Diagnosing dying in the acute hospital setting (2)
Editor – Gibbins and colleagues show that providing end-of-life care is a challenge in hospitalised patients (Clin Med April 2009 pp 116–9). We conducted a similar audit in acute medical patients and reviewed case notes of 50 patients who died following admission to the department. We excluded patients who died within seven days of admission as we felt that the clinical uncertainty during this period would be very high. Our results are similar to the findings in the article with 62% (31/50) of patients being identified as having end-stage disease and only 54% (17/31) of them being offered end-of-life care. The Liverpool Care Pathway (LCP) was used in 13 patients. Five of these also received specialist palliative care input. Four patients had specialist palliative care input without the use of the LCP.
We agree with the authors that the uncertainty in diagnosing dying is perhaps a major contributor to patients not receiving palliative care but we feel that other factors, such as frequent transfers of patients between wards, which occurred in 27/50 patients in our audit, and reduced continuity of care owing to shorter shift patterns and frequent junior staff changes, also contribute to delay or denial of end-of-life care.
The majority of the patients in our audit were admitted with an infection and in the majority of the patients the cause of death was infection. It is often thought that infections can be treated despite the presence of other significant co-morbidities. There is little recognition among healthcare staff, patients and relatives that an infection is often the terminal event in most end-stage diseases. A number of such patients would have had previous admissions with similar infections in the past and recovered, which adds to uncertainty about diagnosing the terminal event. In our audit 15 patients had previous admissions within the last two months.
We feel that it is important to discuss with patients and relatives the role of infection as a terminal event in chronic illness, so that they are informed and not alarmed when healthcare staff decide not to treat infection actively. We also feel that the LCP should indicate that in cases of uncertainty it may be appropriate to give antibiotics despite the decision to provide end-of-life care as we feel that this will help healthcare staff to allay their own and their patients’ anxieties in instances of clinical uncertainty, thereby promoting wider use of the LCP.
Diagnosing dying in the acute hospital setting (2)
We thank Wallis and Guptha for sharing their audit results. Their results show that the majority of their patients were admitted with an infection, which was also stated as the cause of death. Our results revealed that infection was the primary reason for admission in 32% of the cohort.1Symptoms arising as a result of infection can be similar to those of someone who is dying, and as healthcare professionals working in an environment which focuses on cure, we sometimes treat infections without recognising that the patient is actually dying from their underlying illness.2–4
However, we fully agree that the treatment of an infection can be entirely appropriate for patients who may be entering their last days of life – either for symptom control or because the prognosis is uncertain (especially in those with non-malignant disease who have unpredictable disease trajectories). The current version of the Liverpool Care Pathway (LCP) for the dying does not stipulate that all antibiotics should be stopped, but that inappropriate antibiotics should be discontinued.5Thus in those patients where appropriate, it is possible for the patient to be on the LCP while receiving antibiotics. However, as suggested by our audit and the work of others, the ‘diagnosis of dying’ can be difficult to make and thus the ‘right time’ to place a patient onto the LCP or other end-of-life care pathway can be challenging. We therefore advocate that until sensitive and specific prognostication tools are available, as stated above, we should ‘assist clinicians in identifying those patients who might die during their current hospital admission thereby enabling active treatment where appropriate alongside symptom relief’.1This approach would enable those patients who require appropriate antibiotics to receive them, while allowing ‘healthcare professionals to allay their own anxieties in instances of clinical uncertainty’.
- © 2009 Royal College of Physicians
References
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- Gibbins J
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- Ellershaw J
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- ↵Liverpool Care Pathway. www.mcpcil.org.uk/liverpool_care_pathway
- © 2009 Royal College of Physicians
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