BMJ 348: g1219, 2014. Hui D, Nooruddin Z, Didwaniya N, et al. Lloyd-Williams M, Payne S: Can multidisciplinary guidelines improve the palliation of symptoms in the terminal phase of dementia? Gebska et al. Patients may agree to enroll in hospice in the final days of life only after aggressive medical treatments have clearly failed. : Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. WebCarotid sinus syncope: This type of syncope can happen when the carotid artery in the neck is constricted (pinched). Injury can range from localized paralysis to complete nerve or spinal cord damage. 17. J Clin Oncol 28 (28): 4364-70, 2010. Glisch C, Saeidzadeh S, Snyders T, et al. Know the causes, symptoms, treatment and recovery time of Raijmakers NJ, Fradsham S, van Zuylen L, et al. Prognostic Value:For centuries, experts have been searching for PE signs that predict imminence of death (3-5). Rationale for an attentive PE for the dying:Naturally, many clinicians wish to avoid imposing on the dyingpatient (1). However, when the results of published studies of symptoms experienced by patients with advanced cancer are being interpreted or compared, the following methodological issues need to be considered:[1]. CMAJ 184 (7): E360-6, 2012. The Medicare hospice benefit requires that physicians certify patients life expectancies that are shorter than 6 months and that patients forgo curative treatments. : Parenteral antibiotics in a palliative care unit: prospective analysis of current practice. [17] The investigators screened 998 patients from the palliative and supportive care unit and randomly assigned 68 patients who met the inclusion criteria for having agitated delirium refractory to scheduled haloperidol 1 to 8 mg/day to three intervention groups: haloperidol 2 mg every 4 hours, chlorpromazine 25 mg every 4 hours, or haloperidol 1 mg combined with chlorpromazine 12.5 mg every 4 hours. Extracorporeal:Evaluate for significant decreases in urine output. Arch Intern Med 172 (12): 964-6, 2012. [35] For a more complete review of parenteral administration of opioids and opioid rotation, see Cancer Pain. [, Decisions to transfuse red cells should be based on symptoms and not a trigger value. Keating NL, Landrum MB, Rogers SO, et al. Teno JM, Shu JE, Casarett D, et al. It is caused by damage from the stroke. J Clin Oncol 30 (20): 2538-44, 2012. Aldridge Carlson MD, Barry CL, Cherlin EJ, et al. J Palliat Med 23 (7): 977-979, 2020. A small pilot trial randomly assigned 30 Chinese patients with advanced cancer with unresolved breathlessness to either usual care or fan therapy. Arch Intern Med 172 (12): 966-7, 2012. Preparations include the following: For more information, see the Symptoms During the Final Months, Weeks, and Days of Life section. : Predictors of Location of Death for Children with Cancer Enrolled on a Palliative Care Service. [30], The administration of anti-infectives, primarily antibiotics, in the last days of life is common, with antibiotic use reported in patients in the last week of life at rates ranging from 27% to 78%. In conclusion, bedside physical signs may be useful in helping clinicians diagnose impending death with greater confidence, which can, in turn, assist in clinical decision making and communication with families. Barriers are summarized in the following subsections on the basis of whether they arise predominantly from the perspective of the patient, caregiver, physician, or hospice, including eligibility criteria for enrollment. Board members will not respond to individual inquiries. Negative effects included a sense of distraction and withdrawal from patients. Mack JW, Cronin A, Keating NL, et al. Vital signs: Imminent death has been correlated with varying blood pressure, tachypnea (respiratory rate >24), tachycardia, inappropriate bradycardia, fever, and hypothermia (6). Ventilator rate, oxygen levels, and positive end-expiratory pressure are decreased gradually over a period of 30 minutes to a few hours. Opioids are often considered the preferred first-line treatment option for dyspnea. J Pain Symptom Manage 26 (4): 897-902, 2003. : Olanzapine vs haloperidol: treating delirium in a critical care setting. 11 A number of highly specific clinical signs can be used to help clinicians establish the diagnosis of impending death (i.e., death within days). Crit Care Med 27 (1): 73-7, 1999. Education and support for families witnessing a loved ones delirium are warranted. Published in 2013, a prospective observational study of 64 patients who died of cancer serially assessed symptoms, symptom intensity, and whether symptoms were unbearable. [19] Communication with patients and surrogates to determine goal-concordant care in the setting of terminal or hyperactive delirium is imperative to ensure that sedation is an intended outcome of this protocol in which symptom reduction is the primary intention of the intervention. : Alleviating emotional exhaustion in oncology nurses: an evaluation of Wellspring's "Care for the Professional Caregiver Program". Thus, the family will benefit from learning about the nature of this symptom and that death rattle is not associated with dyspnea. [20] Family members at the bedside may find these hallucinations disconcerting and will require support and reassurance. Hui D, Frisbee-Hume S, Wilson A, et al. It is intended as a resource to inform and assist clinicians in the care of their patients. The principle of double effect is based on the concept of proportionality. Hudson PL, Kristjanson LJ, Ashby M, et al. Am J Hosp Palliat Care 27 (7): 488-93, 2010. Schonwetter RS, Roscoe LA, Nwosu M, et al. The authors hypothesized that clinician predictions of survival may be comparable or superior to prognostication tools for patients with shorter prognoses (days to weeks of survival) and may become less accurate for patients who live for months or longer. The goal of this strategy is to provide a bridge between full life-sustaining treatment (LST) and comfort care, in which the goal is a good death. Rescue doses equivalent to the standing dose were allowed every 1 hour as needed and once at protocol initiation, with the goal of producing sedation with a Richmond Agitation-Sedation Scale (RASS) score of 0 to 2. The eight identified signs, including seven neurologic conditions and one bleeding complication, had 95% or higher specificity and likelihood ratios from 6.7 to 16.7 For example, an oncologist may favor the discontinuation or avoidance of LST, given the lack of evidence of benefit or the possibility of harmincluding increasing the suffering of the dying person by prolonging the dying processor based on concerns that LST interferes with the patient accepting that life is ending and finding peace in the final days. Clinical signs of impending death in cancer patients. Rattle does not appear to be distressing for the patient; however, family members may perceive death rattle as indicating the presence of untreated dyspnea. : Pharmacologic paralysis and withdrawal of mechanical ventilation at the end of life. JAMA 284 (22): 2907-11, 2000. Palliat Med 25 (7): 691-700, 2011. Specific studies are not available. [27] The outcome measures included a self-report measure of breathlessness, respiratory rate, and measured oxygen saturation. : Care strategy for death rattle in terminally ill cancer patients and their family members: recommendations from a cross-sectional nationwide survey of bereaved family members' perceptions. In a survey of the attitudes and experiences of more than 1,000 U.S. physicians toward intentional sedation to unconsciousness until death revealed that 68% of respondents opposed palliative sedation for existential distress. Palliat Support Care 9 (3): 315-25, 2011. Ford DW, Nietert PJ, Zapka J, et al. Is there a malodor which could suggest gangrene, anerobic infection, uremia, or hepatic failure? Is physician awareness of impending death in hospital related to better communication and medical care? Bioethics 27 (5): 257-62, 2013. [21] Requests for artificial hydration or the desire for discussions about the role of artificial hydration seem to be driven by quality-of-life considerations as much as considerations for life prolongation. [20] The median survival of the cohort was 20 days (range, 184 days); the mean volume of parenteral hydration was 912 495 mL/day. Hales S, Chiu A, Husain A, et al. : How people die in hospital general wards: a descriptive study. At study enrollment, the investigators calculated the scores from the three prognostication tools for 204 patients and asked the units palliative care attending physician to estimate each patients life expectancy (014 days, 1542 days, or over 42 days). The study was limited by a small sample size and the lack of a placebo group. Cancer. J Pain Symptom Manage 57 (2): 233-240, 2019. Sanchez-Reilly S, Morrison LJ, Carey E, et al. : Quality of life and symptom control in hospice patients with cancer receiving chemotherapy. Epilepsia 46 (1): 156-8, 2005. The ESAS is a patient-completed measure of the severity of the following nine symptoms: Analysis of the changes in the mean symptom intensity of 10,752 patients (and involving 56,759 assessments) over time revealed two patterns:[2]. There were no changes in respiratory rates or oxygen saturations in either group. : The use of crisis medication in the management of terminal haemorrhage due to incurable cancer: a qualitative study. Support Care Cancer 9 (3): 205-6, 2001. A prospective study of 232 adults with terminal cancer admitted to a hospice and palliative care unit in Taiwan indicated that fever was uncommon and of moderate severity (mean score, 0.37 on a scale of 13). Then it gradually starts to close, until it is fully Closed at -/+ 22. Burnout has also been associated with unresolved grief in health care professionals. Patients who preferred to die at home were more likely to do so (56% vs. 37%; OR, 2.21). Hui D, Kilgore K, Nguyen L, et al. Swan neck deformity is a musculoskeletal manifestation of rheumatoid arthritis presenting in a digit of the hand, due to the combination of:. : A clinical study examining the efficacy of scopolamin-hydrobromide in patients with death rattle (a randomized, double-blind, placebo-controlled study). Making the case for patient suffering as a focus for intervention research. Conversely, some situations may warrant exploring with the patient and/or family a time-limited trial of intensive medical treatments. While the main objective in the decision to use antimicrobials is to treat clinically suspected infections in patients who are receiving palliative or hospice care,[62-64][Level of evidence: II] subsequent information suggests that the risks of using empiric antibiotics do not appear justified by the possible benefits for people near death.[65]. A database survey of patient characteristics and effect on life expectancy. J Support Oncol 11 (2): 75-81, 2013. replace or update an existing article that is already cited. Physicians who chose mild sedation were guided more by their assessment of the patients condition.[11]. There are few randomized controlled trials on the management of delirium in patients with terminal or irreversible delirium. Kadakia KC, Hui D, Chisholm GB, Frisbee-Hume SE, Williams JL, Bruera E. Cancer patients perceptions regarding the value of the physical examination: a survey study. J Rural Med. [13] Reliable data on the frequency of requests for hastened death are not available. Palliat Med 20 (7): 693-701, 2006. : Anti-infective therapy at the end of life: ethical decision-making in hospice-eligible patients. With a cervical artery dissection, the neck pain is unusual, persistent, and often accompanied by a severe headache, says Dr. Rost. : Wide variation in content of inpatient do-not-resuscitate order forms used at National Cancer Institute-designated cancer centers in the United States. The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. : To die, to sleep: US physicians' religious and other objections to physician-assisted suicide, terminal sedation, and withdrawal of life support. Higher functional status as measured by the Palliative Performance Scale (OR, 0.53). Reinbolt RE, Shenk AM, White PH, et al. [10] Care of the patient with delirium can include stopping unnecessary medications, reversing metabolic abnormalities (if consistent with the goals of care), treating the symptoms of delirium, and providing a safe environment. Medications, particularly opioids, are another potential etiology. J Clin Oncol 32 (28): 3184-9, 2014. There are many potential barriers to timely hospice enrollment. The most common adverse event was hypotension, which was seen in 40% of patients in the haloperidol group, 31% of those in the chlorpromazine group, and 21% of those in the combination group. Relaxed-Fit Super-High-Rise Cargo Short 4" in bold beige (photo via Lululemon) These utility-inspired, super-high-rise shorts have spacious cargo pockets to hold your keys, phone, wallet, and then some. : Trends in the aggressiveness of cancer care near the end of life. WebEffect of hyperextension of the neck (rose position) on cerebral blood oxygenation in patients who underwent cleft palate reconstructive surgery: prospective cohort study using near-infrared spectroscopy. The PDQ Supportive and Palliative Care Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations. Cancer 101 (6): 1473-7, 2004. Ultimately, the decision to initiate, continue, or forgo chemotherapy should be made collaboratively and is ideally consistent with the expected risks and benefits of treatment within the context of the patient's goals of care. : Frequency, Outcomes, and Associated Factors for Opioid-Induced Neurotoxicity in Patients with Advanced Cancer Receiving Opioids in Inpatient Palliative Care. In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. Of the 68 randomized patients, 45 patients were treated and monitored until death or discharge. Meier DE, Back AL, Morrison RS: The inner life of physicians and care of the seriously ill. JAMA 286 (23): 3007-14, 2001. At least one hospice visit per day in the first 4 days (61% vs. 54%; OR, 1.23). Likar R, Rupacher E, Kager H, et al. Our syndication services page shows you how. Crit Care Med 29 (12): 2332-48, 2001. Yet, PE routinely 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 (2). N Engl J Med 342 (7): 508-11, 2000. Lancet 383 (9930): 1721-30, 2014. Preston NJ, Hurlow A, Brine J, et al. WebProspective studies have monitored clinical signs in advanced cancer patients approaching death and found 13 indicators with high sensitivity (>95%) and positive likelihood ratios (>5) in the last 72 hours of life. The lower part of the neck, just above the shoulders, is particularly vulnerable to pain caused by forward head posture. Such rituals might include placement of the body (e.g., the head of the bed facing Mecca for an Islamic patient) or having only same-sex caregivers or family members wash the body (as practiced in many orthodox religions). Fast Facts are not continually updated, and new safety information may emerge after a Fast Fact is published. Several studies have categorized caregiver suffering with the use of dyadic analysis. J Pain Symptom Manage 50 (4): 488-94, 2015. The primary outcome of RASS score reduction was measured 8 hours after administration of the study drug. Poseidon Press, 1992. Granek L, Tozer R, Mazzotta P, et al. Headlines about a woman who suffered a stroke after getting her hair shampooed at a salon may have sounded like a crazy story right out of a tabloid, but its actually possible. 4. Scores on the Palliative Performance Scale also decrease rapidly during the last 7 days of life. For more information, see the Impending Death section. [1] From an ethical standpoint, withdrawing treatment is equivalent to withholding such treatment. J Clin Oncol 32 (31): 3534-9, 2014. Vancouver, WA: BK Books; 2009 (original publication 1986). Clayton J, Fardell B, Hutton-Potts J, et al. [3] Other terms used to describe professional suffering are moral distress, emotional exhaustion, and depersonalization. [4] For more information, see Informal Caregivers in Cancer: Roles, Burden, and Support. The Respiratory Distress Observation Scale is a validated tool to identify when respiratory distress could benefit from as-needed intervention(s) in those who cannot report dyspnea (14). Wildiers H, Dhaenekint C, Demeulenaere P, et al. To ensure that the best interests of the patientas communicated by the patient, family, or surrogate decision makerdetermine the decisions about LSTs, discussions can be organized around the following questions: Medicine is a moral enterprise. JAMA 272 (16): 1263-6, 1994. Lack of standardization in many institutions may contribute to ineffective and unclear discussions around DNR orders.[44]. J Clin Oncol 30 (12): 1378-83, 2012. Psychosomatics 43 (3): 183-94, 2002 May-Jun. Mental status:Evaluate delirium and prognosis via a targeted assessment of the level of consciousness, affective state, and sensorium. J Cancer Educ 27 (1): 27-36, 2012. This could be the result of disease, a fracture of the spine, a tumor located on or near the spine, or a significant injury such as a gunshot wound. People often believe that there is plenty of time to discuss resuscitation and the surrounding issues; however, many dying patients do not make choices in advance or have not communicated their decisions to their families, proxies, and the health care team. Documented symptoms, including pain, dyspnea, fever, lethargy, and altered mental state, did not differ in the group that received antibiotics, compared with the patients who did not. Methylphenidate may be useful in selected patients with weeks of life expectancy. The full set of Fast Facts are available at Palliative Care Network of Wisconsin with contact information, and how to reference Fast Facts. A significant proportion (approximately 30%) of patients with advanced cancer continue to receive chemotherapy toward the end of life (EOL), including a small number (2%5%) who receive their last dose of chemotherapy within 14 days of death. Furthermore, clinicians are at risk of experiencing significant grief from the cumulative effects of many losses through the deaths of their patients. [8,9], Impending death is a diagnostic issue rather than a prognostic phenomenon because it is an irreversible physiological process. : Randomized double-blind trial of sublingual atropine vs. placebo for the management of death rattle. They also suggested that enhanced screening for depression in patients with cancer may impact hospice enrollment and quality of care provided at the EOL. : Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. [26,27], The decisions about whether to provide artificial nutrition to the dying patient are similar to the decisions regarding artificial hydration. Family members and others who are present should be warned that some movements may occur after extubation, even in patients who have no brain activity. The Airway is fully Open between - 5 and + 5 degrees. Arch Intern Med 171 (3): 204-10, 2011. When specific information about the care of children is available, it is summarized under its own heading. MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. [2], Some patients, family members, and health care professionals express concern that opioid use may hasten death. The treatment of potential respiratory infections with antibiotics likewise calls for a consideration of side effects and risks. J Pediatr Hematol Oncol 23 (8): 481-6, 2001. : Comparing the quality of death for hospice and non-hospice cancer patients. : The terrible choice: re-evaluating hospice eligibility criteria for cancer. Wee B, Hillier R: Interventions for noisy breathing in patients near to death. [34] Patients willing to forgo chemotherapy did not have different levels of perceived needs. [19] There were no differences in survival, symptoms, quality of life, or delirium. For infants, the Airway is also closed when the head is tilted too far backwards. Observing spontaneous limb movement and face symmetry takes but a moment. Suffering was characterized as powerlessness, threat to the caregivers identity, and demands exceeding resources. 11. Despite their limited ability to interact, patients may be aware of the presence of others; thus, loved ones can be encouraged to speak to the patient as if he or she can hear them. Harris DG, Noble SI: Management of terminal hemorrhage in patients with advanced cancer: a systematic literature review. 2015;121(21):3914-21. : Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. Breitbart W, Tremblay A, Gibson C: An open trial of olanzapine for the treatment of delirium in hospitalized cancer patients. [12,14,15], Patients with advanced cancer who receive hospice care appear to experience better psychological adjustment, fewer burdensome symptoms, increased satisfaction, improved communication, and better deaths without hastening death. WebNeck Hyperextended. Results of a retrospective cohort study. The reflex is initiated by stimulation of peripheral cough receptors, which are transmitted to the brainstem by the vagus nerve. It's most often due to car accidents, often as a result of being rear-ended, but less commonly may be caused by sports injuries or falls. A decline in health that was too rapid to allow earlier use of hospice (55%). : Depression and Health Care Utilization at End of Life Among Older Adults With Advanced Non-Small-Cell Lung Cancer. : Antimicrobial use for symptom management in patients receiving hospice and palliative care: a systematic review. Patients may also experience gastrointestinal bleeding from ulcers, progressive tumor growth, or chemotherapy-induced mucositis. Patients in the noninvasive-ventilation group reported more-rapid improvement in dyspnea and used less palliative morphine in the 48 hours after enrollment. [6-8] Risk factors associated with terminal delirium include the following:[9]. A patient who survives may be placed on a T-piece; this may be left in place, or extubation may proceed. Fifty-five percent of the patients eventually had all life support withdrawn. Truog RD, Burns JP, Mitchell C, et al. Is the body athwart the bed? Dy SM: Enteral and parenteral nutrition in terminally ill cancer patients: a review of the literature. Hyperextension of the neck most commonly results in a type of spinal cord injury called central cord syndrome. J Pain Symptom Manage 43 (6): 1001-12, 2012. Caregiver suffering is a complex construct that refers to severe distress in caregivers physical, psychosocial, and spiritual well-being. In contrast, ESAS depression decreased over time. More information about contacting us or receiving help with the Cancer.gov website can be found on our Contact Us for Help page. The authors found that NSCLC patients with precancer depression (depression recorded during the 324 months before cancer diagnosis) and patients with diagnosis-time depression (depression recorded between 3 months before and 30 days after cancer diagnosis) were more likely to enroll in hospice than were NSCLC patients with no recorded depression diagnosis (subhazard ratio [SHR], 1.19 and 1.16, respectively). Schneiderman H. Glasgow coma creep: problems of recognition and communication. [4], Terminal delirium occurs before death in 50% to 90% of patients. J Pain Symptom Manage 34 (5): 539-46, 2007. A 59-year-old drunken man who had been suffering from WebSwan-Neck Deformity (SND) is a deformity of the finger characterized by hyperextension of the proximal interphalangeal joint (PIP) and flexion of the distal interphalangeal joint (DIP). 13. Several points need to be borne in mind: The following questions may serve to organize discussions about the appropriateness of palliative sedation within health care teams and between clinicians, patients, and families: The two broad indications for palliative sedation are refractory physical symptoms and refractory existential or psychological distress. In several surveys of high-dose opioid use in hospice and palliative care settings, no relationship between opioid dose and survival was found.[30-33]. Conclude the discussion with a summary and a plan. Cardiovascular:Unless peripheral pulses are impalpable and one seeks rate and rhythm, listening to the heart may not always be warranted. Bercovitch M, Waller A, Adunsky A: High dose morphine use in the hospice setting. 19. That all patients receive a screening assessment for religious and spiritual concerns, followed by a more complete spiritual history. Board members review recently published articles each month to determine whether an article should: Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary. Edema severity can guide the use of diuretics and artificial hydration. Uncontrollable pain or other physical symptoms, with decreased quality of life. 12. Instead of tube-feeding or ordering nothing by mouth, providing a small amount of food for enjoyment may be reasonable if a patient expresses a desire to eat. Patients often express a sense that it would be premature to enroll in hospice, that enrolling in hospice means giving up, or that enrolling in hospice would disrupt their relationship with their oncologist. : The accuracy of probabilistic versus temporal clinician prediction of survival for patients with advanced cancer: a preliminary report. [15] It has also been shown that providing more comprehensive palliative care increases spiritual well-being as the EOL approaches.[17]. Hui D, dos Santos R, Chisholm G, et al. : Understanding provision of chemotherapy to patients with end stage cancer: qualitative interview study. editorially independent of NCI. Furthermore, deliberate reductions in the depth of sedation may be appropriate if there is a desire for communication with loved ones. Transfusion 53 (4): 696-700, 2013. Wright AA, Keating NL, Balboni TA, et al. Results of one of the larger and more comprehensive studies of symptoms in ambulatory patients with advanced cancer have been reported. Callanan M, Kelley P: Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying. Join now to receive our weekly Fast Facts, PCNOW newsletters and other PCNOW publications by email. Rattle is an indicator of impending death, with an incidence of approximately 50% to 60% in the last days of life and a median onset of 16 to 57 hours before death. The Signs and Symptoms of Impending Death. Chaplains or social workers may be called to provide support to the family. 2015;12(4):379. Wien Klin Wochenschr 120 (21-22): 679-83, 2008. The results of clinical trials examining various pharmacological agents for the treatment of death rattle have so far been negative. : The Clinical Guide to Oncology Nutrition. 2015;121(6):960-7. Musculoskeletal:Change position or replace a pillow if the neck appears cramped. Scullin P, Sheahan P, Sheila K: Myoclonic jerks associated with gabapentin. Eleven patients in the noninvasive-ventilation group withdrew because of mask discomfort. For example, requests for palliative sedation may create an opportunity to understand the implications of symptoms for the suffering person and to encourage the clinician to try alternative interventions to relieve symptoms. Despite the lack of clear evidence, pharmacological therapies are used frequently in clinical practice. EPERC Fast Facts and Concepts;J Pall Med [Internet]. These drugs are increasingly used in older patients and those with poorer performance status for whom traditional chemotherapy may no longer be appropriate, though they may still be associated with unwanted side effects. [4] Autonomy is primarily a negative right to be free from the interference of others or, in health care, to refuse a recommended treatment or intervention. concept: guys who are heavily tattooed like full sleeves, chest piece, hands, neck, all that jazz not sure if big gender or big gay, but tbh at this point its probably both Cowan JD, Palmer TW: Practical guide to palliative sedation. American Cancer Society: Cancer Facts and Figures 2023. Billings JA, Krakauer EL: On patient autonomy and physician responsibility in end-of-life care. Hyperextension of the neck: Overextension of the neck: Absent: Present: Inability to close the eyes: Unable to close the eyes: Absent: Present: Drooping of the However, two qualitative interview studies of clinicians whose patients experienced catastrophic bleeding at the EOL suggest that it is often impossible to anticipate bleeding and that a proactive approach may cause patients and families undue distress. 18. Gone from my sight: the dying experience. : Transfusion in palliative cancer patients: a review of the literature.