End-of-Life Care in Hospital: Current Practice and Potentials for Improvement

Abstract

From July until September 2004, all deaths were registered prospectively in all departments of Freiburg University Hospital, Germany, a large teaching hospital with approximately 55,000 inpatient admissions per year. A retrospective chart review was done for all patients who died during this time period using a tool validated in two American and Australian projects. Main outcome measures were patients' identification as dying by medical staff, Do-Not-Resuscitate (DNR) orders, and the presence of comfort care plans. The cohort comprised 226 consecutive death events. Seven percent of patients had a written advance directive. DNR orders were available for 65% of patients and were entered into the charts on average 5.9 days prior to death. Thirty-eight percent of charts had evidence that staff recognized that the patients were dying. This prognosis was noted on average 3.8 days prior to death. According to chart notes, clinicians documented cancer patients as dying more frequently than patients with cardiovascular disease (P=0.029). In the chart entries, comfort care plans were completed fully for 14% and partially for 27% of patients. On average, comfort care plans were put in place nine days prior to death. Cancer patients had significantly more frequent comfort care plans than patients with cardiovascular diseases (P<0.001). In 59% of medical charts, there was no evidence of a comfort plan. Approximately one-third of dying patients received active life-sustaining treatment at time of death. These data highlight the need for systematic strategies to monitor patients' needs and to improve quality of care, especially during the last four days before death.

Avaliação das decisões médicas durante o processo do morrer

“…However, they often fail to broach the subject with the ill denying them a prescription for adequate relief of symptoms. (9,20) The same was true for this study. It is important to mention that many physicians do not optimize hospice care, mainly pain control, fearing a possible side effect of sedation analgesia drugs.…”

Assessment of Implementation of an Order Protocol for End-of-Life Symptom Management

“…The order protocol aims to overcome many of the barriers to implementation of comfort care including lack of knowledge, inexperience, and discomfort with end-of-life opiate administration. 6,7,[9][10][11][12][13]24,25 The ESMO protocol delineates the patient criteria for use of the protocol, which include: (1) a plan not to resuscitate the patient, (2) the patient has a terminal illness, (3) the patient is experiencing symptoms such as uncontrolled pain or dyspnea for which opiate medications are an accepted treatment, and (4) the goals of treatment have been discussed with patient and/or surrogate. A section of the order protocol guides ordering an opiate continuous infusion aimed at symptom control, including suggested dosing parameters and guidelines for documenting titration for unrelieved symptoms.…”

“…8 Even when clinicians and patients and their families recognize that a patient is nearing death and the goals of care should be reoriented toward the end of life, the shift in care may not proceed. 9,10 A medical record review of patients who died in the Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment (SUPPORT) found that approximately half had dyspnea and half had pain in the last 2 days, but patients with care aimed at comfort measures did not have statistically significantly better symptom management. 9 Furthermore, a retrospective study by Parish et al 11 found through case note auditing and key staff interviews that there was a lack of appropriate assessment and documentation of physical and psychosocial care in the inpatient setting toward the end of life.…”

Do Not Resuscitate Expressly Allowed Natural Death: A Common Ethical Dilemma Among Terminally Ill Cancer Patients

“…In Australia, Canada, Sweden, and USA, a study revealed that the DNR rate order among 15 ICUs was 11% [11]. Approximately 60-70% of the patients who have DNR consent are those receiving palliative care in USA and Germany [12]. More surprisingly, a study reported that 72% of Finnish physicians discussing the DNR with the patients whom able to communicate [13].…”