Factors related to withholding life-sustaining treatment in hospitalized elders

Factors Related to Withholding Life-Sustaining Treatment in Hospitalized Elders



To look for predictors in the clinical records of orders for “limitation of life sustaining treatment” (LLST) or “do not attempt resuscitation” (DNAR) in hospitalized elders and to assess the relationship between the presence of these orders and the quality of end-of-life (EOL) care.


Retrospective clinical record review.


Inpatients of an inner city elderly acute care unit (EACU) in Spain.


Of 103 hospitalized patients who died in the EACU during one year, 90 dying an expected death either from acute or chronic disease were included.


Demographic, functional, cognitive, clinical, and end-of-life (EOL) parameters. The influence of identifying closeness to death and the number of LLST suborders on the quality of EOL-management were considered simultaneously using structural equation modelling with LISREL 8.30 software.


LLST and specific DNAR orders were registered in 91.1% and 83.3% of patients, respectively. Failure of acute treatment, discussions with the patient/family, recognizing the presence of common EOL symptoms, and prescribing specific symptomatic treatment were recorded in 88.9%, 93.3%, 94.4%, and 86.7% of patients, respectively. LLST-orders were more likely to be documented if there was severe functional impairment prior to admission (p<0.001), advanced organ disease criteria were met (p=0.006), or closeness to death was acknowledged in writing (p<0.001). The quality of the EOL-management was better in patients for whom there were LLST-orders (p =0.01) and written acknowledgement of closeness to death (p<0.001).


LLST-orders were more likely to be written in an EACU for patients with previous severe impairment, co-morbidity, or advanced disease. Written acknowledgement of closeness to death and LLST-orders were predictors of better EOL-management.

Key words

End-of-life care geriatric assessment withholding life sustaining treatment resuscitation orders hospitalized elders 


  1. 1.
    Mathers CD, Loncar D. Updated projections of global mortality and burden of disease, 2002–2030: data sources, methods and results. Geneva: World Health Organization, 2006. Available at www.who.int/healthinfo/statistics/bod_projections 2030_paper.pdf. Accessed 23.8.08Google Scholar
  2. 2.
    Temkin-Greener H, Mukamel DB. Predicting place of death in the program of allinclusive care for the elderly (PACE): participant versus program characteristics. J Am Geriatr Soc 2002;50(1):125–135.CrossRefPubMedGoogle Scholar
  3. 3.
    Levy CR, Fish R, Kramer A. Site of death in the hospital versus nursing home of Medicare skilled nursing facility residents admitted under Medicare’s Part A Benefit. J Am Geriatr Soc 2004;52(8):1247–1254.CrossRefPubMedGoogle Scholar
  4. 4.
    van der Heide A, Delinees L, Faisst K, Nilstum T, Norup M, Paci E et al. End of life decision-making in six European countries: descriptive study. Lancet 2003;362(9381):345–350CrossRefPubMedGoogle Scholar
  5. 5.
    van Delden JJ, Löfmark R, Deliens L, Bosshard G, Norup M, Cecioni R et al: EURELD Consortium. Do-not-resuscitate orders in six European countries. Crit Care Med 2006;34(6):1837–1838CrossRefGoogle Scholar
  6. 6.
    Chan DK, Ong B, Zhang K, Li R, Liu JG, Iedema R et al. Hospitalization, care plans and not for resuscitation orders in older people in the last year of life. Age Ageing 2003;32(4):445–449.CrossRefPubMedGoogle Scholar
  7. 7.
    Gleeson K, Wise S. The do not resuscitate order: still too little too late. Arch Intern Med 1990;150(5):1057–1060.CrossRefPubMedGoogle Scholar
  8. 8.
    Aarons E, Beeching N. Survey of “do not resuscitate” orders in a district general hospital. BMJ 1991:303(6816):1504–1506CrossRefPubMedGoogle Scholar
  9. 9.
    Hamel MB, Lynn J, Zhong Zo, Somogyi-Zalud E. Elderly persons’ last six months of life: findings from The Hospitalized Elderly Longitudinal Project. J Am Geriatr Soc 2000;48(S5):S131–139.PubMedGoogle Scholar
  10. 10.
    Lynn J, De Vries KO, Arkes HR Stevens M, Cohn F, Murphy P et al. Ineffectiveness of the SUPPORT intervention: review of explanations. J Am Geriatr Soc 2000;48(S5):S206–213.PubMedGoogle Scholar
  11. 11.
    Formiga F, Vivanco V, Cuapio Y, Porta J, Gómez-Batiste X, Pujol R. Dying in hospital from end-stage non-oncologic disease: a decision-making analysis. Med Clin (Barc.) 2003;121(3):95–97.CrossRefGoogle Scholar
  12. 12.
    Formiga F, Vidaller A, Mascaró J, Pujol R. Morir en el hospital por demencia en fase terminal: análisis de la toma de decisiones después de un programa educativo. (Dying in hospital with end-stage dementia: decision-making analysis after an educational program) Rev Esp Geriatr Gerontol 2005;40(1):18–21.CrossRefGoogle Scholar
  13. 13.
    Cantor M, Braddock CH 3rd, Derse A, Edwards DM, Loque GL, Nelson W et al. DNR orders and medical futility. Arch Intern Med 2003;163(22):2689–2694.CrossRefPubMedGoogle Scholar
  14. 14.
    Meilink M, Van Der Wetering K, Klip H. Discussing and documenting (do not attempt) resuscitation orders in a Dutch hospital: a disappointing reality. Resuscitation 2006:71(3):322–326.CrossRefPubMedGoogle Scholar
  15. 15.
    Harris D, Davies R. An audit of “do not attempt resuscitation” decisions in two district general hospitals: do current guidelines need changing? Postgrad Med J 2007;83(976):137–140.CrossRefPubMedGoogle Scholar
  16. 16.
    Flaming, D. Improve care and comfort: use the label “dying”. J Palliat Care 2000;16(2):30–36.PubMedGoogle Scholar
  17. 17.
    Bailey F, Burgio KL, Woodby LL, Williams BR, Redden DT, Kovac SH et al. Improving processes of hospital care during the last hours of life. Arch Intern Med. 2005;65(5):1722–1727.CrossRefGoogle Scholar
  18. 18.
    Luchins D, Hanraham P, Murphy K. Criteria for enrolling patients in hospice. J Am Geriatr Soc 1997;45:1054–1059.PubMedGoogle Scholar
  19. 19.
    Stuart B, Kinzbrunner B. Guidelines for determining prognosis in selected non cancer diseases. Hospice J 1996;11:47–63.Google Scholar
  20. 20.
    Regalado-Doña P, Valero-Ubierna C, González-Montalvo J, Salgado-Alba A. Las escalas de la Cruz Roja veinticinco años después. Estudio de su validez en un servicio de Geriatría. (Red Cross Scales 25 years after. Analysis of their validity in an Elderly Care Department). Rev Esp Geriatr Gerontol 1997;32(2):93–99Google Scholar
  21. 21.
    Mahoney FI. Barthel DW. Functional evaluation: the Barthel Index. Maryland State Medical J 1965;14:61–65.Google Scholar
  22. 22.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis 1987;40(5):373–383.CrossRefPubMedGoogle Scholar
  23. 23.
    Christakis N, Escarce J. Survival of Medicare patients after enrollment in hospice programs. N Engl J Med 1996;335(3):172–178.CrossRefPubMedGoogle Scholar
  24. 24.
    Hoehn M, Yahr M, Parkinsonism: onset, progression and mortality. Neurology 1967;17:427–442.PubMedGoogle Scholar
  25. 25.
    Jöreskog K, Sörbom, D. L LISREL 8 user’s reference guide. Chicago: Scientific Software International, 1997Google Scholar
  26. 26.
    Löfmark R, Nilstun T, Cartwright C, Fischer S, van der Heide A, Norup M et al. Physicians’ experiences with end-of-life decision-making: Survey in 6 European countries and Australia. BMC Medicine 2008;6:4.PubMedGoogle Scholar
  27. 27.
    Vila-Santasuana A, Celorrio-Jimenez N, Sanz-Salvador X, Martinez-Montantí J, Díez-Cascón-Menéndez E, Puig-Rosell C. Última semana de vida en un hospital de agudos: revision de 401 pacientes consecutivos. (The final week of life in an acute care hospital: review of 401 consecutive patients) In press, Rev Esp Geriatr Gerontol 2008;43(5):284–289.CrossRefPubMedGoogle Scholar
  28. 28.
    Hesse KA. Terminal care of the very old: changes in the way we die. Arch Intern Med 1995;155(14):1513–1518.CrossRefPubMedGoogle Scholar
  29. 29.
    Tschann J, Kaufman S, Micco G. Family involvement in end-of-life hospital care. J Am Geriatr Soc 2003;51(6):835–840.CrossRefPubMedGoogle Scholar
  30. 30.
    Lamberg JL, Person CJ, Kiely DK, Mitchell SL. Decisions to hospitalize nursing home residents dying with advanced dementia. J Am Geriatr Soc 2005;53(8):1396–1401.CrossRefPubMedGoogle Scholar
  31. 31.
    Miccinesi G, Fischer S, Paci E, Onwuteaka-Philipsen BD, Cartwright C, Van Der Heide A et al. Physicians’ attitudes towards end-of-life decisions: a comparison between seven countries. Soc Sci Med 2005;60(9):1961–1974.CrossRefPubMedGoogle Scholar
  32. 32.
    Hakim RB, Teno JM, Harrell FE Jr, Knauss WA, Wengwer N, Phillips RS et al. Factors associated with do not resuscitate orders: patients’ preferences, prognoses, and physicians’ judgements. SUPPORT Investigators. Ann Intern Med 1996;125(4):284–293.PubMedGoogle Scholar
  33. 33.
    Lorenz KA, Rosenfeld K, Wenger N. Quality indicators for palliative and end-of-life-care in vulnerable elders. J Am Geriatr Soc 2007;55(S2):S318–326CrossRefPubMedGoogle Scholar
  34. 34.
    Rietjens JA, Van Der Heide A, Onwuteaka-Philipsen BD, Van Der Maas PJ, Van Der Wal G. Preferences of the Dutch public for a good death and associations with attitudes towards end-of-life decision making. Palliat Med 2006;20(7):685–692CrossRefPubMedGoogle Scholar
  35. 35.
    Kessel H, Pageo M, Marín N. Preferencias respecto a la información médica y directrices sobre soporte vital en una población geriátrica española. (Preferences regarding medical information and orders on life sustaining treatment in a geriatric Spanish population) Rev Esp Geriatr Gerontol 1994;29(2):79–83.Google Scholar
  36. 36.
    Nicolasora, N, Pannala R, Mountantonakis S, Shanmugam B, De Girolamo A, Amoateng-Adjepong Y et al. If asked, hospitalized patients will choose whether to receive life-sustaining therapies. J Hosp Med 2007;1(3):161–167.CrossRefGoogle Scholar
  37. 37.
    Goodlin SJ, Winzelberg GS, Teno J, Whedon M, Lynn J. Death in hospital. Arch Intern Med 1998,158:1570–1572.CrossRefPubMedGoogle Scholar
  38. 38.
    Veerbeek L, Van Zuylen L, Swart SJ, Jongeneel G, Van Der Maas PJ, Van Der Heide A. Does recognition of the dying phase have an effect on the use of medical interventions? J Palliat Care 2008;24(2):94–99.PubMedGoogle Scholar
  39. 39.
    Teno J. Measuring end-of-life care outcomes retrospectively. J Palliat Med. 2005;8(S1):S42–49.PubMedGoogle Scholar

Copyright information

© Serdi and Springer Verlag France 2009

Authors and Affiliations

  1. 1.Department of Geriatric MedicineHospital General Universitario Gregorio MarañónMadridSpain
  2. 2.Department of Geriatric Medicine of the Hospital Central Cruz RojaMadridSpain
  3. 3.Department of Geriatric Medicine of the Hospital La RiojaLogroño, La RiojaSpain
  4. 4.Department of Geriatric Medicine in the Hospital Central Cruz RojaMadridSpain
  5. 5.Geriatric Medicine. Hospital Universitario Gregorio MarañónMadridSpain
  6. 6.Hospital Central Cruz RojaMadridSpain

Personalised recommendations