Background. The physical signs of impending death have not been well characterized in cancer patients. A better understanding of these signs may improve the ability of clinicians to diagnose impending death. We examined the frequency and onset of 10 bedside physical signs and their diagnostic performance for impending death. Methods. We systematically documented 10 physical signs every 12 hours from admission to death or discharge in 357 consecutive patients with advanced cancer admitted to two acute palliative care units. We examined the frequency and median onset of each sign from death backward and calculated their likelihood ratios (LRs) associated with death within 3 days. Results. In total, 203 of 357 patients (52 of 151 in the U.S., 151 of 206 in Brazil) died. Decreased level of consciousness, Palliative Performance Scale #20%, and dysphagia of liquids appeared at high frequency and .3 days before death and had

Background To reduce the risk of long-term swallowing complications after radiation, swallowing exercises may be helpful. Both the rate of adherence to swallowing exercises and its impact on future swallowing function is unknown. Methods 109 oropharyngeal cancer patients beginning radiation were tracked for two years to determine adherence to swallowing exercises. Participants completed the M.D. Anderson Dysphagia Inventory (MDADI) 1–2 years after treatment to assess self-reported swallowing function. Adherence, demographics, tumor and treatment variables were multivariably regressed onto the MDADI physical subscale score. Results Per speech pathologist documentation, 13% of the participants were fully adherent and 32% were partially adherent. Adherence was associated with the Physical MDADI Subscale score in the multivariate model (p=.01). Conclusions The majority of head and neck cancer patients are nonadherent to swallowing exercise regimens and may benefit from supportive care strategies to optimize their adherence.

Clinicians have limited accuracy in the prediction of patient survival. We assessed the accuracy of probabilistic clinician prediction of survival (CPS) and temporal CPS for advanced cancer patients admitted to our acute palliative care unit, and identified factors associated with CPS accuracy. Eight physicians and 20 nurses provided their estimation of survival on admission by (a) the temporal approach, "What is the approximate survival for this patient (in days)?" and (b) the probabilistic approach, "What is the approximate probability that this patient will be alive (0%-100%)?" for >24 hours, 48 hours, 1 week, 2 weeks, 1 month, 3 months, and 6 months. We also collected patient and clinician demographics. Among 151 patients, the median age was 58 years, 95 (63%) were female, and 138 (81%) had solid tumors. The median overall survival time was 12 days. The median temporal CPS was 14 days for physicians and 20 days for nurses. Physicians were more accurate than nurses. A higher accuracy of temporal physician CPS was associated with older patient age. Probabilistic CPS was significantly more accurate than temporal CPS for both physicians and nurses, although this analysis was limited by the different criteria for determining accuracy. With the probabilistic approach, nurses were significantly more accurate at predicting survival at 24 hours and 48 hours, whereas physicians were significantly more accurate at predicting survival at 6 months. The probabilistic approach was associated with high accuracy and has practical implications. The Oncologist 2011;16:1642-1648

Context Episodic breathlessness is common and debilitating in cancer patients. Objectives In this pilot study, we examined the effect of prophylactic fentanyl pectin nasal spray (FPNS) on exercise-induced dyspnea, physiologic function and adverse events. Methods In this parallel, double-blind randomized placebo-controlled trial, opioid-tolerant patients performed three six-minute walk tests (6MWT) to induce dyspnea. They were randomized to receive either FPNS (15−25% of total daily opioid dose each time) or placebo 20 minutes before the second and third 6MWTs. We compared dyspnea numeric rating scale (NRS, 0−10, primary outcome), walk distance, vital signs, neurocognitive function and adverse events between the first and second 6MWTs (T2-T1) and between the first and third 6MWTs (T3-T1). Results Twenty-four patients enrolled, with 96% completion. FPNS was associated with significant within-arm reduction in dyspnea NRS at rest (T2-T1: −0.9 [95% confidence interval [CI] −1.7,−0.1]; T3-T1: −1.3 [95% CI −2.0,−0.5]) and after six minutes (T2-T1: −2.0 [95% CI −3.5,−0.6]; T3-T1: −2.3 [95% CI −4.0,−0.7]), and longer walk distance (T2-T1 +23.8m [95% CI +1.3,+46.2m]; T3-T1: +23.3m [95% CI −1.7,+48.2]). In the placebo arm, we observed no significant change in walk distance nor dyspnea NRS at rest, but significant reduction in dyspnea NRS at 6 minutes (T2-T1: −1.7 [95% CI −3.3,−0.1]; T3-T1: −2.5 [95% CI −4.2,−0.9]). Vital signs, neurocognitive function and adverse effects did not differ significantly. Conclusion FPNS was safe, reduced dyspnea at rest and increased walk distance in before-after comparison. The placebo effect was substantial, which needs to be factored in future study designs.(clinicaltrials.gov registration: NCT01832402)

Context Episodic dyspnea is one of the most common, debilitating and difficult-to-treat symptoms. Objective We conducted a pilot study to examine the effect of prophylactic FBT on exercise-induced dyspnea. Methods In this parallel, double-blind randomized placebo-controlled trial, opioid-tolerant patients were asked to complete a 6 minute walk test (6MWT) at baseline, then a second 6MWT 30 minutes after a single dose of FBT (equivalent to 20-50% of their total opioid dose) or matching placebo. We compared dyspnea numeric rating scale (NRS, 0-10, primary outcome), walk distance, vital signs, neurocognitive function and adverse events between the two 6MWTs. Results Among 22 patients enrolled, 20 (91%) completed the study. FBT was associated with a significant within-arm reduction in dyspnea NRS between 0 and 6 minutes (mean change -2.4, 95% confidence interval [CI] -3.5, -1.3) and respiratory rate (mean change -2.6, 95% CI -4.7, -0.4). Placebo was also associated with a non-statistically significant decrease in dyspnea (mean change -1.1). Between arm comparison of dyspnea scores in the second 6MWT favored FBT, albeit not statistically significant (estimate -0.25, P=0.068). Global impression revealed more patients in the FBT group than placebo group reporting their dyspnea was at least “somewhat better” in the second 6MWT (4/9 vs. 0/11, P=0.03). The other secondary outcomes did not differ significantly between arms. Conclusions This study supports that prophylactic FBT was associated with a reduction of exertional dyspnea and was well-tolerated. Our findings support the need for larger trials to confirm the therapeutic potential of rapid-onset opioids.