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

Abstract

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.

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

“…According to Hui et al, these eight clinical signs occur in 5% to 78% of dying cancer patients and had high specificity (>95%) and a high positive likelihood ratio for death occurring within 3 days (Hui et al, 2015). One recently published prospective observational study buttresses the findings of Hui et al by demonstrating that pulselessness of the radial artery, breathing with mandibular movement, decreased response to verbal stimuli, and decreased response to visual stimuli show high accuracy in predicting death within 7 days in terminally-ill non-cancer individuals (Hosoi et al, 2021).…”

“…Several reliable and valid tools are widely used in palliative and hospice care medicine for assessing functional performance and predicting survival in patients with advanced illness (Simmons et al, 2017). The commonly used tools which include the Palliative Performance Scale (PPS), Karnofsky Performance Status (KPS), Eastern Cooperative Oncology Group Death rattle (Terminal respiratory secretions) (Hui, Dos Santos et al, 2014;Wildiers & Menten, 2002) Decreased level of consciousness (Matsunami et al, 2018) ↓Food intake/Loss of Appetite (Matsunami et al, 2018) Respiratory breathing with mandibular movement (Hui, Dos Santos et al, 2014;Kaneishi et al, 2022) Agitation/Purposeless movement (Hui et al, 2015) Dysphagia to solid (Hui, Dos Santos et al, 2014) Cheyne-Stokes breathing (Goodridge et al, 2005;Hui, Dos Santos et al, 2014) Dysphagia to liquids (Hui, Dos Santos et al, 2014) Intractable pain (Hendriks et al, 2014) Absence of radial artery pulse (Hui, Dos Santos et al, 2014) Mottling (Hui et al, 2015) Dyspnea (Kehl & Kowalkowski, 2013) Urine output less than 200 ml/day (Hui, Dos Santos et al, 2014;Mori et al, 2021) ↓response to verbal stimuli (Hosoi et al, 2021) Delirium/Impaired consciousness (Breitbart & Alici, 2008;Matsunami et al, 2018) Non-reactive pupils (Hui et al, 2015) ↓response to visual stimuli (Hosoi et al, 2021) Cold/Cool extremities (Hui et al, 2015;Hui, Dos Santos et al, 2014) Grunting of vocal cords (Hui et al, 2015) Capillary refill >3 s (Hui et al, 2015) Refractory fatigue and weakness (Plonk & Arnold, 2005) Peripheral cyanosis (Hui, Dos Santos et al, 2014) Decreased speech…”

Uso degli antibiotici nel fine vita

“…L'incertezza prognostica in questa fase rimane comunque una importante criticità, nonostante siano stati condotti numerosi studi internazionali per indagare quali siano i segni e sintomi di morte imminente sia nei pazienti oncologici (OPs) che in quelli non oncologici (NOs), per definire quindi modelli predittivi. 8 I segni di morte imminente più frequentemente individuati dagli studi sono: • rapido declino delle condizioni cliniche generali del paziente e del suo stato di performance; • alterazione del sensorio (sia per i OPs che per i NOs); • flebilità del polso radiale fino all'assenza (più frequente nei NOs); • contrazione della diuresi (soprattutto nei OPs); • comparsa o peggioramento di secrezioni respiratorie rumorose (soprattutto nei pazienti oncologici); • atti respiratori superficiali con movimenti mandibolari (presente sia nei OPs che nei NOs); • perdita della piega nasolabiale (sia OPs che NOs); • incapacità di chiudere gli occhi (soprattutto OPs); • comparsa di apnee o di respiro periodico di Cheyne-Stokes (prevalentemente nei OPs) (Tabella 1).…”