Even at a hospital recognized for managing seriously ill patients, a systematic assessment of clinical measures associated with end-of-life care identified opportunities to improve treatment for those dying in the hospital, according to a report in the June 28 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
Medical care during the last year of life accounts for 10 percent to 12 percent of the U.S. health care budget and 27 percent of Medicare expenditures, according to background information in the article. "Despite this intensive resource use, studies suggest that when lifesaving treatments are unsuccessful, hospitalized patients often die with distressing symptoms," the authors write. "Studies of patients who died in the 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."
Anne M. Walling, M.D., of the University of California, Los Angeles, and colleagues abstracted the medical records of 496 adults (average age 62 years) who were hospitalized for at least three days before dying at a university medical center recognized for providing intensive care to the seriously ill. The researchers assessed the patients' care based on 13 quality indicators in three domains: eliciting goals of care, pain assessment and management, and dyspnea assessment and management.
More than half of the patients were admitted to the hospital with end-stage disease, one-third required removal from mechanical ventilation before death and 15 percent died while receiving cardiopulmonary resuscitation. For 70 percent of the quality indicators studied, patients received recommended care. Goals of care were addressed in a timely fashion about half the time, pain assessments were performed 94 percent of the time, and treatments for pain (95 percent) and dyspnea (87 percent) were given as recommended.
However, follow-up for distressing symptoms was performed less well than initial assessments, and only 29 percent of patients who had ventilation tubes removed before death were evaluated for dyspnea. An important area identified as needing improvement was communication between clinicians and patients or families at the beginning of intensive treatments.
"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 authors write. "Although medical care should be tailored to achieve patient's 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."
"Driven in part by recognition of intensive treatments for seriously ill patients, this rigorous quality of care assessment was undertaken by an academic medical center to better understand the quality of care provided to dying patients," the authors conclude. "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."
(Arch Intern Med. 2010;170[2]:1057-1063. Available pre-embargo to the media at www.jamamedia.org.)
Editor's Note: This project was supported by a donation from Mary Kay Farley to RAND Health. Dr. Walling was supported by a National Research Service Award Training Grant, the UCLA Specialty Training and Advanced Research Program and the NIH Loan Repayment Program. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
For more information, contact JAMA/Archives Media Relations at 312/464-JAMA (5262) or e-mail mediarelations@jama-archives.org.
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Archives of Internal Medicine