Prognostication of impending death is an important variable in end-of-life cancer care. Many families ask nurses for their thoughts about terminal timeframes as they question whether they could leave the hospital or home or if they should call in relatives. Although research has informed clinicians about life’s trajectory over the final months and weeks of life, physical signs of the last days and hours have not been systematically examined.1,2 Having this information could facilitate nurses’ counsel with families who request such information.
In a recent study, 357 patients with advanced cancer who were admitted to two palliative care units were assessed every 12 hours for 10 physical signs: apnea periods, Cheyne-Stokes breathing, death rattle, dysphagia of liquids, decreased level of consciousness, decreased performance status, peripheral cyanosis, pulselessness of radial artery, respiration with mandibular movement, and urine output.3 Findings revealed symptom clusters that the authors categorized as early and late.
Early symptoms (> 3 days before death) included decreased level of consciousness, reduced palliative performance scale (≤ 20%), and dysphagia of liquids. Awareness of these signs are important as they indicate that the patient is deteriorating and likely has a survival projection of weeks or less.3,4 Six late symptoms occurred within the last 3 days of life. These symptoms included periods of apnea, Cheyne-Stokes breathing, death rattle, peripheral cyanosis, pulselessness of the radial artery, respiration with mandibular movement, and decreased urine output.3 These signs were indicative of a survival estimate of days or less. Of note is that the absence of a death rattle did not rule out imminent death, but its presence was highly predictive.
Knowledge of prognostic signs associated with impending death is an important aspect of nursing practice. When these symptoms occur, it represents the presence of an irreversible physiologic process. Nurses’ ability to assist families with the anticipation of death can facilitate their preferred presence at the end of life, which in turn may influence acute grief and mourning. The information presented in the above research can assist oncology nurses with their roles as advocate, educator, and counselor as families deal with the impending reality of the death of a loved one.
Seow H, Barbera L, Sutradhar R, et al. Trajectory of performance status, and symptom scores for patients with cancer during the last six months of life. J Clin Oncol. 2011;29:1151-8.
Georges JJ, Onwuteaka-Phillipsen BD, van der Heide A, et al. Symptoms, treatment and “dying peacefully” in terminally ill cancer patients: A prospective study. Support Care Cancer. 2005;13:160-8.
Hui D, Dos Santos R, Chisholm G, et al. Clinical signs of impending death in cancer patients. Oncologist. 2014;19:681-7.
Maltoni M, Caraceni A, Brunelli C, et al. Prognostic factors in advanced cancer patients: evidence-based clinical recommendations—A study by the Steering Committee of the European Association for Palliative Care. J Clin Oncol. 2005;23:6240-8.
FDA Approves Onivyde for Advanced Pancreatic Cancer Marijke Vroomen Durning, RN, 10/27/2015 3 On October 22, 2015, the US Food and Drug Administration (FDA) approved Onivyde (irinotecan liposome injection, Merrimack Pharmaceuticals, Inc.), in combination with fluorouracil ...