Terminally ill patients are very susceptible to infections, which are the result of disease-related processes and/or therapy-induced mechanisms. These patients are already subject to multiple severe symptoms and associated comorbid conditions, with much resultant distress. Infection increases this symptom burden and further reduces quality of life. We have retrospectively investigated the prevalence of infection and clinical course in 102 consecutive patients who died after admission to a tertiary palliative care unit and assessed the site-specific frequency of infection, pathogenic organisms involved, and the pattern of antibiotic agents used. The prevalence of symptoms and comorbid conditions on admission and during the progress phase of care were noted. Median overall survival of the total cohort was 12 days. The median survival of patients with infections was 22 days. Thirty-seven patients (36.3%) were diagnosed with 42 separate infections. The sites of infections were the urinary tract (42.5%), the respiratory tract (22.9%), blood (12.5%), skin and subcutaneous tissues (12.5%), and the eyes (10.0%). There were 20 separate positive cultures isolated from specimens obtained from 13 individual patients. Three isolates were obtained from 1 patient, 2 isolates obtained from 5 patients, and 1 isolate was obtained from each of the 7 remaining patients. Escherichia coli was the most common pathogen isolated. Eleven patients with infections (31.4%) were diagnosed on admission, and antibiotic treatment was commenced within 48 hours of admission in 21 patients (60%). Overall antibiotic response and symptom control of infections was observed to be a minimum of 40%. Psychological distress was common in this group of patients (P = 0.001) as were disabling symptoms on admission, such as pain, immobility, and weakness. Symptoms indicating poor survival, such as severe pain and dyspnea, were not significantly associated with infection. Decreased patient survival in this cohort was not significantly associated with the presence of bacterial infection (P = 0.07), irrespective of whether or not a positive culture isolate was obtained. We conclude that appropriate management of infection resulted in enhanced palliative symptom control.

The extensive use of sedative and analgesic medication at the end of life is often controversial due to the perception that death may be hastened as a result of progressive drug escalation. Physician attitudes toward prescribing medication in this setting vary, resulting in widely differing prescribing patterns for patients with advanced cancer. This investigation attempted to identify overall prescribing patterns and variation in the use of sedation and analgesia in an inpatient hospice setting at the end of life. A retrospective case review was undertaken of 102 consecutive patients who died in a palliative care hospice. A detailed review of medication prescription, with particular attention to sedation and analgesia in the last week of life, was performed. The review revealed that regular sedation was prescribed in 68 percent of the patients. Almost two-thirds of the patients began regular sedation on admission or within seven days of admission. Although survival was higher in patients who received regular sedation (mean, 36.5 days) versus those that did not (mean, 17 days), the difference was not significant (p = 0.1). Overall, regular sedation with moderate dose increases was observed. In patients prescribed morphine from the time of admission, morphine oral equivalents increased from a mean of 111 mg on admission to a mean of 346 mg at time of death for a mean escalation of 311 percent. The mean duration of admission was 26 days with an opioid-escalation index of 12 percent per day. Survival is a multifactorial phenomenon and was unrelated to the level of analgesia in this cohort. Findings showed that sedation dose increased modestly toward the end of life, and that the increase was not associated with a significant reduction in survival. Further there was no significant impact on survival related to an individual physician's prescribing pattern at the end of life. These results suggest that, in the institution where the review was conducted, neither sedation nor individual variation in physician prescribing habits in terminally ill patients was associated with hastening of death. Overall, the amount of sedative drugs required for adequate symptom control during terminal care was moderate.

This study's aim was to determine the impact of medical technologies on patient comfort and survival time, through retrospective review of the clinical course, symptom profile, and illness trajectory in 102 consecutive patients (50 males and 52 females), and of diagnostic and therapeutic interventions delivered to them. The average age of males was 72.3 years and of females 73.1 years. Ninety-four patients were admitted for palliation of symptoms due to malignant disease and eight other patients for non-malignant diseases. The median survival time was 12 days. On admission, higher univariate hazard risks for survival were significantly associated with male gender, metastatic disease, and dyspnea. Higher adjusted Charlson comorbidity scores were associated with significantly decreased survival time, while de novo symptoms and diagnostic interventions were associated with lower univariate risk rates and increased survival times. Palliative therapeutic interventions were not significantly associated with increased patient survival. A multivariate analysis showed that pain, dyspnea, immobility, and adjusted Charlson comorbidity scores were independent risks for shorter patient survival times. Diagnostic interventions were significant for increased patient survival. No requests for euthanasia had been recorded, which may, in part, reflect the significant family support most of these patients had received. Resume I Cette etude visait adeterminer !'impact des technologies rnedlcales sur Ie confort des patients et sur leur temps de survie. Ainsi nous avons passe en revue les dossiers de 102 patients admis consecutivement (50 hommes, 52 femmes) afin de connaitre leur histoire clinique tels Ie profil des sympt6mes, la trajectoire de la maladie, Ie diagnostic et les interventions therapeutiques. L'age moyen des hommes etaient 72,3 ans et celui des femmes de 73,1. Des patients admis, 94 Ie furent pour Ie traitement palliatif des sympt6mes attribuables a une affection maligne et 8 autres pour des affections non-malignes. Le temps de survie en moyenne etalt de 12 jours. AI'admission, les risques univariables sieves de survie etalent pour une large part assocles aux hommes, aux maladies metastatlques et ala dyspnee, Les indices Charlson de comorbidite slevee etaient associes a une diminution significative du temps de survie; alors que les nouveaux symptomes et les interventions diagnostiques etaient assocles a des risques univariables bas de survie et une augmentation du temps de survie. Les interventions therapeutiques de nature palliative n'etalent pas associees aune augmentation du taux de survie des patients. Une analyse des multivariables a dernontre que la douleur, la dyspnee, l'lrnmobilite et les indices corriqes de cornorbidites de Charlson sont des risques qui n'ont aucun rapport avec un temps de survie plus court chez les patients. Les interventions diagnostiques ont un effet significatif sur Ie temps de survie des patients. Les dossiers n'indiquent aucune demande d'euthanasie, ce qui s'expliquerait par Ie fait que ce...