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The terminal phase of life as a team-based clinical global judgment

Prevalence and associations in an acute geriatric unit

Die terminale Lebensphase als teambasiertes klinisches Globalurteil

Prävalenz und Assoziationen in der Akutgeriatrie

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Abstract

Background

In most elderly people, the final—terminal—phase of life is characterized by permanent dependency and a complete inability to perform activities of daily living. Treatment targets usually switch from rehabilitation to palliation. However, the prevalence of the clinical judgment “last phase of life” and its association with in-hospital death is unknown in geriatric patients.

Patients and methods

We retrospectively analyzed GEMIDAS data from two geriatric units. Patients without cancer and an in-hospital stay of at least 1 week were included in our study. Prevalence of the terminal phase of life was clinically assessed according to the proposals made by M. Gillick. This clinical judgment was pronounced by the geriatric team after a stay in the hospital of at least 1 week. The clinical judgment took into account all available assessment parameters, as well as the impact of a geriatric treatment trial. In addition, the association between the clinical judgment and the risk of in-hospital mortality was analyzed.

Results

Records from 2,433 (56%) patients in hospital A and from 1,912 (44%) patients in hospital B were analyzed. The frequency of a terminal phase of life was 30% and 9% (p<0.01), respectively. The frequency depended on the manner of admission to the hospital. In both hospitals, mortality was significantly higher in terminal patients (27% and 37%) than in other patients (0–8% and 0–6%). In both hospitals, the risk of in-hospital mortality was significantly associated with the clinical judgment (OR 3.1 and 2.7), heart failure (OR 2.2 and 2.1), and dementia (OR 2.0 and 1.8). Age, residency in a nursing home, and the Barthel Index on admission were all without relevant impact.

Conclusion

The frequency of the clinical construct “terminal phase of life” varies in geriatric units between 9% and 30%. This clinical construct is significantly associated with increased in-hospital mortality. Therefore, this construct possesses external validity. Further studies are needed in order to assess the significance of such a clinical judgment, the associations with clinical burdens of symptoms, and the supply structure required to cover the needs of patients and their families.

Zusammenfassung

Hintergrund

In der letzten – terminalen – Phase ihres Lebens zeigen die meisten alten Menschen krankheitsunabhängig ein klinisches Bild, das vom Verlust der Alltagsfähigkeiten gekennzeichnet ist. Die Behandlungsziele ändern sich hin zu einer mehr symptomorientierten, palliativen Betreuung. Die Prävalenz der nach klinischem Urteil „letzten Lebensphase“ und ihre Assoziation zum Tod im Krankenhaus bei Patienten einer geriatrischen Akutklinik ist jedoch unklar.

Patienten und Methodik

Grundlage dieser retrospektiven Analyse waren die GEMIDAS-Datensätze von zwei geriatrischen Einrichtungen. In die Studie eingeschlossen wurden Patienten ohne Krebserkrankung mit einem stationären Aufenthalt von mindestens 1 Woche. Dabei wurde die Häufigkeit des klinischen Bilds einer terminalen Lebensphase nach Gillick untersucht. Das klinische Urteil „terminale Lebensphase“ erfolgte im geriatrischen Team frühestens nach einem 1-wöchigen Krankenhausaufenthalt. Bewertet wurden alle Assessmentparameter und der Effekt eines geriatrischen Behandlungsversuchs. Zusätzlich wurde die Assoziation zwischen dem Urteil und dem Risiko, während des stationären Aufenthaltes zu versterben, analysiert.

Ergebnisse

Datensätze von 2433 (56%) Patienten der Klinik A und 1912 (44%) Patienten der Klinik B konnten analysiert werden. Die Häufigkeit einer terminalen Lebensphase nach Gillick betrug abhängig vom praktizierten Aufnahmeverfahren 30% bzw. 9% (p<0,01). Die Krankenhaussterblichkeit war in beiden Kliniken mit 27% und 37% bei Patienten in der terminalen Lebensphase vergleichbar (p<0,08) und signifikant höher als bei den anderen Klinikpatienten (0–8% und 0–6%). Das Risiko, im Krankenhaus zu versterben, war in beiden Kliniken signifikant mit dem klinischen Globalurteil (OR 3,1 und 2,7), einer Herzinsuffizienz (OR 2,2 und 2,1) und einer Demenz (OR 2,0 und 1,8) assoziiert. Lebensalter, Wohnen im Heim und der Barthel-Index bei Klinikaufnahme waren ohne relevanten Einfluss.

Schlussfolgerung

Das klinische Konstrukt einer terminalen Lebensphase ist in seiner Häufigkeit bei geriatrischen Klinikpateinten vom Aufnahmeverhalten der Klinik abhängig und schwankt zwischen 9% und 30%. Obwohl bisher verlässliche Beurteilungskriterien fehlen, verfügt es angesichts der in zwei Kliniken unabhängig voneinander gefundenen Assoziation mit einer erhöhten stationären Sterblichkeit über eine gewisse externe Validität. Weitere Untersuchungen sind erforderlich, um den Stellenwert einer solchen klinischen Beurteilung hinsichtlich der Assoziation mit klinischen Symptomen und mit der für die Patienten und ihre Familien erforderlichen Versorgungsstruktur einschätzen zu können.

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Conflict of interest

The corresponding author states that he gave lectures for Amgen and Lundbeck.

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Authors and Affiliations

  1. Kliniken Essen Mitte, Zentrum für Altersmedizin, Am Deimelsberg 34a, 45276, Essen, Deutschland

    H. Frohnhofen, H.C. Heuer, C. Falkenhahn & P. Willschrei

  2. Fakultät für Gesundheit, Department Humanmedizin, Universität Witten-Herdecke, Witten, Deutschland

    H. Frohnhofen

  3. Geriatrische Klinik, Augusta Krankenanstalten Bochum, Bochum, Deutschland

    O. Hagen

  4. Geriatriezentrum Haus Berge, Elisabeth-Krankenhaus, Essen, Deutschland

    H.G. Nehen

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  1. H. Frohnhofen
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  2. O. Hagen
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Correspondence to H. Frohnhofen.

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Frohnhofen, H., Hagen, O., Heuer, H. et al. The terminal phase of life as a team-based clinical global judgment. Z Gerontol Geriat 44, 329–335 (2011). https://doi.org/10.1007/s00391-011-0180-7

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