Review Finds Pain, Agitation Prevalent Among Dying
Seniors in U.S. Hospitals
Medical care during the last year of life accounts
for 10 to 12% of U.S. health care budget and 27% of Medicare
expenditures
June 29, 2010 - 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.
Most of today's primary care physicians are not
adequately trained to provide the complex care needed by older adults
with multiple chronic conditions
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."
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.
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June 29, 2010 - 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. 
