In a study published in the Journal of Palliative Medicine, Fannie Gaston-Johansson, a professor in the Johns Hopkins School of Nursing, and researchers at Goteborg University, Sweden, determined through a review of Swedish patient death records that in 70 percent of cases health care providers documented a "turning point, reflecting identification of dying and re-orientation [of] care."

In the majority of cases recording a turning point, 53 percent were written into the case records very close to the time of actual dying, 20 percent on the day of death and 33 percent between two and seven days before death occurred.

The authors propose that the lack of a turning point, or its delay until very close to death, may mean that individuals die with unnecessary pain and distress due to invasive and ineffective therapies.

Gaston-Johansson and colleagues also found that both deterioration of an individual's condition and sporadic confinement to bed were strongly associated with the presence of a documented turning point, making the probability of such a turning point 94 percent when both signs were present. The indicators were not related to specific chronic conditions or causes of death but may be particularly relevant to cardiovascular disease, where the commonly held belief is that the life expectancy of patients is difficult to estimate.

The authors conclude that "with most of the individuals in the study, the turning point is not adequate time to start palliative care, since it is usually too late. Palliative care should start gradually from the time of an incurable life-threatening disease and broaden its scope toward the terminal phase of the illness."

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