Recognising and managing dying patients in the acute hospital setting: can we do better?

'How long do you think?' Unresponsive dying patients in a specialist palliative care service: A consecutive cohort study

BACKGROUND

Predicting length of time to death once the person is unresponsive and deemed to be dying remains uncertain. Knowing approximately how many hours or days dying loved ones have left is crucial for families and clinicians to guide decision-making and plan end-of-life care.

AIM

To determine the length of time between becoming unresponsive and death, and whether age, gender, diagnosis or location-of-care predicted length of time to death.

DESIGN

Retrospective cohort study. Time from allocation of an Australia-modified Karnofsky Performance Status (AKPS) 10 to death was analysed using descriptive narrative. Interval-censored survival analysis was used to determine the duration of patient's final phase of life, taking into account variation across age, gender, diagnosis and location of death.

SETTING/PARTICIPANTS

A total of 786 patients, 18 years of age or over, who received specialist palliative care: as hospice in-patients, in the community and in aged care homes, between January 1st and October 31st, 2022.

RESULTS

The time to death after a change to AKPS 10 is 2 days (n = 382; mean = 2.1; median = 1). Having adjusted for age, cancer, gender, the standard deviation of AKPS for the 7-day period prior to death, the likelihood of death within 2 days is 47%, with 84% of patients dying within 4 days.

CONCLUSION

This study provides valuable new knowledge to support clinicians' confidence when responding to the 'how long' question and can inform decision-making at end-of-life. Further research using the AKPS could provide greater certainty for answering 'how long' questions across the illness trajectory.

How clinicians recognise people who are dying: An integrative review

BACKGROUND

Timely recognition of dying is important for high quality end-of-life care however, little is known about how clinicians recognise dying. Late recognition is common and can lead to futile treatment that can prolong or increase suffering and prevent a change in the focus of care.

AIM

To explore how clinicians caring for dying people recognise that they are in the last days or hours of life, as well as the factors that influence the recognition of dying.

DESIGN

A systematically constructed integrative review of the literature.

METHODS

Medline, Scopus, Cumulative Index to Nursing and Allied Health Literature, PsycInfo and Allied and Complementary Medicine were searched in July 2022. Papers were included if they were original research, discussed how clinicians recognise dying, available in English language and published in 2012 or later. A constant comparison approach was applied to the analysis and synthesis of the literature.

RESULTS

24 papers met the inclusion criteria. There were 3 main categories identified: 'Clues and signals' refers to prompts and signs that lead a clinician to believe a person is dying, incorporating the sub-categories 'knowing the patient over time', and 'intuition and experience'. 'Recognition by others' is where clinicians come to recognise someone is dying through others. This can be through a change in the context of care such as a tool or care plan or by communication with the team. 'Culture, system and practice' refers to the cultural beliefs of a setting that influences awareness of dying and denial of death as a possibility and avoidance of naming death and dying directly. System and practice of the setting also impact on recognition of dying. This involves work pace and intensity, shift systems and timing of senior reviews of patients. Uncertainty and its impact on recognition of dying are evident throughout the findings of this review. The seeking of certainty and the absence of the possibility of dying contributes to late recognition of dying.

DISCUSSION

Recognition of dying is a complex process that occurs over time, involving a combination of intuition and gathering of information, that is influenced by contextual factors. A culture where dying is not openly acknowledged or even named explicitly contributes to late recognition of dying. A shared language and consistent terminology for explicitly naming dying are needed. Uncertainty is intrinsic to the recognition of dying and therefore a shift to recognising the possibility of dying rather than seeking certainty is needed.

REGISTRATION

(PROSPERO) CRD42022360900. Registered September 2022.

Transdermal Rotigotine at End-of-Life for Parkinson's Disease: Association With Measures of Distress

BACKGROUND

End-of-life (EOL) care for Parkinson's disease (PD) can be challenging when oral medications are no longer tolerated.

MEASURES

To assess EOL prescribing for people with PD (PWP), focusing on rotigotine dosing and proxy measures of distress: benzodiazepine and opioid use.

INTERVENTION

A retrospective audit of patient records from PWP who died between January 2019 and May 2022 at the Royal Hobart Hospital (RHH), Australia, was conducted. Data was systematically collated on demographics, symptoms, levodopa equivalent daily dose (LEDD) and rotigotine, oral morphine equivalent (OME) and benzodiazepine doses in the last 72 hours of life .

OUTCOMES

Pain (72%), respiratory secretions (66%) and agitation (66%) were the most documented EOL symptoms. 83% (n = 52) of PWP were eligible for rotigotine and, of those, 13% (n = 7) received the correct dose, 38% (n = 20) a lower dose, 12% (n = 6) a higher dose and 37% (n = 19) did not receive any. Rotigotine dose was positively associated with total (P = 0.016) and PRN (P = 0.037) benzodiazepine dose. LEDD was positively associated with total benzodiazepine (P = 0.018) and total OME dose (P = 0.046). Contraindicated dopamine antagonists were prescribed for 43% of PWP and administered in 31% of those cases.

CONCLUSIONS

Rotigotine dose and admission LEDD were both associated with proxy measures of distress in the last 72 hours of life. This suggests cautious use of rotigotine at EOL. LEDD may help identify patients at risk of distress. Rates of inappropriate prescribing and symptom prevalence were high, indicating a need for further staff education to optimize the care of PWP.

Organizational structures influencing timely recognition and acknowledgment of end-of-life in hospitals - A qualitative study of nurses' and doctors' experiences

PURPOSE

Healthcare personnel's timely recognition and acknowledgment of end-of-life (EOL) is fundamental for reducing futile treatment, enabling informed decisions regarding the last days or weeks of life, and focusing on high-quality palliative care. The aim of this study is to explore and describe nurses' and doctors' experiences of how organizational structures in hospitals influence timely recognition and acknowledgment of EOL.

METHODS

A qualitative explorative design was applied, with data collected through 12 individual in-depth interviews using a semi-structured interview guide. A total of 6 nurses and 6 doctors were strategically recruited from medical and surgical wards in a Norwegian hospital. Qualitative content analysis was used.

RESULTS

The analysis revealed the theme The importance of hospital organizational structures in timely recognition and acknowledgment of EOL and a subtheme comprising three areas of organizational structures influencing timely recognition and acknowledgment of EOL; Challenges to and demands of continuity, collaboration, and time.

CONCLUSIONS

The study's results show challenges in identifying when cancer patients approach the last weeks and days of life within hospital wards. For nurses and doctors to be able to recognize and acknowledge EOL, continuity of care, collaboration, and time is needed. A fragmented healthcare system, with a predominant focus on treatment and cure, may prevent cancer patients from receiving timely palliative, care causing unnecessary suffering.

Instruments for the identification of patients in need of palliative care in the hospital setting: a systematic review of measurement properties

OBJECTIVE

The objective of this review was to provide a comprehensive overview of the measurement properties of the available instruments used by clinicians for identifying adults in need of general or specialized palliative care in hospital settings.

INTRODUCTION

Identification of patients in need of palliative care has been recognized as an area where many health care professionals need guidance. Differentiating between patients who require general palliative care and patients with more complex conditions who need specialized palliative care is particularly challenging.

INCLUSION CRITERIA

We included development and validation studies that reported on measurement properties (eg, content validity, reliability, or responsiveness) of instruments used by clinicians for identifying adult patients (>18 years and older) in need of palliative care in hospital settings.

METHODS

Studies published until March 2020 were searched in four databases: Embase.com, Medline Ovid, PubMed, and CINAHL EBSCO. Unpublished studies were searched in Google Scholar, government websites, hospice websites, the Library Network of Western Switzerland, and WorldCat. The search was not restricted by language; however, only studies published in English or French were eligible for inclusion. The title and abstracts of the studies were screened by two independent reviewers against the inclusion criteria. Full-text studies were reviewed for inclusion by two independent reviewers. The quality of the measurement properties of all included studies were assessed independently by two reviewers according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology.

RESULTS

Out of the 23 instruments identified, four instruments were included, as reported in six studies: the Center to Advance Palliative Care (CAPC) criteria, the Necesidades Paliativas (NECPAL), the Palliative Care Screening Tool (PCST), and the Supportive and Palliative Care Indicators Tool (SPICT). The overall psychometric quality of all four instruments was insufficient according to the COSMIN criteria, with the main deficit being poor construct description during development.

CONCLUSIONS

For the early identification of patients needing palliative care in hospital settings, there is poor quality and incomplete evidence according to the COSMIN criteria for the four available instruments. This review highlights the need for further development of the construct being measured. This may be done by conducting additional studies on these instruments or by developing a new instrument for the identification of patients in need of palliative care that addresses the current gaps in construct and structural validity.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020150074.

End-of-life care and intensive care unit clinician involvement in a private acute care hospital: A retrospective descriptive medical record audit

INTRODUCTION

More Australians die in the hospital than in any other setting. This study aimed to (i) evaluate the quality of end-of-life (EOL) care in the hospital against an Australian National Standard, (ii) describe the characteristics of intensive care unit (ICU) clinician involvement in EOL care, and (iii) explore the demographic and clinical factors associated with quality of EOL care.

METHOD

A retrospective descriptive medical record audit was conducted on 297 adult inpatients who died in 2017 in a private acute care hospital in Melbourne, Australia. Data collected related to 20 'Processes of Care', considered to contribute to the quality of EOL care. The decedent sample was separated into three cohorts as per ICU clinician involvement.

RESULTS

The median age of the sample was 81 (25th-75th percentile = 72-88) years. The median tally for EOL care quality was 16 (25th-75th percentile = 13-17) of 20 care processes. ICU clinicians were involved in 65.7% (n = 195) of cases; however, contact with the ICU outreach team or an ICU admission during the final inpatient stay was negatively associated with quality of EOL care (coefficient = -1.51 and -2.07, respectively). Longer length of stay was positively associated with EOL care (coefficient = .05). Specialist palliative care was involved in 53% of cases, but this was less likely for those admitted to the ICU (p < .001). Evidence of social support, bereavement follow-up, and religious support were low across all cohorts.

CONCLUSION

Statistically significant differences in the quality of EOL care and a negative association between ICU involvement and EOL care quality suggest opportunities for ICU outreach clinicians to facilitate discussion of care goals and the appropriateness of ICU admission. Advocating for inclusion of specialist palliative care and nonclinical support personnel in EOL care has merit. Future research is necessary to investigate the relationship between ICU intervention and EOL care quality.

Improving quality in hospital end-of-life care: honest communication, compassion and empathy

Background

With over half of expected deaths occurring in acute hospitals, and a workforce not trained to care for them, good quality end-of-life care in these settings is hard to achieve. The National Consensus Statement on Essential Elements for Safe and High-Quality End-of-Life Care has been translated into e-learning modules by the End of Life Essentials project, and this study aims to demonstrate how clinicians interpret the Consensus Statement in their day-to-day practice by answering the question at the end of each module: 'Tomorrow, the one thing I can change to more appropriately provide end-of-life care is…'.

Methods

The modules were developed by a palliative care educator with the support of a peer review group and were piloted with 35 health professionals. Pre-post module evaluation data were collected and during a 10-month period from 2016 to 2017 a total of 5181 individuals registered for the project accessing one or more of the six modules. The data from 3201 free-text responses to the post hoc practice change question have been analysed, and themes generated.

Findings

Five themes are derived from the data: communication, emotional insight, professional mindset, person-centred care and professional practice.

Conclusion

Learners who have completed End of Life Essentials have shared the ways they state they can change their practice tomorrow which may well be appreciated as a clinical response to the work by the Australian Commission on Safety and Quality in Health Care in leading and coordinating national improvements in quality and safety in healthcare in Australia. While intent cannot guarantee practice change, theory on intention-behaviour relations indicate that intentions have a strong association with behaviour. This indicates that the modules have the ability to influence end-of-life care in acute hospitals.