Clinical Signs of Imminent Mortality in Advanced Cancer Patients Identified

Clinicians and researchers may be able to identify patients at risk of impending death by monitoring particular bodily changes that can be observed at the bedside

  • Date: 10 Feb 2015
  • Author: Shreeya Nanda, Senior medwireNews Reporter
  • Topic: Palliative Care

medwireNews: Researchers have identified eight highly specific physical signs that are associated with impending mortality in individuals with advanced cancer.

“This study shows that simple bedside observations can potentially help us to recognize if a patient has entered the final days of life”, commented lead author David Hui, from University of Texas MD Anderson Cancer Center in Houston, USA, in a press release.

“Upon further confirmation of the usefulness of these ‘tell-tale’ signs, we will be able to help doctors, nurses, and families to better recognize the dying process, and in turn, to provide better care for the patients in the final days of life.”

In the study published in Cancer, the researchers report the results of a planned secondary analysis of the Investigating the Process of Dying Study, comprising 357 advanced cancer patients who were monitored every 12 hours from admission to the acute palliative care unit until death or discharge. A total of 203 (57%) participants died during the course of this prospective, longitudinal study.

Of the 52 clinical signs assessed, nonreactive pupils, decreased response to visual and verbal stimuli, inability to close eyelids, drooping of the nasolabial fold, neck hyperextension, grunting of vocal cords and upper gastrointestinal bleeding were associated with imminent mortality with a high specificity of 95% or higher.

These signs had a late onset, from a median 1.5 days prior to death for the inability to close eyelids and grunting of vocal cords to 5.5 days for upper gastrointestinal bleeding. The positive likelihood ratio for death within 3 days was also high, ranging from 6.7 for decreased response to visual stimuli to 16.7 for nonreactive pupils.

“Given the high likelihood of impending death, the clinician may recommend discontinuation of blood work and select medications and hold hospital discharge after a discussion with the patient and/or his or her family”, say the researchers, cautioning, however, that “their absence cannot rule out that the patient will die shortly because of their low sensitivity”.

David Hui et al note that with one exception (upper gastrointestinal bleeding) all identified signs relate to neurocognitive deterioration and neuromuscular function, adding that three of the five signs identified in the primary analysis, namely Cheyne–Stokes breathing, respiration with mandibular movement and death rattle, also signify an altered neurological status.

“Our findings highlight that the progressive decline in neurological function is associated with the dying process”, they write.

Multivariate analysis showed that decreased response to verbal stimuli and drooping of the nasolabial fold, but not the remaining six signs, correlated independently and significantly with mortality within 3 days. But the authors add that the other physical signs could still be helpful in the diagnosis of imminent mortality, especially as patients do not always present with all the physical signs at the same time.


Hui D, dos Santos R, Chisholm G, et al. Bedside clinical signs associated with impending death in patients with advanced cancer: Preliminary findings of a prospective, longitudinal cohort study. Cancer 2015; Article first published online 9 February. doi:10.1002/cncr.29048

medwireNews ( ) is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2015