From Our 2010 Archives

End-of-Life Care Has 'Room for Improvement'

MONDAY, June 28 (HealthDay News) -- U.S. hospitals need to do more to improve care for dying patients, researchers say.

Tending to patients in their last year of life accounts for 10% to 12% of the U.S. health care budget and 27% of Medicare costs, according to background information in the study published in the June 28 issue of the Archives of Internal Medicine.

"Despite this intensive resource use, studies suggest that when lifesaving treatments are unsuccessful, hospitalized patients often die with distressing symptoms. Studies of patients who died in hospital find that pain, dyspnea [trouble breathing] and restlessness or agitation are prevalent before death. Furthermore, persons dying in the hospital often receive burdensome care immediately before death that may not match patient preferences," Dr. Anne M Walling, of the University of California, Los Angeles, and colleagues wrote in a news release from the journal.

In the study, Walling's team analyzed the medical records of 496 adult patients, average age 62, who were hospitalized for at least three days before they died. The care of the patients, who were in a university medical center recognized for providing intensive care to seriously ill people, was assessed using 13 quality indicators.

The researchers found that more than half of the patients were admitted to hospitals with end-stage disease, one-third had to be taken off mechanical ventilation before death, and 15% died while receiving cardiopulmonary resuscitation (CPR).

Patients received recommended care for 70% of the quality indicators. For example, pain assessments were performed 94% of the time, and treatment for pain (95%) and breathing difficulties (87%) was given as recommended.

However, the researchers found that follow-up for distressing symptoms was less rigorous than initial assessments, and only 29% of patients who had ventilation tubes removed before death were evaluated for breathing difficulties.

"Even after 48 hours in the intensive care unit or on the ventilator, more than half of patients had no medical record documentation about goals of care or an attempt to pursue the topic," the study authors wrote.

"Although medical care should be tailored to achieve patients' goals and prior work shows that patients' preferences depend on prognosis, medical care cannot be guided by informed choices absent communication about current clinical status and what course is likely to follow," the authors added.

"Deficits in communication, dyspnea assessment, implantable cardioverter-defibrillator deactivation and bowel regimens for patients prescribed opioids should be targeted for quality improvement. The findings suggest much room for improvement in treating patients dying in the hospital," they concluded.

-- Robert Preidt

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SOURCE: JAMA/Archives journals, news release, June 28, 2010