End of life management in Internal Medicine Wards: a single centre real life report

Abstract

The burden of end of life in Internal Medicine wards is not neglegible. However, literature evidence about end of life care in Internal Medicine wards lacks. Therefore, the aim of this study was to report on end of life management in a Internal Medicine ward. We performed a retrospective study focusing on characteristics and management of patients consecutively died in an italian Internal Medicine ward between 2018, July-1 and 2019, June-30. Demographic, co-morbidity, pharmacological treatment at hospital admission and in the last 48- hours of life and procedures during hospital stay were collected. Study population was composed by 354 patients (190 females), corresponding to about ten percent of patients admitted in the ward, with mean age ± DS 83.5 ± 10.6 years. Eighty-four percent of deaths was exepected in the last 48 hours before exitus. The main co-morbidities were blood hypertension (66.3 %), solid or haematological malignancies (40.3%), arhythmias (34.7%), pressure ulcers (31.3%) and diabetes (27.4%). The main causes of hospitalization were infectious diseases (23.1%) and cardiac or respiratory failure (20.9%). In seven percent of patients palliative cares had been already activated before the hospital admission. No patient had written living wills or advance directives. In the last 48 hours of life, the main phramacological classes prescribed were opioids (63.2%), antibiotics (46.9%) and corticosteroids (46.3%). Compared with pharmacological classes prescribed at hospital admission, in the last 48 hours of life the prescription of antibiotics, corticosteroids, opioids and benzodiazepines was significantly increased, whereas the prescription of antihypertensive agents, proton pump inhibitors and antithrombotic drugs resulted significantly reduced. Written order to withdrawal of vital parameters relevation or active treatment were found in 30.7% and 31.9%, respectively. In the last 48 hours of life, 61% of patients underwent to at least one blood assay, 34% arterial blood gas analysis and about 35% at least one of radiography, computer tomography, magnetic resonance or endoscopy. During hospital stay 9% of patients underwent to blood transfusion. Of them 28.1% of patients received blood transfusion in the last 48 hours of life. Appropriate management of end of life represents a challenge in Internal Medicine wards.

Do Sex-Related Differences of Comorbidity Burden and/or In-Hospital Mortality Exist in Cancer Patients? A Retrospective Study in an Internal Medicine Setting

“…Currently, we do not have enough evidence of possible sex-related differences. The study by Stefanelli et al did not provide data on this aspect [ 38 ], and we only found that IHM was not significantly different among females and males, although it was independently associated with cachexia and metastasis only in women. Studies on sex-specific differences in comorbidity, outcome, and possible relevance of marital status are also needed in the delicate topic of end-of-life.…”

“…Although cancer patients are usually admitted to internal medicine settings, available data from Italian hospitals are very limited. A single-center retrospective study, performed in the region of Tuscany, nearest to Emilia-Romagna in terms of both geographic position and health service organization, analyzed 354 patients (54% females) who consecutively died in an internal medicine unit during a 1-year of observation [ 38 ]. The authors observed that, in the last 48 h of life, approximately 2/3 of patients underwent at least one blood assay, 1/3 arterial blood gas analysis, and 1/3 at least one procedure, e.g., X-ray, computerized tomography, magnetic resonance, or endoscopy.…”