The likelihood of impending death of patients with advanced cancer “is one of those questions that many people want to know about, but they are too afraid to ask,” David Hui, MD, MSc, said in an interview with The ASCO Post. Dr. Hui is lead author of a study, published in Cancer, on clinical signs of impending death and Assistant Professor, Department of Palliative Care and Rehabilitation Medicine and Department of General Oncology at The University of Texas MD Anderson Cancer Center, Houston.
Foreseeing and Foretelling
Physicians can use the clinical signs to estimate probability of death within 3 days, “foreseeing” what is likely to happen to the patient and “foretelling this to the family,” Dr. Hui stated. Although sometimes afraid to bring up the topic of death, “a majority of families do want to understand what is happening to the patient,” Dr. Hui said. “Of course, we will ask them, ‘Do you want to know more about his prognosis?’ If they say, ‘I really do not want to hear anything about that,’ then we will be careful not to potentially traumatize them.”
In many cases, Dr. Hui noted, family members already realize the patient is dying, but will say, “I just don’t know when it is going to happen and I need to plan ahead. I need to be able to decide whether I am going to stay tonight. If he might die over the next few days, I really want to spend the time here. I want to make sure that I get my family members in. When is a good time to get them?”
“Of course, each patient is unqiue. But when the probability of impending death is very high, then we can start to think about making decisions based on this diagnosis,” Dr. Hui stated. “For example, should we continue the daily blood work if the patient has only 3 days to live and the blood work is not going to contribute further to the patient care? This is a very individualized decision that the team needs to make together with the family. The family will get a better sense of what to do and plan ahead,” Dr. Hui said.
“[Impending death] is not just a simple diagnosis but one that is made with great care and often in consultation with other members of the team looking after the patient. If we all agree this is happening, then we will feel confident in talking to the family about this. We can say, ‘Based on our understanding, there is a very high chance that your loved one will die within the next 3 days.’ That can help families plan ahead during this very stressful time,” Dr. Hui added.
“The more data we have, the more confident that we get. The diagnosis of impending death is one where we don’t want to make a mistake,” he stressed.
“Having data to back up that confidence helps me a lot,” Dr. Hui said. “Before this study, I would say, ‘I think this is going to happen. There is a high chance, but I can’t give you a number.’ Now I know there is an 80% to 90% chance that the patient is going to die in the next 3 days … or even potentially in the next hour,” Dr. Hui clarified.
Caregivers Often Notice the Signs
“When we explain the process of dying to families, we may tell them that the patient’s breathing might change or that it might be hard to recognize the pulse. And then the families say, ‘You know, I noticed that already,’” Dr. Hui said. “They are the ones who are by the bedside a lot of the time, and some of these signs are not difficult to detect.” Dr. Hui said that if the reliability of the signs to predict impending death is confirmed by further studies, they could prove more useful to family caregivers as well as clinicians.
“Some of the signs may contribute to our better understanding of the very end of life and can help support decision-making. But we need to recognize that these signs are just one piece of the big puzzle when we do make decisions like that,” Dr. Hui concluded. ■
In a recently published study of patients with advanced cancer whose status was systematically documented twice a day, from the time of admission to a palliative care unit until death or discharge, investigators identified eight physical signs associated with death within 3 days. Taken together...