Bedside Neurological Signs of Impending Death in Terminal Cancer Patients Receiving Home Hospice Care

BackgroundAccurate prognostication during the actively dying phase remains a major challenge in palliative care, particularly in home hospice settings where bedside assessment plays a central role. Neurological deterioration preceding death may provide clinically useful indicators of impending death; however, its temporal progression has not been well characterized.MethodsWe conducted a prospective observational study of terminal cancer patients receiving home hospice care between April 2022 and March 2025. A total of 236 patients who died at home were included. Neurological signs-including newly developed neuropathic pain, urinary retention, loss of facial expression, dysphagia, neck rigidity, head rotation, seizures, impaired consciousness, open mouth posture, hyperpyrexia, apnea episodes, and pupillary dilation-were prospectively recorded. The timing of each neurological sign relative to death was documented.ResultsNeurological signs appeared in a recognizable temporal sequence preceding death. Urinary retention appeared earliest, with a median onset of 4 days before death (interquartile range [IQR], 1-7 days), followed by newly developed neuropathic pain at 3 days (IQR, 1-5 days). Loss of facial expression, dysphagia, neck rigidity, head rotation, seizures, and apnea episodes typically occurred approximately 2 days before death. Impaired consciousness, open mouth posture, hyperpyrexia, and pupillary dilation occurred closer to death, with median onset times of 1 day before death. Loss of facial expression was the most frequent neurological sign (96.6%).ConclusionsNeurological deterioration follows a recognizable temporal pattern in terminal cancer patients receiving home hospice care. Systematic assessment of these neurological signs may support bedside prognostication, facilitate anticipatory guidance, and help families prepare for the dying process at home.