‘Triple Threat’ Conditions May Predict Mortality in Patients With Cancer Presenting to Emergency Departments

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Dyspnea, delirium, and poor performance—so-called “triple threat” conditions—are known to predict short survival in palliative care. According to data presented at the 2017 Palliative and Supportive Care in Oncology Symposium,1 however, the presence of at least two of these symptoms in patients with advanced cancer presenting to an emergency department (ED) significantly increased the odds of 30-day mortality. Using the triple threat as a quick tool to assess mortality in these patients may help to address end-of-life issues and avoid costly interventions, the authors reported.

“We think these three conditions could predict the majority of patients who come through the emergency room and die,” said Ahmed Elsayem, MD, MPH, of the Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston. “This is important because in the emergency room, we make the decision to send patients to the intensive care unit, but with earlier discussions of goals of care, we may be able to send some of these patients to regular hospital beds or hospice instead.”

Study Design and Results

For this study, Dr. Elsayem and colleagues randomly selected 243 English-speaking patients with advanced cancer who presented to the MD Anderson’s Emergency Center and who were judged clinically stable. Patients were assessed for the presence of delirium (Confusion Assessment Method and Memorial Delirium Assessment Scale [MDAS]), poor performance (Eastern Cooperative Oncology Group [ECOG] score of 3 or 4), and dyspnea (MD Anderson Symptom Inventory shortness of breath score > 5). The researchers obtained survival data from medical records, and the analysis was conducted for 233 participants.

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Dr. Elsayem and colleagues initially assessed the frequency of delirium and found that 18% of patients with advanced cancer had delirium per MDAS when presenting to the emergency department. The researchers also found a strong association between delirium and poor performance status. Over 80% of delirious patients had an ECOG score of 3 or 4, but delirium was not associated with dyspnea. Death within 30 days occurred in 12% of patients (n = 28; Table 1).

In pairwise comparisons adjusting for multiple comparisons, participants with two or more of the symptoms had poorer 30-day and overall survival. Approximately half of patients with at least two of the triple threat conditions will die within 30 days, said Dr. Elsayem, who emphasized that these odds ratios likely underestimate the probability of mortality.

Predicting Mortality in Patients With Advanced Cancer

  • Dyspnea, delirium, and poor performance are known to predict short survival in palliative care.
  • In a study of patients with advanced cancer presenting to an emergency department, participants with two or more of these symptoms had poorer 30-day survival and overall survival.
  • Early discussion of goals of care with patients who have advanced cancer may avoid costly and aggressive interventions.

“This is actually underreporting because patients who were judged to be unstable by our emergency physicians were not included in the original delirium study,” he observed. “Thus, further research including clinically unstable patients should be performed.”

According to Dr. Elsayem, however, these results highlight the potential utility of the triple threat for early identification of cancer patients with short survival. “With earlier goals-of-care discussions, we may be able to make a do-not-resuscitate order for many of these patients and send some of them out to hospice,” he explained. “It’s also important to make a consult to palliative care the moment you have that discussion…to shorten the length of stay of these patients.” ■

DISCLOSURE: Dr. Elsayem reported no conflicts of interest.


1. Elsayem AF, Warneke CL, Reyes-Gibby CC, et al: Triple threat of mortality among advanced cancer patients presenting to an emergency department. 2017 Palliative and Supportive Care in Oncology Symposium. Abstract 138. Presented October 27, 2017.

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