Diagnosing dying in the acute hospital setting (1)
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* Kalman Kafetz
* Nicola Atkin

Editor – The paper by Gibbins and colleagues (*Clin Med* April 2009 pp 116–9) deals with an important subject. It shows the limitations of an approach grounded in the specialty of palliative care, which deals with death from single pathology, when analysing death on acute wards. There is no mention in their paper of dementia when those patients over 80 who die from pneumonia are often those with concomitant advanced dementia. The Liverpool Care Pathway (LCP) is less helpful in predicting dying in these patients as many of them have been bedbound for many months and have a long-term fluctuating inability to take medication and fluids. Predicting when these patients enter the terminal phase is difficult.1,2

In a pilot study we looked at 83 acute patients aged 75 and over to examine prediction of death in two weeks. In total, six died. Experienced consultant opinion had a positive predictive value (PPV) of 44% and a specificity (S) of 94%. Farrer's criteria, similar but more extensive than the LCP criteria, had PPV of 30% and S 91%.3Serum albumin less than 31 g/l had PPV 24% and S 79%. To minimise false positives any prediction method needs high positive predictive value and high specificity.

The culture of specific wards for the care of elderly people is to look for what is remediable and palliate what is not. Geriatric medicine and palliative care need to work together to find ways to make clinicians more confident in ‘diagnosing dying’.

*   © 2009 Royal College of Physicians

## References

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    Murray SA, Kendall M, Boyd K *et al*. Illness trajectories and palliative care. BMJ 2005; 330:1007–11.doi:10.1136/bmj.330.7498.1007
    
    [FREE Full Text](http://www.rcpjournals.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjEzOiIzMzAvNzQ5OC8xMDA3IjtzOjQ6ImF0b20iO3M6Mjg6Ii9jbGlubWVkaWNpbmUvOS80LzM5OC4yLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  1.  Preston M
    
    
    
    
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    Murtagh FEM, Preston M, Higginson I. Patterns of dying: palliative care for non-malignant disease. Clin Med 2004; 4:39–44.
    
    [Abstract/FREE Full Text](http://www.rcpjournals.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MTI6ImNsaW5tZWRpY2luZSI7czo1OiJyZXNpZCI7czo2OiI0LzEvMzkiO3M6NDoiYXRvbSI7czoyODoiL2NsaW5tZWRpY2luZS85LzQvMzk4LjIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

3.  1.  Clark D
    
    Hockley J, Clark D. Palliative care for older people in care homes. Buckingham: Open University Press, 2002.doi:10.1177/0269216306073111
    
    [Abstract/FREE Full Text](http://www.rcpjournals.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToic3BwbWoiO3M6NToicmVzaWQiO3M6ODoiMjAvOC84MzUiO3M6NDoiYXRvbSI7czoyODoiL2NsaW5tZWRpY2luZS85LzQvMzk4LjIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

# Diagnosing dying in the acute hospital setting (1) {#article-title-4}

Thank you for the opportunity to respond to the letter by Kafetz and Atkin. They state that our paper ‘shows the limitations of an approach grounded in the specialty of palliative care that deals with death from a single pathology, when analysing deaths on acute wards’. First and foremost, we would like to highlight the fact that palliative care does not just deal with death from a single pathology. The World Health Organization definition describes palliative care as ‘an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems; physical, psychological and spiritual’.1Of note, there is no reference to diagnosis; the definition encompasses the care of patients with a spectrum of illnesses and prognoses. As clinicians working in this specialty we have daily encounters with patients with complex needs from many ‘pathologies’ other than cancer.

As suggested in our article, we agree the Liverpool Care Pathway (LCP) is not particularly helpful in ‘diagnosing dying’ for patients with many non-cancer illnesses. For example, patients with stroke and dementia may be bed bound and unable to swallow tablets, but not dying. For this reason, we used a pragmatic approach for our audit using the LCP criteria and/or case note documentation to determine whether and when a patient had been ‘diagnosed as dying’. Kafetz and Atkin suggest many patients over the age of 80 dying of pneumonia have concomitant dementia; in our audit, of the 49 individuals who fell into this age category, 16 had a primary diagnosis of a chest infection and four of these had a documented diagnosis of dementia.

The authors suggest, ‘The culture of specific wards for the care of elderly people is to look for what is remediable and palliate what is not’. Surely this is how medicine should be practised across all specialties and all ages, not just for the elderly? They propose that ‘geriatric medicine and palliative medicine find ways to make clinicians more confident in ‘diagnosing dying’. We agree, and acknowledge that the diagnosis of dying is difficult to make.2,3 Our current research into end-of-life care on acute hospital wards suggests that a huge cultural shift is needed away from the concept of death as failure, and towards open discussions about death as a possible outcome so that it can be anticipated and planned for. We therefore still believe the key approach is ‘to assist clinicians in identifying those patients who might die during their current hospital admission thereby enabling active treatment where appropriate alongside symptom relief and advanced care planning for the future’.2

*   © 2009 Royal College of Physicians

## References

1.  World Health Organization. [www.who.int/cancer/palliative/definition/en/](http://www.who.int/cancer/palliative/definition/en/)
    
    

2.  1.  McCoubrie R
    
    
    
    
    1.  Alexander N
    
    
    
    
    1.  Kinzel C
    
    
    
    
    1.  Forbes K
    
    Gibbins J, McCoubrie R, Alexander N, Kinzel C, Forbes K. Diagnosing dying in the acute hospital setting; are we too late? Clin Med 2009; 4:116–9.
    
    

3.  Higgs R. The diagnosis of dying. J R Coll Physicians 2000; 33:110–2.