• Sebastian Bruera, Gary Chisholm, Renata Dos Santos, Eduardo Bruera, and David Hui.
• Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
• J Pain Symptom Manage. 2015 May 1; 49 (5): 822-7.

ContextFew studies have examined the frequency of unexpected death and its associated factors in a palliative care setting.ObjectivesTo determine the frequency of unexpected death in two acute palliative care units (APCUs); to compare the frequency of signs of impending death between expected and unexpected deaths; and to determine the predictors associated with unexpected death.MethodsIn this prospective, longitudinal, observational study, consecutive patients admitted to two APCUs were enrolled and physical signs of impending death were documented twice daily until discharge or death. Physicians were asked to complete a survey within 24 hours of APCU death. The death was considered unexpected if the physician answered "yes" to the question "Were you surprised by the timing of the death?"ResultsIn total, 193 of 203 after-death assessments (95%) were collected for analysis. Nineteen of 193 patients died unexpectedly (10%). Signs of impending death, including non-reactive pupils, inability to close eyelids, decreased response to verbal stimuli, drooping of nasolabial folds, peripheral cyanosis, pulselessness of the radial artery, and respiration with mandibular movement, were documented more frequently in expected deaths than unexpected deaths (P < 0.05). Longer disease duration was associated with unexpected death (33 months vs. 12 months, P = 0.009).ConclusionUnexpected death occurred in an unexpectedly high proportion of patients in the APCU setting and was associated with fewer signs of impending death. Our findings highlight the need for palliative care teams to be prepared for the unexpected.Copyright © 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

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