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 wordsEnd-of-life care geriatric assessment withholding life sustaining treatment resuscitation orders hospitalized elders
- 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
- 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
- 19.Stuart B, Kinzbrunner B. Guidelines for determining prognosis in selected non cancer diseases. Hospice J 1996;11:47–63.Google Scholar
- 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.Mahoney FI. Barthel DW. Functional evaluation: the Barthel Index. Maryland State Medical J 1965;14:61–65.Google Scholar
- 25.Jöreskog K, Sörbom, D. L LISREL 8 user’s reference guide. Chicago: Scientific Software International, 1997Google Scholar
- 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
- 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