Variations in Vital Signs in the Last Days of Life in Patients With Advanced Cancer

Abstract

Context Few studies have examined variation in vital signs in the last days of life. Objectives We determined the variation of vital signs in the final two weeks of life in patients with advanced cancer and examined their association with impending death in three days. Methods In this prospective, longitudinal, observational study, we enrolled consecutive patients admitted to two acute palliative care units and documented their vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature) twice a day serially from admission to death or discharge. Results Of 357 patients, 203 (55%) died in hospital. Systolic blood pressure (P < 0.001), diastolic blood pressure (P < 0.001), and oxygen saturation (P < 0.001) decreased significantly in the final three days of life, and temperature increased slightly (P < 0.04). Heart rate (P = 0.22) and respiratory rate (P = 0.24) remained similar in the last three days. Impending death in three days was significantly associated with increased heart rate (odds ratio [OR] = 2; P = 0.01), decreased systolic blood pressure (OR = 2.5; P = 0.004), decreased diastolic blood pressure (OR = 2.3; P = 0.002), and decreased oxygen saturation (OR = 3.7; P = 0.003) from baseline readings on admission. These changes had high specificity (≥80%), low sensitivity (≤35%), and modest positive likelihood ratios (≤5) for impending death within three days. A large proportion of patients had normal vital signs in the last days of life. Conclusion Blood pressure and oxygen saturation decreased in the last days of life. Clinicians and families cannot rely on vital sign changes alone to rule in or rule out impending death. Our findings do not support routine vital signs monitoring of patients who are imminently dying.

Clinical Signs of Impending Death in Cancer Patients

“…To determine the diagnostic performance of each sign, we computed the sensitivity, specificity, positive likelihood ratio (LR), and negative LR using a 2 3 2 diagnostic table with random sampling, as described previously [23]. We used data from all 357 patients, instead of only those 203 patients who died, because it is the entire population in which the diagnostic test will be applied.…”

Unexpected death in palliative care

“…In the last days of life, the average heart rate increases, the blood pressure decreases and the oxygen saturation decreases. [18,20] However, over half of the patients had vital signs in the normal range in the last 3 days. This may explain why both the absolute and relative changes in blood pressure and oxygen saturation only had low to moderate positive likelihood ratios for impending death.…”

“…This may explain why both the absolute and relative changes in blood pressure and oxygen saturation only had low to moderate positive likelihood ratios for impending death. [18,20] At the same time, it should be emphasized that the cutoffs used to define abnormal vital signs in these studies were relatively conservative. More significant changes, such as decrease of systolic blood pressure from 140 mmHg to 50 mmHg, may indicate that the patient has hours or less to life.…”

“…Objective prognostic factors, prognostic models, serial prognostication, and recognition of the signs of impending death may help clinicians to formulate prognosis more accurately. [18–20,42–44] Optimizing communication with patients and family. In addition to over-estimating survival, Clinicians often inflate the prognosis when communicating with patients, which may contribute to heightened optimism and unrealistic expectations.…”

“…Objective prognostic factors, prognostic models, serial prognostication, and recognition of the signs of impending death may help clinicians to formulate prognosis more accurately. [18–20,42–44]…”