Table 20Summary of evidence: Theme 3 - difficulty in recognising dying- health care professionals experiences in recognising adults that are likely to be entering their final days of life or who may be recovering, and how the uncertainties about either situation can dealt with

Study design and sampleDescriptors of themesQuality assessment
No. of studiesDesignCriteriaRatingOverall
Sub-theme 1: Complexity of recognising dying
32 interviews
1 Delphi study		Two qualitative studies29,99 interviewed nursing staff with experience of caring for oncology patients in the last days of life. They described the complexity of recognising dying and acknowledged the importance of their intuition rather than people's presentations.
  • ‘“I hardly ever see a transition or something like that, that makes me think: these are the final days [for that patient]”’
  • 84% of nurses in 1 study acknowledged that death had occasionally ‘“caught them by surprise”’
  • The importance of intuition in recognising people entering the last days of life.
This was further reflected in 1 Delphi study12 that asked all healthcare professionals and lay members (n=252) to identify the symptoms they found relevant in recognising people in the last hours and days of life dying from all conditions. They identified ‘the intuition of professional, gut feeling’ as relevant in recognising people entering the end of life.		Limitations of evidenceMinor limitationsMODERATE
Coherence of findingsCoherent
Applicability of evidenceApplicable
Theme saturation/sufficiencySaturated
Sub-theme 2: Factors that affect prognostic accuracy
22 surveysTwo surveys2,22 explored the factors that improved doctors' ability to recognise dying people, through questions relating to the person, and their relationship with the doctor. One study found that only 20% of the diagnoses were accurate, 63% underestimated the survival time of the person and 17% over estimated. The study showed statistically significant relationships after multivariate analysis between:
  • doctors in non-oncological medical subspecialties were the least likely to give correct estimates
  • predications that overestimated the survival time were associated with the most recent examinations and longer patient doctor relationships
  • no relationship found between accuracy and number of years of practice of the doctor and the number of hospice referrals that doctor had made in the past year.
A further survey found an association between patient factors and accuracy in recognising dying in the near future. On multivariate analysis a diagnosis of cancer and low functional states both increased the chance of recognising death in the near future. Death in the near future was not recognised 3 times as often among people with cardiorespiratory (26%) and other (43%) illnesses compared to cancer (12%).		Limitations of evidenceMinor limitationsMODERATE
Coherence of findingsCoherent
Applicability of evidenceApplicable
Theme saturation/sufficiencySaturated

From: 5, Recognising when a person may be in the last days of life

Cover of Care of Dying Adults in the Last Days of Life
Care of Dying Adults in the Last Days of Life.
NICE Guideline, No. 31.
National Clinical Guideline Centre (UK).
Copyright © 2015 National Clinical Guideline Centre.

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