A test devised by Sydney researchers to determine the likelihood of a patient's death within the next 30 days will be trialled in local hospitals from March. 
 
 The Criteria for Screening and Triaging to Appropriate aLternative care, or CriSTAL, developed by University of New South Wales researcher Magnolia Cardona-Morrel, would take into account 29 different criteria to assess whether it was worthwhile carrying out life-saving treatments and procedures. 
 
 Careful criteria: The CriSTAL test is designed to help terminally ill and elderly patients choose whether to undergo further treatment. Photo: Greg Newington 
 
 Dr Cardona-Morrel said the test was designed to help doctors begin a conversation with terminally ill patients, particularly elderly patients, as to whether they would like to continue to receive treatment and where they would prefer to die. 
 
 "The test is easy to administer and the [answers] are readily available in the patient's clinical records and it can be completed in five or 10 minutes," she said. "The score by no means decides the treatment." 
 
 She said the aim of CriSTAL was to stop the common practice of terminally ill patients being put through unnecessary treatments and surgery in an attempt to save their lives. 
 
 "Doctors are keeping people alive because they can," Dr Cardona-Morrel said. "Hospitals are full of elderly people living longer because technology allows it. A lot of them would like to die at home." 
 
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 Dr Cardona-Morrel said the results of the test were designed as a tool for doctors to use in discussing the available options with patients. 
 
 "When a patient is diagnosed with a terminal illness their first question is always, 'Doctor, how long do I have left?," she said. 
 
 "Doctors see their role as to protect their patients so they don't like to give them sad or bad news." 
 
 The test, which was presented at a medical conference in the US recently, has been welcomed by medical professionals around the world. 
 
 "I had lots of nurses and doctors standing there saying, 'We have been waiting for a tool like this for years, when can we start using it?'" she said. 
 
 "To me that is an indication there is a need out there." 
 
 Once the score is determined the doctor could have a transparent conversation with the patient about their wishes. 
 
 She said once the score is determined the doctor could have a "transparent conversation" with the patient about their wishes and give them all the options available, including palliative care at home, or in a hospice. 
 
 The test is undergoing retrospective testing, looking at patients who have died and seeing if it would have been able to calculate the time they had left, before it is introduced into hospitals. 
 
 Dr Cardona-Morrel said the test was already being used in some Irish and US hospitals, and she hoped it would be in use in Australian hospitals by the end of the year. 
 
 Even though the test has not been designed for general practitioners to use, Dr Cardona-Morrel said she hoped it would encourage them to keep an eye out for the signs of a terminally ill patient and begin discussions about advanced care directives before the patient became too unwell. 
 
 The full list of criteria can be found in the paper by Dr Cardona-Morrell and Ken Hillman in the British Medical Journal. ||||| Researchers at the University of New South Wales, in Sydney, Australia, insist that the checklist does not intend to withhold treatment but said it intends to stop “intrusive, expensive and ultimately pointless medical procedures”. 
 
 The programme, dubbed CriSTAL (Criteria for Screening and Triaging to Appropriate alternative care), will be trialled in Sydney A&Es later this year to identify patients deemed likely to die within three months of going into hospital. 
 
 Among the points listed as risk factors is low blood pressure, a weak pulse, history of disease, dementia, repeat hospitalisation, weakness, heart failures and sudden weight loss. 
 
 Dr Magnolia Cardona-Morrell, who led the research at the university’s Simpson Centre for Health Services Research, said: “Most terminally ill people want to die at home, but in fact three quarters end up dying in acute hospitals, often after intrusive, expensive and ultimately pointless medical procedures. 
 
 The study's authors claim the list would improve care by enabling doctors to be honest about patients' chances with families and giving them greater choice “Current acute hospital systems often fail to recognise or cater to the needs of people for whom death is imminent and unavoidable. They are geared for aggressive treatment and emergency resuscitation, not peaceful, harm-free transitions. 
 
 “Elderly people who are dying need to be protected from heroic but intrusive live-saving hospital interventions that often only prolong suffering rather than enhance quality of remaining life.” 
 
 The checklist is only meant to be used for patients aged 65 or over and a number of factors must combine for death to be considered “unavoidable”. 
 
 A spokesperson for the University of New South Wales said CriSTAL had been compiled using an “extensive review of the strengths and weaknesses of medical literature that attempts to diagnose dying”. Most of the existing tools were found to rely on clinical judgment, subjective assessments and value judgments. 
 
 A paper describing the assessment procedure has been published in the BMJ Supportive and Palliative Care journal. 
 
 In it, Dr Cardona-Morrell and Ken Hillman, a professor of intensive care, argue that a balance must be struck between limited health resources, families’ expectations and the dignity of the patient. 
 
 CrisTAL is being trialled in selected hospital emergency departments in Sydney this year. The programme includes communication training for medical staff, so they can sensitively discuss with dying patients and their carers the limitations of medical treatment and their choices. 
 
 Dr Cardona-Morrell said medicine “cannot work miracles” against old age and multiple chronic conditions in elderly patients. 
 
 Her co-author Professor Hillman believes the management of elderly patients at the end of their lives is “one of the greatest challenges facing health care”. 
 
 “Most patients and their carers do not wish to be admitted to a hospital at the end of their life and this is a major contributor to the unsustainable costs of health care,” he said. 
 
 No such list exists in Britain but the director of Age UK said the move would be welcomed on the condition that discussions with relatives were handled “compassionately”. 
 
 “The best time to begin discussing end of life issues and an older person’s wishes is well in advance, when they are fit and well, but we acknowledge that this isn't always possible,” Caroline Abrahams added. 
 
 “The ability to accurately identify people entering hospital who are nearing the end of their lives ought to help ensure they receive high quality care, appropriate to their needs, so we welcome this development. 
 
 "However, in practice, access to good end of life care services remains extremely variable and discussions with older people and their families about this most difficult of subjects are not always handled sensitively and well.” ||||| A test to determine if elderly patients will die within 30 days of being admitted to hospital has been developed by doctors to give them the chance to go home or say goodbye to loved ones. 
 
 Health experts say the checklist will prevent futile and expensive medical treatments which merely prolong suffering. 
 
 The screening test looks at 29 indicators of health, including age, frailty, illness, mental impairment, previous emergency admissions and heart rate and produces a percentage chance of death within one month and 12 weeks. 
 
 Researchers say the aim of Critera for Screening and Triaging to Appropriate aLternative care, or CriSTAL for short, is to kick-start frank discussions about end of life care, and minimise the risk of invasive ineffective treatment. 
 
 “Delaying unavoidable death contributes to unsustainable and escalating healthcare costs, despite aggressive and expensive interventions,” said lead author Dr Magnolia Cardona-Morrel, a researcher at the University of New South Wales. 
 
 “These interventions may not influence patient outcome; often do not improve the patient’s quality of life; may compromise bereavement outcomes for families; and cause frustration for health professionals.” 
 
 Earlier this week Professor Sir Mike Richards, the Chief Inspector of Hospitals for the Care Quality Commission, warned that dying patients are receiving wide variations in care because of hospital failure to replace the Liverpool Care Pathway. 
 
 The controversial end-of-life plan was scrapped after a review of the regime found that hospital staff wrongly interpreted its guidance for care of the dying, leading to patients being drugged and deprived of fluids in their last weeks of life. 
 
 The Health Select Committee is currently examining palliative and end of life care in the wake of the LCP controversy. 
 
 However the new test aims to provide a ‘starting point’ for ‘honest communication with patients and families about recognising that dying is part of the life cycle’ 
 
 Researchers looked at 112 peer-reviewed studies to find out which tests and questions were the best predictors of death. 
 
 They claim the test will help doctors and nurses who are often under great pressure from family members and society to prolong the life of patients at all costs. 
 
 “While there are accepted policies for de-escalating treatment in terminally ill patients, there are also inherent and societal pressures on medicine to continue utilising technological advances to prolong life even in plainly futile situations,” said Dr Cardona-Morrel. 
 
 “Training for nurses and doctors in the use of the screening tool and in approaching patients and families with concrete information about inevitability of death and lack of benefit of further intensive treatment are paramount.” 
 
 Most patients end up dying in hospital, even though that is not their stated preference, when asked. 
 
 Caroline Abrahams, Charity Director at Age UK, said:“The best time to begin discussing end of life issues and an older person’s wishes, is well in advance, when they are fit and well, but we acknowledge that this isn’t always possible. 
 
 “The ability to accurately identify people entering hospital who are nearing the end of their lives ought to help ensure they receive high quality care, appropriate to their needs, so we welcome this development. However, in practice, access to good end of life care services remains extremely variable and discussions with older people and their families about this most difficult of subjects are not always handled sensitively and well. 
 
 “So as well as improved analysis and triage of people’s needs, better training and support for medical staff in speaking compassionately with older people and their families about end of life care is also required. “ 
 
 By giving families and patients some options about the preferred place of death, the test could also help terminally ill elderly people choose to go home, the authors said. 
 
 The checklist is yet to be tested but the researchers hope it will eventually be used for all hospital admissions. 
 
 The research was published in the BMJ Open publication Supportive & Palliative Care. ||||| While many would rather not think about when someone might die, knowing how much longer a seriously ill person has left to live can be very useful for managing how they spend their final days. Researchers have now revealed eight signs in patients with advanced cancer associated with death within 3 days. 
 
 
 
 The ability to accurately diagnose impending death in patients would be beneficial to clinicians, patients and their families. The ability to accurately diagnose impending death in patients would be beneficial to clinicians, patients and their families. 
 
 Diagnosis of an impending death can help clinicians, patients and their friends and family to make important decisions. Doctors can spare time and resources by stopping daily bloodwork and medication that will not make a short-term difference. Families will know if they still have time to visit their relatives. 
 
 "This study shows that simple bedside observations can potentially help us to recognize if a patient has entered the final days of life," says study author Dr. David Hui. 
 
 "Upon further confirmation of the usefulness of these 'tell-tale' signs, we will be able to help doctors, nurses, and families to better recognize the dying process, and in turn, to provide better care for the patients in the final days of life." 
 
 The study, published in Cancer, follows on from the Investigating the Process of Dying Study - a longitudinal observational study that documented the clinical signs of patients admitted to an acute palliative care unit (APCU). During the study, the researchers identified five signs that were highly predictive of an impending death within 3 days. 
 
 For the new study, the researchers again observed the physical changes in cancer patients admitted to two APCUs - at the MD Anderson Cancer Center in Houston, TX, and the Barretos Cancer Hospital in Brazil. 
 
 Eight highly-specific physical signs were identified 
 
 A total of 357 cancer patients participated in the study. The researchers observed them and documented 52 physical signs every 12 hours following their admission to the APCUs. The patients were observed until they died or were discharged from the hospitals, with 57% dying during the study. 
 
 The researchers found eight highly-specific physical signs identifiable at the bedside that strongly suggested that a patient would die within the following 3 days if they were present. The signs identified were: 
 
 Decreased response to verbal stimuli 
 
 Decreased response to visual stimuli 
 
 Drooping of "smile lines" 
 
 Grunting of vocal cords 
 
 Hyperextension of neck 
 
 Inability to close eyelids 
 
 Non-reactive pupils 
 
 Upper gastrointestinal bleeding. 
 
 With the exception of upper gastrointestinal bleeding, all of these signs are related to deterioration in neurocognitive and neuromuscular function. 
 
 Neurological decline strongly associated with death 
 
 "The high specificity suggests that few patients who did not die within 3 days were observed to have these signs," the authors write. "These signs were commonly observed in the last 3 days of life with a frequency in patients between 38% and 78%. Our findings highlight that the progressive decline in neurological function is associated with the dying process." 
 
 As the study is limited by only examining cancer patients admitted to APCUs, it is not known whether these findings will apply to patients with different types of illness. The findings are currently being evaluated in other clinical settings such as inpatient hospices. 
 
 On account of the relatively small number of patients observed for this study, the authors also suggest that their findings should be regarded as preliminary until validated by further research. 
 
 In the meantime, the authors of the study are working to develop a diagnostic tool to assist clinical decision-making and educational materials for both health care professionals and patients' families. 
 
 "Upon further validation, the presence of these telltale signs would suggest that patients [...] are actively dying," they conclude. "Taken together with the five physical signs identified earlier, these objective bedside signs may assist clinicians, family members, and researchers in recognizing when the patient has entered the final days of life." 
 
 Recently, Medical News Today reported on a study finding that colorectal cancer survivors who smoke have more than twice the risk of death compared to those that do not smoke. ||||| Study identifies clinical signs suggestive of impending death in patients with advanced cancer 
 
 09 Feb 2015 
 
 While the diagnosis of an impending death is always sad, it can be important for patients, families, and clinicians as they make decisions related to hospital discharge, hospice referral, and treatments. 
 
 Now a new study published early online in Cancer, has revealed eight highly specific physical signs associated with death within three days in cancer patients. 
 
 When a patient has entered the final days of life, it makes sense to stop daily bloodwork and potentially futile medications, and to focus on comfort care. 
 
 Knowing whether the patient is imminently dying can also inform many personal decisions for family caregivers, such as whether a wife wants to stay overnight in the hospital and whether a son still has time to fly in to see his father. 
 
 Unfortunately, very few studies have examined the signs of impending death, making it difficult for healthcare professionals to make a diagnosis with confidence and to communicate this with the family. 
 
 To address this, David Hui, MD, MSc, of the MD Anderson Cancer Center, and his colleagues recorded the physical changes in the final days of life in 357 cancer patients who were admitted to acute palliative care units in two cancer centers: MD Anderson Cancer Center in Houston and Barretos Cancer Hospital in Brazil. 
 
 The investigators systematically documented 52 physical signs every 12 hours from admission to death or discharge. 
 
 During the study, 57 percent of the patients died. 
 
 The researchers identified eight bedside physical signs that, if present, strongly suggest that a patient will die within three days. 
 
 The signs include non-reactive pupils, decreased response to verbal stimuli, decreased response to visual stimuli, inability to close eyelids, drooping of the nasolabial fold (which makes the face appear more relaxed), hyperextension of the neck (in which the head tilts back when the patient is lying down), grunting of vocal cords, and upper gastrointestinal bleed. 
 
 These signs may help doctors and nurses to make the diagnosis of impending death. 
 
 “This study shows that simple bedside observations can potentially help us to recognise if a patient has entered the final days of life,” said Dr Hui. 
 
 “Upon further confirmation of the usefulness of these ‘tell-tale’ signs, we will be able to help doctors, nurses, and families to better recognise the dying process, and in turn, to provide better care for the patients in the final days of life.” 
 
 Based on the study’s findings, Dr Hui and his team are now creating some educational materials to help healthcare professionals and families recognise when a patient has entered the final days of life, and they are developing a diagnostic tool of impending death based on these physical signs to support clinical decision making. 
 
 While the findings are relevant for clinicians who care for dying cancer patients, it’s unclear whether they also translate outside of cancer centres. 
 
 Therefore, the investigators are in the process of validating their results in other healthcare settings, such as home and inpatient hospice. 
 
 Reference 
 
 David Hui, Renata dos Santos, Gary Chisholm et al., Bedside clinical signs associated with impending death in patients with advanced cancer: Preliminary findings of a prospective longitudinal cohort study. Cancer, published Online: February 9, 2015 
 
 Source: Wiley
– Seniors had better brace themselves: Some US hospitals are now administering the "death test," which estimates an elderly patient's chance of dying over the next 30 days. Invented in Australia, the test weighs 29 different criteria—including blood pressure, respiratory rate, and medical history—to determine whether hospitalization is worthwhile or the patient should return home or go to a hospice, the Sydney Morning Herald reports. The idea is to prevent needless and expensive procedures while allowing patients to spend their last days with loved ones. "Most terminally ill people want to die at home, but in fact three quarters end up dying in acute hospitals, often after intrusive, expensive, and ultimately pointless medical procedures," says study author Magnolia Cardona-Morrell, the Independent reports. The test also aims to take pressure off doctors and nurses to prolong patients' lives "at all costs," the Telegraph reports. "I had lots of nurses and doctors standing there saying, 'We have been waiting for a tool like this for years, when can we start using it?'" says Cardona-Morrell, whose work was presented recently at a US medical conference. "To me that is an indication there is a need out there." She says the test takes just five or 10 minutes, and helps doctors have a more "transparent" conversation with patients. Called CriSTAL, it's now being tested to see if it would have predicted the future of patients who have since died. Then it may be used in more hospitals. (In related news, a study says those who feel younger than their age will live longer.)