Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine

Purpose: To review clinical interventions designed to change care at the end of life. Data Sources: Published results of clinical trials identified by MEDLINE searches, review of abstracts from mee...

Can Clinical Interventions Change Care at the End of Life

Objectives:The need for better understanding of end-of-life care has never been greater. Debate about recent U.S. healthcare system reforms has highlighted that end-of-life decision-making is contentious. Providing compassionate end-of-life care that is appropriate and in accordance with patient wis

Patient and healthcare professional factors influencing end-of-life decision-making during critical illness: a systematic review.

Although increasing numbers of very elderly patients are requiring intensive care, few large sample studies have investigated ICU admission of very elderly patients. Data on pre triage by physicians from other specialities is limited. This observational cohort study aims at examining inter-hospital variability of ICU admission rates and its association with patients’ outcomes. All patients over 80 years possibly qualifying for ICU admission who presented to the emergency departments (ED) of 15 hospitals in the Paris (France) area during a one-year period were prospectively included in the study. Main outcome measures were ICU eligibility, as assessed by the ED and ICU physicians; in-hospital mortality; and vital and functional status 6 months after the ED visit. 2646 patients (median age 86; interquartile range 83–91) were included in the study. 94% of participants completed follow-up (n=2495). 12.4% (n=329) of participants were deemed eligible for ICU admission by ED physicians and intensivists. The overall in-hospital and 6-month mortality rates were respectively 27.2% (n=717) and 50.7% (n=1264). At six months, 57.5% (n=1433) of patients had died or had a functional deterioration. Rates of patients deemed eligible for ICU admission ranged from 5.6% to 38.8% across the participating centers, and this variability persisted after adjustment for patients’ characteristics. Despite this variability, we found no association between level of ICU eligibility and either in-hospital death or six-month death or functional deterioration. In France, the likelihood that a very elderly person will be admitted to an ICU varies widely from one hospital to another. Influence of intensive care admission on patients’ outcome remains unclear. Trial Registration: ClinicalTrials.gov NCT00912600

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Variability of Intensive Care Admission Decisions for the Very Elderly

Older people (those aged 65 years and over) are the major users of health care services, especially acute hospital beds. Since the creation of the NHS there has been concern that older people inappropriately occupy acute hospital beds when their needs would be best served by other forms of care. Many factors have been associated with delayed discharge (age, sex, multiple pathology, dependency and administrative inefficiencies). However, many of these factors are interrelated (or confounded) and few studies have taken this into account. Using data from a large study of assessment of older patients upon discharge from hospital in England, this paper examines the extent of delayed discharge, and analyses the factors associated with such delays using a conceptual model of individual and organisational factors. Specifically, this paper evaluates the relative contribution of the following factors to the delayed discharge of older people from hospital: predisposing factors (such as age), enabling factors (availability of a family carer), vulnerability factors (dependency and multiple pathology), and organisational/administrative factors (referral for services, type of team undertaking assessments). The study was a retrospective patient case note review in three hospitals in England and included four hundred and fifty-six patients aged 75 years and over admitted from their own homes, and discharged from specialist elderly care wards. Of the 456 patients in the sample, 27% had a recorded delay in their discharge from hospital of three plus days. Multivariate statistical analysis revealed that three factors independently predicted delay in discharge: absence of a family carer, entry to a nursing/residential home, and discharge assessment team staffing. Delayed discharge was not related to the hypothesised vulnerability factors (multiple dependency and multiple pathology) nor to predisposing factors (such as age or whether the older person lived alone). The delayed discharge of older people from hospital is a topic of considerable policy relevance. Our study indicated that delay was independently related to two organisational issues. First, entry into long-term care entailed lengthy assessment procedures, uncertainty over who pays for this care, and waiting lists. Second, the nature of the team assessing people for discharge was associated with delay (the nurse-coordinated team made the fewest referrals for multidisciplinary assessments and had the longest delays). Additionally, the absence of a family carer was implicated in delay, which underlines the importance of family and friends in providing posthospital care and in maintaining older people in the community. Our study suggests that considerable delay in discharging older people from hospital originates from administrative/organisational issues; these were compounded by social services resource constraints. There is still much to be done therefore to improve coordination of care in order to provide a truly 'seamless service'.

Older patients and delayed discharge from hospital.

OBJECTIVES: To determine what treatment decisions physicians will make when faced with a hypothetical incompetent elderly patient with life-threatening gastrointestinal bleeding and to examine the relative importance of physician characteristics and factors (legal and ethical concerns, hospital costs, level of dementia, patient9s age, physician9s religion, patient9s wishes and family9s wishes) in making those decisions. DESIGN: Survey. SETTING: Family practice, medical and geriatrics rounds in academic medical centres and community hospitals in seven countries. PARTICIPANTS: Physicians who regularly cared for incompetent elderly patients. MAIN OUTCOME MEASURES: A self-administered questionnaire describing the elderly patient. Respondents were asked to choose one of four levels of care and to identify the level of importance factors had in making that decision. Older physicians, those less concerned about litigation, those for whom the level of dementia was important and those for whom the patient9s age was important were expected to give less aggressive care than the other physicians. MAIN RESULTS: Supportive care was chosen by 8.1% of the respondents, limited therapeutic care by 41.5%, maximum therapeutic care without admission to the intensive care unit (ICU) by 32.2% and maximum care with admission to the ICU by 18.2%. The patient9s wishes were reported by 91.0% as being extremely or very important in choosing the treatment. Stepwise logistic regression analysis revealed that the following variables independently predicted the level of treatment: level of dementia, country of residence, duration of practice, legal concerns, patient9s age and ethical concerns. These factors were significantly correlated with the physicians9 treatment choices (p less than 0.05). CONCLUSIONS: The importance that the physicians placed on the level of dementia was the strongest predictor of the level of care that would be provided. A societal consensus on the influence of cognitive function on the appropriate level of care as well as training of physicians in ethical issues are required.

Paul Finucane

Papers

Factors affecting physicians' decisions on caring for an incompetent elderly patient: an international study