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44 An evidenced-based heuristics model (or rule of thumb) to improve doctors’ intuition about when patients are imminently dying
  1. Nicola White1,
  2. Priscilla Harries2,
  3. Adam JL Harris3,
  4. Victoria Vickerstaff1,
  5. Philip Lodge4,
  6. Catherine McGowan5,
  7. Ollie Minton6,
  8. Christopher Tomlinson7,
  9. Adrian Tookman4,
  10. Fiona Reid8* and
  11. Patrick Stone1*
  1. 1Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
  2. 2Department of Clinical Sciences, Brunel University London, London, UK
  3. 3Department of Experimental Psychology, University College London
  4. 4Royal Free London NHS Foundation Trust, London, UK
  5. 5St. George’s University Hospitals NHS Foundation Trust, Tooting, London, UK
  6. 6Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
  7. 7Bioinformatics Data Science Group, Imperial College London, London, UK
  8. 8Department of Primary Care and Public Health Sciences, King’s College London, London, UK
  9. *Denotes Joint Last Authorship


Introduction Evidence suggests that the majority of doctors are not very good at identifying when a patient is dying1 however there is little training available to improve this skill. Even experts are unable to articulate how they recognise when a patient is dying other than by saying that ‘I just knew’.2

Aim To understand how expert palliative care doctors recognise a dying person.

Methods Rather than relying on ‘years of experience’ as a surrogate measure of expertise we developed a test to identify which doctors really are the prognostic ‘experts’. The prognostic test consisted of 20 real patient case summaries. Participants (palliative care doctors) were asked to predict whether or not they expected the patient to die within the next 3 days. Those who were the most accurate at this task were deemed to be the ‘prognostic experts’ and were invited to complete an additional online judgement task. In this task it was possible to identify which factors were most influential in their prognostic decision-making.

Results 19/99 doctors who completed the prognostic test were deemed to be ‘experts’. Of those 14 also completed the additional judgement task. The following factors influenced the experts’ decisions: Cheyne Stokes breathing palliative performance score (PPS) a decline in condition in the previous 24 hours respiratory secretions cyanosis and level of agitation or sedation.

Conclusion This novel study presents a simple evidenced-based heuristic (or rule of thumb) to help novices recognise when a patient is imminently dying.


  1. . Neuberger J, Guthrie C, Aaronovitch D. More care less pathway: A review of the Liverpool Care Pathway. Department of Health2013.

  2. . Taylor P, Dowding D, Johnson M. Clinical decision making in the recognition of dying: A qualitative interview study. BMC Palliative Care2017;16(1):11.

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