Physical examination (PE) provides practical clinical information for prognosis and symptom assessment, which may improve communication and decision-making regarding palliative therapies, disposition, and whether family members wish to remain at bedside.
• Recent studies in terminal cancer patients have correlated five clinical signs (loss of radial pulse, mandibular movement during breathing, anuria, Cheyne-Stokes breathing, excessive oral secretions) with death in < 3 days
. Yet, only about half of the studied patients displayed any of these 5 signs (low sensitivity). So, while their presence may correlate with death within 3 days, their absence does NOT permit the opposite conclusion.
• Neurologic and neuro-muscular signs that have been correlated with death within 3 days
include: non-reactive pupils; decreased response to verbal/visual stimuli; inability to close the eyelids; drooping of both nasolabial folds (face may appear more relaxed); neck hyperextension (head tilted back when supine); and grunting of vocal cords, chiefly on expiration.
• Decreased performance status, dysphagia, and decreased oral intake constitute more commonly encountered, “early” clinical signs suggesting a prognosis of 1-2 weeks or less
. Encourage family to stay at the bedside during the PE to explain findings in lay-person language during the process.
The following is a list of targeted elements in addition to the signs already mentioned.
• General appearance
: Does the patient interact with their environment? Is there a malodor that could suggest gangrene, anaerobic infection, uremia, or hepatic failure? Is the body transverse to the bed? Would adjustment of head position, trunk, or limbs ease muscle tension, discomfort, or dyspnea?
• Vital signs
: Imminent death has been correlated with varying blood pressure, tachypnea (respiratory rate >24), tachycardia, inappropriate bradycardia, fever, and hypothermia.
: Evaluate for peripheral cyanosis, which is strongly correlated with imminent death, or proximal mottling (e.g., knees) that hints at approaching death.
• Head, eyes, ears, nose, and throat
: Drooping eyelids or a bilateral facial droop may suggest imminent death, and an acetone or musky smell is common.
: Evaluate the breathing pattern: apneic pauses, Cheyne-Stokes respirations, and deep, labored rapid breaths (Kussmaul respirations) are associated with imminent death.
: Unless peripheral pulses are impalpable and one seeks rate and rhythm, listening to the heart may not always be warranted. Evaluate distal extremities, especially the toes for insight into perfusion and volume status.
: If only the briefest survival is expected, a targeted exam to assess for bowel sounds, distention, and the presence of uncomfortable ascites can sufficiently guide the bowel regimen and ascites management.
: Indications for these examinations are uncommon, but may include concern for fecal impaction, scrotal edema, bladder fullness, or genital skin infections.
: Painful spasms or excess tonus may be treated with benzodiazepine, a muscle relaxant, topical heat, or massage.
• Neurologic and neuromuscular
: Myoclonus or seizure could suggest the need for a rescue benzodiazepine and/or the presence of opioid-induced neurotoxicity; but these are not strong predictors of imminent death. Mid-size pupils suggest that obtundation is due to imminence of death rather than a pharmacologic origin. Large and asymmetrically nonreactive pupils may be a dire warning for imminent death from brain herniation.
• Mental status
: Evaluate delirium and prognosis via a targeted assessment of the level of consciousness, affective state, and sensorium.
: Evaluate for significant decreases in urine output. A meconium-like stool odor has been associated with imminent death in dementia populations.
See reference for more information.
Adapted from Schneiderman N, Marks S. Physical examination of the dying patient. Palliative Care Network of Wisconsin. Fast facts and concepts #392. Internet. Available at https://www.mypcnow.org/fast-fact/physical-examination-of-the-dying-patient/. Accessed on January 25, 2020