PubMed · 1637907
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D B Smith. Advance directive.. https://doi.org/10.1097/00152192-199207000-00003
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BACKGROUND: Most Americans die in the acute care hospital, where aggressive, life-prolonging interventions are readily performed. Although patients with incurable illness might prefer palliative care, perceived differences in prognosis by physicians may influence the type of care provided. Patients with advanced cancer and advanced dementia represent 2 extremes in the use of hospice services and may also be treated differently in the acute care hospital. We tested this hypothesis and quantitated the use of nonpalliative interventions in hospitalized, incurably ill patients. METHODS: Charts of elderly patients with advanced dementia or metastatic solid tumor malignancy who died during a 13-month period in a tertiary care acute teaching hospital were reviewed. Main outcome measures included the number of patients receiving invasive of noninvasive (but complex) diagnostic tests, invasive nonpalliative treatments, cardiopulmonary resuscitation, systemic antibiotics, and do-not-resuscitate orders. RESULTS: Charts of 164 patients (80 with dementia and 84 with cancer) were reviewed. Overall, 47% received invasive nonpalliative treatments. Controlling for age, sex, length of stay, and insurance status, the groups were equally likely to receive nonpalliative treatments (P = .75), but patients with dementia were more likely to receive new feeding tubes (P = .02). Cardiopulmonary resuscitation was attempted for 24% of each group. Patients with cancer more often received invasive (41% vs 13%; P = .002) and complex noninvasive diagnostic tests (49% vs 23%; P = .02). Overall, 88% received antibiotics, often empirically, but, controlling for neutropenia and invasive tests and treatments, patients with dementia were significantly more likely to receive antibiotics for an identifiable infection (P = .004). CONCLUSIONS: Incurably ill patients often receive nonpalliative interventions at the end of life. Patients with cancer receive more diagnostic tests, but patients with dementia receive more enteral tube feeding. Patients commonly receive systemic antibiotics, often empirically. Cardiopulmonary resuscitation is equally applied, but is out of proportion to expected survival.
BACKGROUND: Relatively little attention has been paid to how physicians care for dying patients once an initial decision to forgo life-sustaining treatment is made. OBJECTIVES: To describe characteristics of patients forgoing treatment, determine the range and sequential process of forgoing treatment, and suggest ethical and practice implications. METHODS: Charts of 75 consecutive patients dying at each of 4 hospitals were reviewed for this case series. Two hundred ninety-one (98%) of 297 charts were available for review; 274 patients died in acute care beds and are included in this study. Data collected included patients' diagnoses, mental statuses, lengths of stay, timing of the first decision to forgo treatment, and range and sequence of interventions forgone. MAIN OUTCOME MEASURES: Proportion forgoing life-sustaining treatment, number of interventions forgone and decision times per patient, and ranked order of treatment withdrawal. RESULTS: Two hundred twenty-nine (84%) of 274 patients who died had some intervention forgone before death. Only 35% of patients forgoing life-sustaining treatment were able to participate in decision making. On average, 3.8 interventions were forgone per patient. Resuscitation and/or intubation were generally the first measures withheld; once a patient required ventilatory support, withdrawing ventilatory support was a late decision. CONCLUSIONS: The majority of patients dying at these institutions did so after decisions to limit treatment, but few patients were able to participate in these decisions. Forgoing life-sustaining treatment generally occurred in a sequential manner over several days; the rationale for this stepwise retreat is not, however, clinically or ethically obvious.
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