale (IPOS) for which oxycodone or morphine was initiated by continuous infusion. We measured dyspnea IPOS scores over 24 hours.

RESULTS

We analyzed 164 patients who received oxycodone (n = 26) and morphine (n = 138) for dyspnea (median survival = 5 days). The mean age was 70 years, 58 patients (35%) had lung cancer, and 97 (59%) had lung metastases. Complete case analysis revealed that mean dyspnea IPOS scores decreased from 3.0 (standard deviation = 0.7) to 1.5 (0.7) in the oxycodone group (difference in means = 1.5; P < 0.001), and from 2.9 (0.7) to 1.6 (1.0) in the morphine group (difference in means = 1.3; P < 0.001). No significant between-group differences existed in the IPOS scores at 24 hours (P = 0.753). Adverse events were seen in no and 5 patients in the oxycodone and morphine groups, respectively.

CONCLUSION

Parenteral oxycodone may be equally effective and safe as morphine in the treatment of terminal dyspnea in cancer patients. Future randomized controlled trials should confirm the efficacy and safety of opioids other than morphine for terminal dyspnea.

Communication and Behavior of Palliative Care Physicians of Patients With Cancer Near End of Life in Three East Asian Countries

BACKGROUND

The characteristics of physician communication with patients at the end of life (EOL) in East Asia have not been well studied. We investigated physicians' communications with imminently dying patients with cancer and their families in palliative care units (PCUs) in Japan, South Korea, and Taiwan.

METHODS

This observational study included patients with cancer newly admitted and deceased during their first admission to 39 PCUs in three countries. We evaluated 1) the prevalence and timing of informing patients and families of patients' impending death and 2) the prevalence of communication to assure the families of the patient's comfort.

RESULTS

We analyzed 2138 patients (Japan: 1633, South Korea: 256, Taiwan: 249). Fewer Japanese (4.8%: 95% confidence interval [95% CI], 3.8%-5.9%) and South Korean (19.6%: 95% CI, 15.2%-25.0%) patients were informed of their impending death, whereas 66.4% (95% CI, 60.2%-72.1%) of Taiwanese were informed; among all three countries, ≥90% of families were informed. Although most patients in all three countries and the families in South Korea and Taiwan were informed of the impending death greater than or equal to four days before death, 62.1% (95% CI, 59.6%-64.6%) of Japanese families were informed less than or equal to three days prior. Most families in all three countries received assurance that the patient would remain comfortable (could hear until death, no distress with death rattle or respiration with mandibular movement).

CONCLUSIONS

Physicians in Taiwan communicated about patient's impending death most frequently, and physicians in all three countries generally provided assurance to families that the patients would remain comfortable. Further studies should explore the reasons for these differences and the effects of such communications in East Asia.

Spanish and Portuguese Societies of Internal Medicine consensus guideline about best practice in end-of-life care

AIM

To develop consensus recommendations about good clinical practice rules for caring end-of-life patients.

METHODS

A steering committee of 12 Spanish and Portuguese experts proposed 37 recommendations. A two rounds Delphi method was performed, with participation of 105 panelists including internists, other clinicians, nurses, patients, lawyers, bioethicians, health managers, politicians and journalists. We sent a questionnaire with 5 Likert-type answers for each recommendation. Strong consensus was defined when > 95% answers were completely agree or > 90% were agree or completely agree; and weak consensus when > 90% answers were completely agree or > 80% were agree or completely agree.

RESULTS

The panel addressed 7 specific areas for 37 recommendations spanning: identification of patients; knowledge of the disease, values and preferences of the patient; information; patient's needs; support and care; palliative sedation, and after death care.

CONCLUSIONS

The panel formulated and provided the rationale for recommendations on good clinical practice rules for caring end-of-life patients.

Oxygen use and survival in patients with advanced cancer and low oxygen saturation in home care: a preliminary retrospective cohort study

Background

The role of oxygen therapy in end-of-life care for patients with advanced cancer is incompletely understood. We aimed to evaluate the association between oxygen use and survival in patients with advanced cancer and low oxygen saturation in home care.

Methods

We conducted a retrospective cohort study at a primary care practice in suburban Tokyo. Adult patients in home care with advanced cancer demonstrating first low oxygen saturation (less than 90%) detected in home visits were consecutively included in the study. Cox proportional hazards regression was used to investigate the effect of oxygen use on overall survival and survival at home, adjusted for systolic blood pressure, decreased level of consciousness, dyspnea, oral intake, performance status, and cardiopulmonary comorbidity.

Results

Of 433 identified patients with advanced cancer, we enrolled 137 patients (oxygen use, n = 35; no oxygen use, n = 102) who developed low oxygen saturation. In multivariable analysis, the adjusted hazard ratio (HR) of oxygen use was 0.68 (95% confidence interval 0.39–1.17) for death and 0.70 (0.38–1.27) for death at home. In patients with dyspnea, the HR was 0.35 (0.13–0.89) for death and 0.33 (0.11–0.96) for death at home; without dyspnea, it was 1.03 (0.49–2.17) for death and 0.84 (0.36–1.96) for death at home.

Conclusions

Oxygen use was not significantly associated with survival in patients with advanced cancer and low oxygen saturation, after adjusting for potential confounders. It may not be necessary to use oxygen for prolongation of survival in such patients, particularly in those without dyspnea.

Duration of palliative care before death in international routine practice: a systematic review and meta-analysis

BACKGROUND

Early provision of palliative care, at least 3-4 months before death, can improve patient quality of life and reduce burdensome treatments and financial costs. However, there is wide variation in the duration of palliative care received before death reported across the research literature. This study aims to determine the duration of time from initiation of palliative care to death for adults receiving palliative care across the international literature.

METHODS

We conducted a systematic review and meta-analysis that was registered with PROSPERO (CRD42018094718). Six databases were searched for articles published between Jan 1, 2013, and Dec 31, 2018: MEDLINE, Embase, CINAHL, Global Health, Web of Science and The Cochrane Library, as well undertaking citation list searches. Following PRISMA guidelines, articles were screened using inclusion (any study design reporting duration from initiation to death in adults palliative care services) and exclusion (paediatric/non-English language studies, trials influencing the timing of palliative care) criteria. Quality appraisal was completed using Hawker's criteria and the main outcome was the duration of palliative care (median/mean days from initiation to death).

RESULTS

One hundred sixty-nine studies from 23 countries were included, involving 11,996,479 patients. Prior to death, the median duration from initiation of palliative care to death was 18.9 days (IQR 0.1), weighted by the number of participants. Significant differences between duration were found by disease type (15 days for cancer vs 6 days for non-cancer conditions), service type (19 days for specialist palliative care unit, 20 days for community/home care, and 6 days for general hospital ward) and development index of countries (18.91 days for very high development vs 34 days for all other levels of development). Forty-three per cent of studies were rated as 'good' quality. Limitations include a preponderance of data from high-income countries, with unclear implications for low- and middle-income countries.

CONCLUSIONS

Duration of palliative care is much shorter than the 3-4 months of input by a multidisciplinary team necessary in order for the full benefits of palliative care to be realised. Furthermore, the findings highlight inequity in access across patient, service and country characteristics. We welcome more consistent terminology and methodology in the assessment of duration of palliative care from all countries, alongside increased reporting from less-developed settings, to inform benchmarking, service evaluation and quality improvement.

Spanish and Portuguese Societies of Internal Medicine consensus guideline about best practice in end-of-life care

AIM

To develop consensus recommendations about good clinical practice rules for caring end-of-life patients.

METHODS

A steering committee of 12 Spanish and Portuguese experts proposed 37 recommendations. A two rounds Delphi method was performed, with participation of 105 panelists including internists, other clinicians, nurses, patients, lawyers, bioethicians, health managers, politicians and journalists. We sent a questionnaire with 5 Likert-type answers for each recommendation. Strong consensus was defined when >95% answers were completely agree or >90% were agree or completely agree; and weak consensus when >90% answers were completely agree or >80% were agree or completely agree.

RESULTS

The panel addressed 7 specific areas for 37 recommendations spanning: identification of patients; knowledge of the disease, values and preferences of the patient; information; patient's needs; support and care; palliative sedation, and after death care.

CONCLUSIONS

The panel formulated and provided the rationale for recommendations on good clinical practice rules for caring end-of-life patients.

Physical and psychological symptoms and signs in dying digestive tract cancer patients: the East Asian collaborative cross-cultural Study to Elucidate the Dying process (EASED)

BACKGROUND

Well detection of the symptoms and signs of dying patients is essential for providing proper palliative care. Our goal is to evaluate the predominant symptoms and compare the changes in dying patients with digestive tract cancer in Japan, South Korea, and Taiwan.

METHODS

A total of 1057 cancer patients aged 18 years or older admitted in palliative care units with locally advanced or metastatic gastroesophageal, colorectal, and pancreaticobiliary cancer were enrolled from January 2017 to March 2019. The severity of physical and psychological symptoms and signs assessed by physicians and/or nurses upon admission, 1 week after admission, and within 3 days of death, was compared according to cancer type and country of origin.

RESULTS

Among the 338 gastroesophageal, 358 pancreaticobiliary, and 361 colorectal cancer patients, 894 (93.1%) died during the observation period. Fatigue was the most severe symptom in all cancer groups before dying. Dyspnea, fatigue, drowsiness, and ascites improved after hospitalization albeit they worsened prior to death. In particular, ascites was a marked symptom in patients with pancreaticobiliary cancer. Delirium and hallucination gradually worsened during the period leading to death. Differences in manifestations with respect to the country of origin were not significant.

CONCLUSION

We identified the most prevalent signs and symptoms in patients from East Asia who were dying from digestive tract cancers. Proper management, based on these prevalent signs and symptoms during the dying period, plays a vital role in providing adequate palliative care.

Survival time after marked reduction in oral intake in terminally ill noncancer patients: A retrospective study

Background

Methods

Results

Conclusion

Models of Palliative Care Delivery for Patients With Cancer

Palliative care has evolved over the past five decades as an interprofessional specialty to improve quality of life and quality of care for patients with cancer and their families. Existing evidence supports that timely involvement of specialist palliative care teams can enhance the care delivered by oncology teams. This review provides a state-of-the-science synopsis of the literature that supports each of the five clinical models of specialist palliative care delivery, including outpatient clinics, inpatient consultation teams, acute palliative care units, community-based palliative care, and hospice care. The roles of embedded clinics, nurse-led models, telehealth interventions, and primary palliative care also will be discussed. Outpatient clinics represent the key point of entry for timely access to palliative care. In this setting, patient care can be enhanced longitudinally through impeccable symptom management, monitoring, education, and advance care planning. Inpatient consultation teams provide expert symptom management and facilitate discharge planning for acutely symptomatic hospitalized patients. Patients with the highest level of distress and complexity may benefit from an admission to acute palliative care units. In contrast, community-based palliative care and hospice care are more appropriate for patients with a poor performance status and low to moderate symptom burden. Each of these five models of specialist palliative care serve a different patient population along the disease continuum and complement one another to provide comprehensive supportive care. Additional research is needed to define the standards for palliative care interventions and to refine the models to further improve access to quality palliative care.

Prognosticating for Adult Patients With Advanced Incurable Cancer: a Needed Oncologist Skill

Patients with advanced cancer and their families commonly seek information about prognosis to aid decision-making in medical (e.g. surrounding treatment), psychological (e.g. saying goodbye), and social (e.g. getting affairs in order) domains. Oncologists therefore have a responsibility to identify and address these requests by formulating and sensitively communicating information about prognosis. Current evidence suggests that clinician predictions are correlated with actual survival but tend to be overestimations. In an attempt to cultivate prognostic skills, it is recommended that clinicians practice formulating and recording subjective estimates of prognosis in advanced cancer patient’s medical notes. When possible, a multi-professional prognostic estimate should be sought as these may be more accurate than individual predictions alone. Clinicians may consider auditing the accuracy of their predictions periodically and using feedback from this process to improve their prognostic skills.

Clinicians may also consider using validated prognostic tools to complement their clinical judgements. However, there is currently only limited evidence about the comparative accuracy of different prognostic tools or the extent to which these measures are superior to clinical judgement. Oncologists and palliative care physicians should ensure that they receive adequate training in advanced communication skills, which builds upon their pre-existing skills, to sensitively deliver information on prognosis. In particular, clinicians should acknowledge their own prognostic uncertainty and should emphasise the supportive care that can continue to be provided after stopping cancer-directed therapies.

State of palliative care services at US cancer centers: An updated national survey

BACKGROUND

This study examined the changes in outpatient palliative care services at US cancer centers over the past decade.

METHODS

Between April and August 2018, all National Cancer Institute (NCI)-designated cancer centers and a random sample of 1252 non-NCI-designated cancer centers were surveyed. Two surveys used previously in a 2009 national study were sent to each institution: a 22-question cancer center executive survey regarding palliative care infrastructure and attitudes toward palliative care and an 82-question palliative care program leader survey regarding detailed palliative care structures and processes. Survey findings from 2018 were compared with 2009 data from 101 cancer center executives and 96 palliative care program leaders.

RESULTS

The overall response rate was 69% (140 of 203) for the cancer center executive survey and 75% (123 of 164) for the palliative care program leader survey. Among NCI-designated cancer centers, a significant increase in outpatient palliative care clinics was observed between 2009 and 2018 (59% vs 95%; odds ratio, 12.3; 95% confidence interval, 3.2-48.2; P < .001) with no significant changes in inpatient consultation teams (92% vs 90%; P = .71), palliative care units (PCUs; 26% vs 40%; P = .17), or institution-operated hospices (31% vs 18%; P = .14). Among non-NCI-designated cancer centers, there was no significant increase in outpatient palliative care clinics (22% vs 40%; P = .07), inpatient consultation teams (56% vs 68%; P = .27), PCUs (20% vs 18%; P = .76), or institution-operated hospices (42% vs 23%; P = .05). The median interval from outpatient palliative care referral to death increased significantly, particularly for NCI-designated cancer centers (90 vs 180 days; P = 0.01).

CONCLUSIONS

Despite significant growth in outpatient palliative care clinics, there remain opportunities for improvement in the structures and processes of palliative care programs.

Emerging Challenges to the Safe and Effective Use of Methadone for Cancer-Related Pain in Paediatric and Adult Patient Populations

Methadone continues to be an important medication for the treatment of paediatric and adult cancer-related pain. Appropriate patient selection to ensure safe and effective treatment by a team of clinicians who appreciate and are familiar with methadone and its unique pharmacology is crucial. Unlike morphine and other more common opioids, methadone is purported to have involvement with delta-opioid receptor and higher affinity as an N-methyl-D-aspartate-receptor antagonist. Clinically this gives it the advantage of being effective for both nociceptive and neuropathic pain, but also may be useful in the setting of tolerance to other opioids. Methadone also comes in multiple available formulations that can be administrated through a variety of routes beyond the oral route. Challenges with methadone in treating cancer-related pain include drug interactions specifically as it relates to new targeted cancer therapies. Recent guidelines recommend electrocardiogram monitoring with methadone and there is potential for additive cardiac toxicity in the oncology setting. Appropriate dosing of methadone for pain management given age, organ dysfunction, and patients who are on methadone maintenance therapy are also key factors. This article aims to provide clinicians with evidence and clinical practice guidelines for safe and appropriate use of methadone including indication, initiation, and monitoring given its complexity for management of pain in the dynamic oncology setting.

Association Between Plasma Brain Natriuretic Peptide and Overall Survival in Patients With Advanced Cancer: Preliminary Findings

CONTEXT

Atrial and brain natriuretic peptides (ANP and BNP) are established diagnostic and prognostic markers in heart failure, but their utility in patients with advanced cancer is unclear.

OBJECTIVES

Our objective was to examine the association between plasma natriuretic peptides and survival in patients with advanced cancer without clinical evidence of heart failure.

METHODS

This exploratory analysis of a multicenter, randomized clinical trial of cancer patients receiving hospice care assessed the association between elevated plasma ANP, BNP, or Pro-BNP (cutoffs of >77, 100, and 900 pg/mL, respectively) and overall survival. Time-to-event analyses, including multivariate Cox regression, were conducted.

RESULTS

Among 97 patients, the mean age was 67.2 years and the overall survival was 16 days (95% CI, 13-23 days). ANP, BNP, and Pro-BNP were elevated in 29 of 36 (81%), nine of 23 (39%), and 32 of 38 (84%) patients, respectively. Elevated ANP, BNP, or Pro-BNP was associated with worse survival (median 14 vs. 21 days; P = 0.02). BNP or Pro-BNP was inversely associated with overall survival (hazard ratio = 2.27; 95% CI, 1.29-3.97) in univariate Cox regression analysis, and remained significant in multivariate Cox regression analysis (hazard ratio = 3.09; 95% CI, 1.40-6.84) after adjusting for treatment group and known prognostic variables such as performance status, albumin, creatinine, delirium, dyspnea, and anorexia. Elevated ANP alone was not significantly associated with survival (P = 0.17).

CONCLUSION

Our preliminary findings suggest that BNP or Pro-BNP may be a novel objective prognostic marker in cancer patients without heart failure. Further research is needed to confirm these findings.

The (un)availability of prognostic information in the last days of life: a prospective observational study

OBJECTIVES

The aims of this study were (1) to document the clinical condition of patients considered to be in the last 2 weeks of life and (2) to compare patients who did or did not survive for 72 hours.

DESIGN

A prospective observational study.

SETTING

Two sites in London, UK (a hospice and a hospital palliative care team).

PARTICIPANTS

Any inpatient, over 18 years old, English speaking, who was identified by the palliative care team as at risk of dying within the next 2 weeks was eligible.

OUTCOME MEASURES

Prognostic signs and symptoms were documented at a one off assessment and patients were followed up 7 days later to determine whether or not they had died.

RESULTS

Fifty participants were recruited and 24/50 (48%) died within 72 hours of assessment. The most prevalent prognostic features observed were a decrease in oral food intake (60%) and a rapid decline of the participant's global health status (56%). Participants who died within 72 hours had a lower level of consciousness and had more care needs than those who lived longer. A large portion of data was unavailable, particularly that relating to the psychological and spiritual well-being of the patient, due to the decreased consciousness of the patient.

CONCLUSIONS

The prevalence of prognostic signs and symptoms in the final days of life has been documented between those predicted to die and those who did not. How doctors make decisions with missing information is an area for future research, in addition to understanding the best way to use the available information to make more accurate predictions.

Prognostication in palliative care

An accurate prognosis about how long a terminally ill patient has left to live, when disclosed sensitively in open discussions, can facilitate patient-centred care and shared decision making. In addition, several guidelines, policies and funding streams rely, to some extent, on a clinician estimated prognosis. However, clinician predictions alone have been shown to be unreliable and over-optimistic. The factors underlying clinicians' prognostic decisions (particularly at the very end of life) are beginning to be elucidated. As an alternative to clinicians' subjective estimates, a number of prognostic algorithms and scores have been developed and validated, but only a few have consistently shown superiority to clinician predictions. Therefore, an element of uncertainty remains and this needs to be acknowledged when having conversations with patients and their families. Guidelines are available to advise clinicians about how to prepare for, participate in and record prognostic conversations.

Prognostication in advanced cancer: update and directions for future research

The objective of this review is to provide an update on prognostication in patients with advanced cancer and to discuss future directions for research in this field. Accurate prognostication of survival for patients with advanced cancer is vital, as patient life expectancy informs many important personal and clinical decisions. The most common prognostic approach is clinician prediction of survival (CPS) using temporal, surprise, or probabilistic questions. The surprise and probabilistic questions may be more accurate than the temporal approach, partly by limiting the time frame of prediction. Prognostic models such as the Glasgow Prognostic Score (GPS), Palliative Performance Scale (PPS), Palliative Prognostic Score (PaP), Palliative Prognostic Index (PPI), or Prognosis in Palliative Care Study (PiPS) predictor model may augment CPS. However, care must be taken to select the appropriate tool since prognostic accuracy varies by patient population, setting, and time frame of prediction. In addition to life expectancy, patients and caregivers often desire that expected treatment outcomes and bodily changes be communicated to them in a sensible manner at an appropriate time. We propose the following 10 major themes for future prognostication research: (1) enhancing prognostic accuracy, (2) improving reliability and reproducibility of prognosis, (3) identifying the appropriate prognostic tool for a given setting, (4) predicting the risks and benefits of cancer therapies, (5) predicting survival for pediatric populations, (6) translating prognostic knowledge into practice, (7) understanding the impact of prognostic uncertainty, (8) communicating prognosis, (9) clarifying outcomes associated with delivery of prognostic information, and (10) standardizing prognostic terminology.