You are here

Article Text

Article menu

Download PDFPDF

XML
Palliative care
Research
The (un)availability of prognostic information in the last days of life: a prospective observational study
  1. Nicola White1,
  2. Fiona Reid2,
  3. Priscilla Harries3,4,
  4. Adam J L Harris5,
  5. Ollie Minton6,
  6. Catherine McGowan7,
  7. Philip Lodge8,9,
  8. Adrian Tookman8,9,
  9. Patrick Stone1
  1. 1 Marie Curie Palliative Care Research Department, University College London, London, London, UK
  2. 2 Department of Primary Care & Public Health Sciences, King’s College London, London, London, UK
  3. 3 Centre for Applied Health and Social Care Research (CAHSCR), Kingston University & St George’s, University of London, London, UK
  4. 4 Department of Clinical Sciences, Brunel University London, London, UK
  5. 5 Experimental Psychology, University College London, London, London, UK
  6. 6 Palliative Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, Brighton and Hove, UK
  7. 7 Palliative Medicine, St. Georges University Hospitals NHS Foundation Trust, London, UK
  8. 8 Palliative Medicine, Royal Free London NHS Foundation Trust, London, London, UK
  9. 9 Marie Curie Hospice Hampstead, London, UK
  1. Correspondence to Dr Nicola White; n.g.white{at}ucl.ac.uk

Abstract

Objectives The aims of this study were (1) to document the clinical condition of patients considered to be in the last 2 weeks of life and (2) to compare patients who did or did not survive for 72 hours.

Design A prospective observational study.

Setting Two sites in London, UK (a hospice and a hospital palliative care team).

Participants Any inpatient, over 18 years old, English speaking, who was identified by the palliative care team as at risk of dying within the next 2 weeks was eligible.

Outcome measures Prognostic signs and symptoms were documented at a one off assessment and patients were followed up 7 days later to determine whether or not they had died.

Results Fifty participants were recruited and 24/50 (48%) died within 72 hours of assessment. The most prevalent prognostic features observed were a decrease in oral food intake (60%) and a rapid decline of the participant’s global health status (56%). Participants who died within 72 hours had a lower level of consciousness and had more care needs than those who lived longer. A large portion of data was unavailable, particularly that relating to the psychological and spiritual well-being of the patient, due to the decreased consciousness of the patient.

Conclusions The prevalence of prognostic signs and symptoms in the final days of life has been documented between those predicted to die and those who did not. How doctors make decisions with missing information is an area for future research, in addition to understanding the best way to use the available information to make more accurate predictions.

  • palliative care
  • dying
  • prognosis

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2019-030736

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Strengths and limitations of this study

    • An observational study that prospectively documented prognostic signs and symptoms in relation to survival of 72 hours.

    • Highlights the prevalence of missing data in palliative care.

    • The results reflect only the participants that were recruited as part of this study, those who were referred to specialist palliative care. Other results might have been prevalent in a different population.

    Background

    Caring for a dying person is a core skill required of every doctor and healthcare professional.1 Part of this competency is to be able to recognise when the person is dying in order to facilitate a ‘good death’.2 Recognising this terminal phase can enable the dying person to spend time with their loved ones in a location of their choice. The ‘More Care; Less Pathway’ report3 alongside other research4 5 has highlighted that medical teams are not very accurate at recognising when patients are (or are not) imminently dying.

    One way to improve this skill is to teach staff which signs and symptoms are most prevalent at the end of life. There are a number of reports from organisations such as The National Council for Palliative Care and the National Institute for Health and Care Excellence, which present narrative summaries of the symptoms and signs that are most common during the last few days of life.6–11 Previous research and systematic reviews have identified which signs and symptoms are prevalent among patients dying from cancer12–18 or other diseases.19–27 Interviews or surveys with health professionals have also been used to determine which signs or symptoms staff believe are most indicative of imminent death.28–31 From the literature, it appears that common signs include changes in breathing patterns, altered consciousness, agitation, changes to the appearance of the skin, incontinence or reduced urinary output, changes in functional ability and social withdrawal. Common symptoms include tiredness, reduced appetite and confusion.

    Despite this body of evidence regarding signs and symptoms, these findings have not translated in to practice; medical teams continue to be inaccurate at recognising imminent death.3 It has been highlighted from recent reports that evidence regarding the clinical presentation of people who were predicted to die, but subsequently did not, is lacking.3 4 Finally, findings from palliative care research highlight the high degree of missing or unavailable data.32 If the common signs and symptoms identified from previous research are not available, or are missing, in the final days of life, then just how is death recognised?

    This study was the first stage of a larger study investigating the recognition of dying.33 The objectives of this reasearch are:

    1. To prospectively document the clinical condition of patients considered to be in the last 2 weeks of life.

    2. To compare the clinical condition of patients who did or did not survive for 72 hours.

    Methods

    A prospective observational study of patients referred to specialist palliative care. This study follows the Strengthening the Reporting of OBbservational Studies in Epidemiology reporting guidelines (see online supplementary file 1). The original protocol for the study is in online supplementary file 2.

    Supplementary file 1

    Supplementary file 2

    Settings

    Recruitment took place at two palliative care services in London, UK (a hospice and a hospital) between January 2015 and October 2015.

    Participants

    All inpatient referrals to the palliative care team were screened by their respective clinical teams for eligibility. Palliative care was selected as the specialty to mitigate risk that the death would be sudden or unexpected.

    Inclusion criteria

    1. 18 years old and over.

    2. Identified by the palliative care team as likely to die in the next 2 weeks.

    3. The patient or family could speak enough English for the researcher to discuss the study.

    Exclusion criteria

    1. Assessed as not suitable to approach by the clinical team (ie, discussing the research would cause too much distress)

    2. Lacked capacity and no personal consultee (family member) available

    3. Refused to participate, either verbally or through an advance directive

    Sample size

    This study formed part of a programme of research designed to devise a test for assessing clinicians’ prognostic accuracy.34 For the purpose of devising a prognostic test,33 it was necessary to obtain data from at least 20 patients (10 of whom died and 10 of whom survived for 72 hours). To ensure that at least 20 cases were suitable for inclusion in the study to devise a prognostic test, we aimed to recruit approximately 50 cases in total. The final sample was determined by the number of inpatient referrals who were eligible and willing to participate during the study recruitment period.

    Patient and public involvement

    Feedback on the protocol was sought from a consumer research panel (South West London Cancer Research Group). The suggestions from the group were reflected in the study protocol, specifically the study information sheets.

    Ethical issues

    Recruiting people who are at the ends of their lives presents ethical challenges. In both the hospice and hospital, this may have been the first time that the individual had been referred to palliative care. An inclusion criterion for the study was that the patient was considered to be likely to die within 2 weeks. This information had the potential to cause upset to both the family and the patient, unless it was handled sensitively by clinical staff. We addressed these concerns by allowing clinical teams to exclude potentially eligible patients if they judged that discussing the research would cause too much distress. Since this study did not require a consecutive series of patients, it was not felt to affect the integrity of the study to allow clinical teams the discretion to operate this form of research ‘gate-keeping’.

    Consent procedure

    We expected a high number of participants to be unconscious or unresponsive and, as a consequence, to lack capacity. We adhered to the Mental Capacity Act35 guidelines for recruiting patients without capacity. We also mirrored the approach taken in a similar study that had recruited patients admitted to the acute setting.36

    If the clinician felt that involvement in the study would not cause distress, the clinician asked the patient, or their family member, if they wished to meet the researcher to discuss taking part in the study. If they agreed to this, the researcher briefed the patient and/or their family member about the research and obtained either informed consent or personal consultee agreement.

    Due to the time sensitive nature of the research, there was no enforced delay between informing the patient about the study and seeking consent to participate. Each patient who entered the study was informed that they could withdraw at any time, without reason and without consequence to their care. It was possible to gain telephone advice from a personal consultee should they not live locally. If telephone advice was obtained, an information sheet and a ‘documentation of advice’ form were posted to the family member with a return address. If the form was not returned, or was returned incomplete, the data pertaining to that patient were removed from the database and destroyed (see online supplementary file 3).

    Supplementary file 3

    Procedure

    All participants, on entering the study, underwent a single observer-rated assessment of key prognostic features (see below), medications and overall condition. Information regarding their medical history, their reason for admission and their demographic details were extracted from the medical notes. Data regarding signs and symptoms over the last 24 hours were obtained from direct observation of, or discussion with, the patient or from discussing their care with medical or nursing staff.

    Measures

    We collected data on prognostic variables that had previously been identified from the literature. We used validated measures to record agitation or sedation, functional ability and comorbidities.

    Richmond Agitation Sedation Scale

    This scale assesses patients’ level of agitation or sedation. The scale ranges from +4 (combative) to −5 (unarousable). The Richmond Agitation Sedation Scale (RASS) has high validity and reliability within a hospital setting.37 This measure has previously been used in mortality research.38 It distinguishes in greater detail than other scales the different levels of sedation.

    Palliative Performance Scale

    This scale is used to assess palliative care patients’ functional ability.39 It consists of five domains: Ambulation, Activity and Evidence of Disease, Self-Care, Intake and Conscious Level. Scores can range between 10% (fully dependent) and 100% (fully independent). A decrease in the patient’s functional ability has been shown to predict death.40

    Charlson Comorbidity Index score

    This score summarises the severity of chronic comorbidities. It includes 19 diseases that are weighted by their association with mortality. Higher scores reflect a greater number and/or severity of comorbidities.41 This was obtained from the patient’s medical records. The Charlson Comorbidity Index (CCI) has been shown to predict short and long term mortality.42

    Clinical signs and symptoms

    As we wanted to provide a rich description of the patients who were potentially in the final days of life, we included all symptoms and signs that have previously been identified as being potentially predictive of the dying phase12 14–16 19–22 24–26 28–30:

    • Respiration (rate and character)

    • Blood circulation (pulse rate, blood pressure, peripheral perfusion, cyanosis)

    • Physical condition (performance status, mobility)

    • Skin integrity

    • Excretion (continence, presence of indwelling catheter)

    • Oral intake

    • Pain

    • Consciousness (level of sedation or agitation)

    • Psychological/Spiritual condition

    • Other

    The full list of clinical signs and symptoms recorded is shown in online supplementary file 4.

    Supplementary file 4

    We reported on the prevalence of missing data, which are common in palliative care studies.32 For example, for several self-reported symptoms, it was not possible to obtain an answer for patients who were unconscious, unless the patient’s family members or attending nurse were able to act as a proxy provider of information. This was particularly common when assessing the psychological state of the participant. Similarly, when a patient had a urinary catheter or a stoma, it was not possible to determine continence level.

    Main outcome

    The main outcomes of interest were the characteristics of patients who did and did not die within 72 hours of assessment. Each participant was followed up 7 days after the day of observation. During this time, if the participant died, the date of death was recorded.

    Analysis

    The purpose of this study was to describe the presence or absence of key prognostic features in patients who were or were not dying, under the care of palliative care services, rather than to test specific hypotheses about differences between subgroups of participants. Therefore, to avoid overinterpretation of our data, no statistical tests have been performed to assess for such differences. Results have been summarised using descriptive statistics.

    Results

    Recruitment

    In total, 60 patients were approached to participate in this study (see figure 1). Ten were not included because: they had died before the researcher could see them (n=5); they had declined to participate (n=3); or they had no personal consultee available (n=2). Therefore, 50 patients were included in this analysis, of whom 24 (48%) died within 72 hours of assessment.

    Figure 1
    Figure 1

    Recruitment flowchart.

    Participant characteristics

    The characteristics of participants recruited are presented in table 1.

    View this table:
    Table 1

    Participant characteristics

    By site

    The patients in hospital were older compared with the hospice (mean 76 years, SD 16 vs 64, SD 14) with a higher prevalence of non-cancer diagnoses (48% vs 11%). They had fewer serious comorbidities than the patients from the hospice (CCI mean 5.0, SD 2.1 vs 6.2, SD 1.8) and more patients died within 72 hours within the hospital (65% vs 21%).

    By survival

    Slightly more men than women died within 72 hours (58% vs 42%). The mean age of patients who died within 72 hours was higher (78 years, SD 13) than those who did not (67, SD 18). There was little difference in comorbidities between those who died within 72 hours (CCI mean 5.2, SD 2.2) and those who did not (5.7, SD 1.9). Of those who died within 72 hours, 50% had cancer, and 50% did not.

    Palliative Performance Scale

    The Palliative Performance Status (PPS) was assessed for every participant. The PPS scores ranged between 10% and 70%, with a median of 30% (IQR 10, 40). The participants who died within 72 hours had a median PPS score of 10% (IQR 10, 30). Participants who survived beyond 72 hours had a median PPS score of 40% (IQR 20, 50).

    Richmond Agitation Sedation Scale

    Scores for the RASS ranged between +2 and −5. The median score for the total population was −1 (IQR −4, 0). The distribution of scores was bimodal; 12 patients (24%) had a score of 0 and nine (18%) had a score of −5. The participants who died within 72 hours of assessment were either deeply unconscious (n=15, 62.5% scored either −4 or −5) or were agitated (n=5, 20% scored +1 or +2) with a median score of −4 (IQR −4.5,–0.5). The participants who did not die within 72 hours were largely calm with mild agitation or sedation (n=18, 70% scored between −1 and +1) and a median score of −0.5 (IQR −2, 0).

    Clinical signs and symptoms prevalence

    Table 2 details the prevalence of the signs and symptoms noted during the study. Overall, the most prevalent features observed were a decrease in oral food intake (60%) and a rapid decline of the participant’s global health status (56%).

    View this table:
    Table 2

    Prevalence of key prognostic features over the previous 24 hours in patients who did or did not die imminently

    Participants who died within 72 hours were more frequently noted to have: a rapid decline of their global condition (75% vs 38%); decreased urine production (71% vs 23%); more concentrated urine (67% vs 31%); incontinence of faeces (71% vs 19%); noisy respiratory secretions (54% vs 15%); Cheyne-Stoke breathing (17% vs 4%); peripheral cyanosis (21% vs 4%); and refusal of food (21% vs 4%). There were two symptoms that were only seen in participants who died within 72 hours: respiration with mandibular movement (n=2; 8%) and pulselessness of the radial artery (n=2; 8%). Participants who survived longer than 72 hours were more frequently noted to have a loss of appetite (69% vs 25%) and pain (42% vs 4%) and were more likely to express anxiety or fear (54% vs 17%) and were more accepting of their death (38% vs 8%); however, these data were more likely to be missing for patients who survived less than 72 hours.

    Missing data

    As shown in table 2, there were some prognostic features for which almost half of the data were recorded as missing. In general, the proportion of missing data was higher in patients who died within 72 hours compared with those who survived. Measures such as the physical condition, oral intake, psychological well-being and whether they were experiencing shortness of breath were often not available either because there was no meaningful answer (ie, the patient had a catheter/stoma or the patient was not alert enough to respond, with no proxy measure available) or the information was not recorded. The aim of this study was to document all previously identified prognostic features in patients who were referred to specialist palliative care teams. While the diminished consciousness of the patient, which is an evidence-based prognostic indicator in its own right, could have limited the ability to collect some of this data; the fact that data relating to some of these features were frequently missing in those who died within 72 hours is a relevant and novel finding which has implications for clinical practice.

    Discussion

    This study described the presence or absence of key prognostic features in palliative care patients who were thought to be in the last 2 weeks of life and who did or did not die within 72 hours of assessment.

    In patients thought to be in the last 2 weeks of life, there was a reduction in physical ability, as measured by the palliative performance scale. Three symptoms affected at least half of the patients: reduced oral intake, a rapid decline in condition and a change in excretions. This result is slightly inconsistent with other studies that have suggested that other symptoms such as fatigue and mental haziness are more prevalent in the last weeks of life.43–45

    Different symptoms were prevalent in patients who died within 72 hours and in those who survived for longer. Patients who died within 72 hours had a lower palliative performance score and experienced either more agitation or more sedation than patients who survived longer than 72 hours. Some symptoms were more prevalent in patients who died imminently, such as a rapid decline in global condition, decreased urine output, increased anxiety, incontinence, noisy respiratory secretions, Cheyne-Stoke breathing and peripheral cyanosis. The small sample size of this study means that the estimates of the prevalence of particular symptoms should only be regarded as tentative. Two symptoms, although uncommon, were only noticed in patients who died imminently: respiration with mandibular movement and pulselessness of the radial artery. These symptoms have been previously suggested to predict imminent death.12 13 16 One previous study reported that observations of the patient, such as heart rate and oxygen saturation, may also be predictive of imminent death but that for a large portion of patients, these vital signs were within a normal range in the last days of life.17 Most of the patients in our study did not have routine observations undertaken and so no such data were available.

    This reiterates the importance of further research within a palliative care context particularly in the final days of life and about how to make prognostic decisions in the context of incomplete data.32 A large volume of data was recorded as missing for patients who died within 72 hours in this study. This is an interesting finding and highlights the complicated landscape in which the medical team are asked to make predictions about imminent death based on information that is not always possible to obtain about the patient. The prevalence of prognostic factors in this study demonstrates the large amount of potential prognostic information that medical teams have to weigh up when making a decision about end of life care. Further research is required to determine how these decisions are made in practice.

    Strengths and weaknesses

    This study is one of the first, to the authors knowledge, to prospectively observe prognostic signs and symptoms in the final days of life. However, these data are only taken from two london specialist palliative care teams. If a different population had been recruited, it is possible that other signs and symptoms may have been more prevalent. For example, patients who are not referred to specialist palliative care teams might present differently towards the end of life. This is an area for further research. This study was not designed to demonstrate an association between the prevalence of symptoms at the end of life and death within days, and any apparent differences between groups need further confirmation in a comparative study.

    Conclusion

    This study lends support to the usefulness of certain key prognostic features for predicting immnent death in palliative care inpatients. Further work is required to understand how clinicans should best integrate these prognostic features, while taking into account the volume of missing information, to refine their prognostic estimates of imminent death.

    Acknowledgments

    We would like to thank all staff, patients, and their next of kin at the participating sites for their contribution and assistance in completing this research.

    References

    1. 1.↵
      2. Ferris FD
      . Last hours of living. Clin Geriatr Med 2004;20:641–67.doi:10.1016/j.cger.2004.07.011
      OpenUrlCrossRefPubMed
    2. 2.↵
      The End of Life Care Strategy: Department of Health, ed, 2008.
    3. 3.↵
      2. Neuberger J ,
      3. Guthrie C ,
      4. Aaronovitch D
      . More care, less pathway: a review of the Liverpool Care Pathway. In: Department of Health CC, editor, 2013.
    4. 4.↵
      2. Parry R ,
      3. Seymour J ,
      4. Whittaker B , et al
      . Rapid evidence review: pathways focused on the dying phase in end of life care and their key components, 2013.
    5. 5.↵
      2. Gibbins J ,
      3. McCoubrie R ,
      4. Alexander N , et al
      . Diagnosing dying in the acute hospital setting--are we too late? Clin Med 2009;9:116–9.doi:10.7861/clinmedicine.9-2-116
      OpenUrlAbstract/FREE Full Text
    6. 6.↵
      National Institute for Health and Care Excellence (NICE). Care of dying adults in the last days of life. 2017.
    7. 7.↵
      2. Carter L
      . How to have difficult conversations. Age UK, editor, 2017.
    8. 8.↵
    9. 9.↵
      Macmillan Cancer Support and Marie Curie. End of life: a guide. 2nd ed, 2015.
    10. 10.↵
      The National Council For Palliative Care, Hospice UK, Sue Ryder. What to expect when someone important to you is dying. 2015.
    11. 11.↵
    12. 12.↵
      2. Hui D ,
      3. dos Santos R ,
      4. Chisholm G , et al
      . Clinical signs of impending death in cancer patients. Oncologist 2014;19:681–7.doi:10.1634/theoncologist.2013-0457
      OpenUrlAbstract/FREE Full Text
    13. 13.↵
      2. Hui D ,
      3. Dos Santos R ,
      4. 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;121:960–7.doi:10.1002/cncr.29048
      OpenUrlCrossRefPubMed
    14. 14.↵
      2. Hwang IC ,
      3. Ahn HY ,
      4. Park SM , et al
      . Clinical changes in terminally ill cancer patients and death within 48 h: when should we refer patients to a separate room? Support Care Cancer 2013;21:835–40.doi:10.1007/s00520-012-1587-4
      OpenUrlCrossRefPubMed
    15. 15.↵
      2. Ventafridda V ,
      3. Ripamonti C ,
      4. De Conno F ,
      5. Fc D , et al
      . Symptom prevalence and control during cancer patients' last days of life. J Palliat Care 1990;6:7–11.doi:10.1177/082585979000600303
      OpenUrlPubMed
    16. 16.↵
      2. Morita T ,
      3. Ichiki T ,
      4. Tsunoda J , et al
      . A prospective study on the dying process in terminally ill cancer patients. Am J Hosp Palliat Care 1998;15:217–22.doi:10.1177/104990919801500407
      OpenUrlCrossRefPubMed
    17. 17.↵
      2. Bruera S ,
      3. Chisholm G ,
      4. Dos Santos R , et al
      . Variations in vital signs in the last days of life in patients with advanced cancer. J Pain Symptom Manage 2014;48:510–7.doi:10.1016/j.jpainsymman.2013.10.019
      OpenUrlCrossRefPubMedWeb of Science
    18. 18.↵
      2. Eychmüller S ,
      3. Benedetti FD ,
      4. Latten R , et al
      . Diagnosing dying in cancer patients-a systematic literature review. European Journal of Palliative Care 2013;20:292–6.
      OpenUrl
    19. 19.↵
      2. Haig S
      . Diagnosing dying: symptoms and signs of end-stage disease. End of Life Care Journal 2009;3.
    20. 20.↵
      2. Hall P ,
      3. Schroder C ,
      4. Weaver L
      . The last 48 hours of life in long-term care: a focused chart audit. J Am Geriatr Soc 2002;50:501–6.doi:10.1046/j.1532-5415.2002.50117.x
      OpenUrlCrossRefPubMedWeb of Science
    21. 21.↵
      2. Gonçalves JF ,
      3. Alvarenga M ,
      4. Silva A
      . The last forty-eight hours of life in a Portuguese palliative care unit: does it differ from elsewhere? J Palliat Med 2003;6:895–900.doi:10.1089/109662103322654776
      OpenUrlCrossRefPubMed
    22. 22.↵
      2. Lindley-Davis B
      . Process of dying. Defining characteristics. Cancer Nurs 1991;14:328–33.
      OpenUrlPubMed
    23. 23.↵
      2. Lichter I ,
      3. Hunt E
      . The last 48 hours of life. J Palliat Care 1990;6:7–15.doi:10.1177/082585979000600403
      OpenUrlPubMed
    24. 24.↵
      2. Kehl KA ,
      3. Kowalkowski JA
      . A systematic review of the prevalence of signs of impending death and symptoms in the last 2 weeks of life. Am J Hosp Palliat Care 2013;30:601–16.doi:10.1177/1049909112468222
      OpenUrlCrossRefPubMed
    25. 25.↵
      2. Taylor PM ,
      3. Johnson M
      . Recognizing dying in terminal illness. Br J Hosp Med 2011;72:446–50.doi:10.12968/hmed.2011.72.8.446
      OpenUrlCrossRef
    26. 26.↵
      2. Ellershaw J ,
      3. Ward C
      . Care of the dying patient: the last hours or days of life. Bmj 2003:326.
    27. 27.↵
      2. Plonk WM ,
      3. Arnold RM
      . Terminal care: the last weeks of life. J Palliat Med 2005;8:1042–54.doi:10.1089/jpm.2005.8.1042
      OpenUrlCrossRefPubMed
    28. 28.↵
      2. Domeisen Benedetti F ,
      3. Ostgathe C ,
      4. Clark J , et al
      . International palliative care experts' view on phenomena indicating the last hours and days of life. Support Care Cancer 2013;21:1509–17.doi:10.1007/s00520-012-1677-3
      OpenUrlCrossRefPubMedWeb of Science
    29. 29.↵
      2. Corkum M ,
      3. Viola R ,
      4. Veenema C , et al
      . Prognosticating in palliative care: a survey of Canadian palliative care physicians. J Palliat Care 2011;27:89–97.doi:10.1177/082585971102700204
      OpenUrlPubMedWeb of Science
    30. 30.↵
      2. van der Werff GF ,
      3. Paans W ,
      4. Nieweg RM
      . Hospital nurses' views of the signs and symptoms that herald the onset of the dying phase in oncology patients. Int J Palliat Nurs 2012;18:143–9.doi:10.12968/ijpn.2012.18.3.143
      OpenUrlPubMed
    31. 31.↵
      2. Kennedy C ,
      3. Brooks-Young P ,
      4. Brunton Gray C , et al
      . Diagnosing dying: an integrative literature review. BMJ Support Palliat Care 2014;4:263–70.doi:10.1136/bmjspcare-2013-000621
      OpenUrlAbstract/FREE Full Text
    32. 32.↵
      2. Hussain JA ,
      3. White IR ,
      4. Johnson MJ , et al
      . Analysing data in palliative care trials. BMJ 2018;362:k2943.doi:10.1136/bmj.k2943
      OpenUrlFREE Full Text
    33. 33.↵
      2. White N ,
      3. Harries P ,
      4. Harris AJ , et al
      . How do palliative care doctors recognise imminently dying patients? A judgement analysis. BMJ Open 2018;8:8.doi:10.1136/bmjopen-2018-024996
    34. 34.↵
      Marie Curie Palliative Care Research Department. Current Research Projects University College London. http://www.ucl.ac.uk/mcpcru/research_projects.
    35. 35.↵
      Department of Health. Mental Capacity Act. London: HSMO, 2005.
    36. 36.↵
      2. Scott S ,
      3. Jones L ,
      4. Blanchard MR , et al
      . Study Protocol: The Behaviour and Pain in Dementia Study (BePAID). BMC Geriatr 2011;11:1–8.doi:10.1186/1471-2318-11-61
      OpenUrlCrossRefPubMed
    37. 37.↵
      2. Sessler CN ,
      3. Gosnell MS ,
      4. Grap MJ , et al
      . The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002;166:1338–44.doi:10.1164/rccm.2107138
      OpenUrlCrossRefPubMedWeb of Science
    38. 38.↵
      2. Shehabi Y ,
      3. Bellomo R ,
      4. Reade MC , et al
      . Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med 2012;186:724–31.doi:10.1164/rccm.201203-0522OC
      OpenUrlCrossRefPubMedWeb of Science
    39. 39.↵
      Victoria Hospice Society. The Palliative Performance Scale. 2: Available from: http://www.palliative.org/newpc/professionals/tools/pps.html.
    40. 40.↵
      2. Glare P ,
      3. Sinclair C ,
      4. Downing M , et al
      . Predicting survival in patients with advanced disease. Eur J Cancer 2008;44:1146–56.doi:10.1016/j.ejca.2008.02.030
      OpenUrlCrossRefPubMedWeb of Science
    41. 41.↵
      2. Charlson M ,
      3. Szatrowski TP ,
      4. Peterson J , et al
      . Validation of a combined comorbidity index. J Clin Epidemiol 1994;47:1245–51.doi:10.1016/0895-4356(94)90129-5
      OpenUrlCrossRefPubMedWeb of Science
    42. 42.↵
      2. Christensen S ,
      3. Johansen MB ,
      4. Christiansen CF , et al
      . Comparison of Charlson comorbidity index with SAPS and APACHE scores for prediction of mortality following intensive care. Clin Epidemiol 2011;3:203–11.doi:10.2147/CLEP.S20247
      OpenUrlPubMed
    43. 43.↵
      2. Coyle N ,
      3. Adelhardt J ,
      4. Foley KM , et al
      . Character of terminal illness in the advanced cancer patient: pain and other symptoms during the last four weeks of life. J Pain Symptom Manage 1990;5:83–93.doi:10.1016/S0885-3924(05)80021-1
      OpenUrlCrossRefPubMed
    44. 44.↵
      2. Moens K ,
      3. Higginson IJ ,
      4. Harding R , et al
      . Are there differences in the prevalence of palliative care-related problems in people living with advanced cancer and eight non-cancer conditions? A systematic review. J Pain Symptom Manage 2014;48:660–77.doi:10.1016/j.jpainsymman.2013.11.009
      OpenUrlCrossRefPubMedWeb of Science
    45. 45.↵
      2. Hui D ,
      3. dos Santos R ,
      4. Chisholm GB , et al
      . Symptom Expression in the Last Seven Days of Life Among Cancer Patients Admitted to Acute Palliative Care Units. J Pain Symptom Manage 2015;50 488–94.doi:10.1016/j.jpainsymman.2014.09.003
      OpenUrl

    Footnotes

    • Contributors NW developed the study concept, design and aims, designed data collection tools, completed the data collection for the whole study, cleaned and analysed the data and drafted and revised the paper. FR developed the design and aims of the study, monitored the data collection tools for the observational study and data collection, aided in the analysis of the results and revised the paper. AJLH developed the study concept, design and aims, monitored data collection throughout the study, aided in the analysis plan and analysis of the results and revised the paper. PL, CMG, OM and AT assisted in the study design, aided the data collection for the observational study and revised the paper. PS and PH initiated the PhD study concept, developed the design and aims of the study, monitored the data collection tools for the entire study and data collection, monitored the analysis of the results and revised the paper. All authors approved the final version of the paper.

    • Funding Financial support for this study was provided by a UCL PhD studentship, by Marie Curie Care (MCCC-FPO-16-U) and the UCLH NIHR Biomedical Research Centre.

    • Competing interests None declared.

    • Ethics approval This study received ethical approval from West Midlands – Coventry and Warwickshire Research Ethics Committee in May 2014 (14/WM/0121).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement The dataset supporting the conclusions of this article is included within the article and its supplementary files.

    • Patient consent for publication Not required.