Care of the dying patient: the last hours or days of life.
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ABSTRACT:
SUBMITTER: Ellershaw J
PROVIDER: S-EPMC1124925 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:A clinical practice guideline for patients in the dying process in general wards and their families, developed through an evidence-based process, is presented herein. The purpose of this guideline is to enable a peaceful death based on an understanding of suitable management of patients' physical and mental symptoms, psychological support, appropriate decision-making, family care, and clearly-defined team roles. Although there are limits to the available evidence regarding medical issues in patients facing death, the final recommendations were determined from expert advice and feedback, considering values and preferences related to medical treatment, benefits and harms, and applicability in the real world. This guideline should be applied in a way that takes into account specific health care environments, including the resources of medical staff and differences in the available resources of each institution. This guideline can be used by all medical institutions in South Korea.
| S-EPMC10332720 | biostudies-literature
Project description:PurposeWe sought to analyze trends in radiation therapy (RT) technology use and costs in the last 30 days of life for patients dying as a result of cancer.MethodsWe used the Surveillance, Epidemiology, and End Results (SEER) -Medicare and Texas Cancer Registry-Medicare databases to analyze claims data for 13,488 patients dying as a result of lung, breast, prostate, colorectal, melanoma, and pancreas cancers from 2000 to 2009. Logistic regression modeling was used to conduct adjusted analyses regarding influence of demographic, clinical, and health services variables on receipt of types of RT. Costs were calculated in 2009 US dollars.ResultsThe proportion of patients treated with two-dimensional RT decreased from 74.9% of those receiving RT in the last 30 days of life in 2000 to 32.7% in 2009 (P < .001). Those receiving three-dimensional RT increased from 27.2% in 2000 to 58.5% in 2009 (P < .001). The proportion of patients treated with intensity-modulated radiation therapy in the last 30 days of life increased from 0% in 2000 to 6.2% in 2009 (P < .001), and those undergoing stereotactic radiosurgery increased from 0% in 2000 to 5.0% in 2009 (P < .001). The adjusted mean costs of per-patient RT services delivered in the last 30 days of life were higher in the years 2007 to 2009.ConclusionAmong patients receiving RT in the last month of life, there was a shift away from the simplest technique toward more advanced RT technologies. Studies are needed to ascertain whether these technology shifts improve palliative outcomes and quality of life for patients dying as a result of cancer who receive RT services.
| S-EPMC4094648 | biostudies-literature
Project description:BackgroundHigh-quality end-of-life (EOL) care requires both comfort care and the maintenance of dignity. However, delivering EOL in the emergency department (ED) is often challenging. Therefore, we aimed to investigate characteristics of EOL care for dying patients in the ED.MethodsWe conducted a retrospective cohort study of patients who died of disease in the ED at a tertiary hospital in Korea between January 2018 and December 2020. We examined medical care within the last 24 h of life and advance care planning (ACP) status.ResultsOf all 222 disease-related mortalities, 140 (63.1%) were men, while 141 (63.5%) had cancer. The median age was 74 years. As for critical care, 61 (27.5%) patients received cardiopulmonary resuscitation, while 80 (36.0%) received mechanical ventilation. The absence of serious illness (p = 0.011) and the lack of an advance statement (p < 0.001) were both independently associated with the receipt of more critical care. Only 70 (31.5%) patients received comfort care through opioids. Younger patients (< 75 years) (p = 0.002) and those who completed life-sustaining treatment legal forms (p = 0.001) received more comfort care. While EOL discussions were initiated in 150 (67.6%) cases, the palliative care team was involved only in 29 (13.1%).ConclusionsPatients in the ED underwent more aggressive care and less comfort care in a state of imminent death. To ensure better EOL care, physicians should minimize redundant evaluations and promptly introduce ACP.
| S-EPMC9170493 | biostudies-literature
Project description:BackgroundFew studies have described the settings cancer decedents spend their end-of-life stage, with none considering homecare specifically. We describe the different settings of care experienced in the last 100 days of life by individuals with cancer and how settings of care change as they approached death.MethodsA retrospective cohort study from January 2013 to December 2017, of decedents whose primary cause of death was cancer, using linked population-level health administrative datasets in Ontario, Canada.ResultsDecedents 125,755 were included in our cohort. The average age at death was 73, 46% were female, and 14% resided in rural regions. And 24% died of lung cancer, 7% breast, 7% colorectal, 7% pancreatic, 5% prostate, and 50% other cancers. In the last 100 days of life, decedents spent 25.9 days in institutions, 25.8 days receiving care in the community, and 48.3 days at home without any care. Individuals who died of lung and pancreatic cancers spent the most days at home without any care (52.1 and 52.6 days), while individuals who died of prostate and breast cancer spent the least days at home without any care (41.6 and 45.1 days). Regardless of cancer type, decedents spent fewer days at home and more days in institutions as they approached death, despite established patient preferences for an end-of-life experience at home.ConclusionsIn the last 100 days of life, cancer decedents spent most of their time in either institutions or at home without any care. Improving homecare services during the end-of-life may provide people dying of cancer with a preferred dying experience.
| S-EPMC9972173 | biostudies-literature
Project description:ObjectivesTo analyse patterns of use and costs of unscheduled National Health Service (NHS) services for people in the last year of life.DesignRetrospective cohort analysis of national datasets with application of standard UK costings.Participants and settingAll people who died in Scotland in 2016 aged 18 or older (N=56 407).Main outcome measuresFrequency of use of the five unscheduled NHS services in the last 12 months of life by underlying cause of death, patient demographics, Continuous Unscheduled Pathways (CUPs) followed by patients during each care episode, total NHS and per-patient costs.Results53 509 patients (94.9%) had at least one contact with an unscheduled care service during their last year of life (472 360 contacts), with 34.2% in the last month of life. By linking patient contacts during each episode of care, we identified 206 841 CUPs, with 133 980 (64.8%) starting out-of-hours. People with cancer were more likely to contact the NHS telephone advice line (63%) (χ2 (4)=1004, p<0.001) or primary care out-of-hours (62%) (χ2 (4)=1924,p<0.001) and have hospital admissions (88%) (χ2 (4)=2644, p<0.001). People with organ failure (79%) contacted the ambulance service most frequently (χ2 (4)=584, p<0.001). Demographic factors associated with more unscheduled care were older age, social deprivation, living in own home and dying of cancer. People dying with organ failure formed the largest group in the cohort and had the highest NHS costs as a group. The cost of providing services in the community was estimated at 3.9% of total unscheduled care costs despite handling most out-of-hours calls.ConclusionsOver 90% of people used NHS unscheduled care in their last year of life. Different underlying causes of death and demographic factors impacted on initial access and subsequent pathways of care. Managing more unscheduled care episodes in the community has the potential to reduce hospital admissions and overall costs.
| S-EPMC7684800 | biostudies-literature
Project description:BackgroundThe impact of assisted hydration on symptoms and survival at the end of life is unclear. Little is known about optimal strategies for communicating and decision-making about this ethically complex topic. Hydration near end of life is known to be an important topic for family members, but conversations about assisted hydration occur infrequently despite guidance suggesting these should occur with all dying people.AimTo explore the views and experiences of doctors experienced in end-of-life care regarding communicating with patients and families and making decisions about assisted hydration at the end of life.DesignQualitative study involving framework analysis of data from semi-structured interviews.Setting/participantsSixteen UK-based Geriatrics and Palliative Medicine doctors were recruited from hospitals, hospices and community services from October 2019 to October 2020.ResultsParticipants reported clinical, practical and ethical challenges associated with this topic. The hospital setting provides barriers to high-quality communication with dying patients and their families about assisted hydration, which may contribute to the low incidence of documented assisted hydration-related conversations. Workplace culture in some hospices may make truly individualised decision-making about this topic more difficult. Lack of inclusion of patients in decision-making about assisted hydration appears to be common practice.ConclusionsProactive, routine discussion with dying people about hydration-related issues is indicated in all cases. There is room for debate regarding the limits of shared decision-making and the benefits of routine discussion of assisted hydration with all dying people. Clinicians have to navigate multiple barriers as they strive to provide individualised care.
| S-EPMC9248002 | biostudies-literature
Project description:BackgroundThe Neuberger review made a number of recommendations to improve end of life care, including research into the biology of dying. An important aspect of the biology of dying is the identification of biomarkers as indices of disease processes. Biomarkers have the potential to inform the current, limited understanding of the dying process and assist clinicians in recognising dying, in particular how to distinguish dying from reversible acute deterioration.ObjectivesTo critically appraise the literature on biological factors that may be used as prognostic indicators in advanced cancer patients and to identify candidate biomarkers of the dying process that can be measured serially in cancer patients' bodily fluids.MethodsA systematically structured review was conducted using three electronic databases. A hand search of six peer-reviewed journals and conference abstracts was also conducted. Studies reporting prognostic biomarkers in cancer patients with a median survival of ≤90 days and post-mortem studies were included. Final levels of evidence and recommendations were made using the Evidence Based Medicine modified GRADE system.Results30 articles were included. Seven prognostic biological factors demonstrated Grade A evidence (lymphocyte count, white blood cell count, serum C-reactive protein, albumin, sodium, urea and alkaline phosphatase). An additional eleven prognostic factors were identified with Grade B evidence (platelet count, international normalised ratio, serum vitamin B12, prealbumin, bilirubin, cholesterol, aspartate aminotransferase, alanine transaminase, lactate dehydrogenase, pseudocholinesterase and urate). A number of biomarkers were specifically identified in the last two weeks of life but limitations exist. No post-mortem studies met the inclusion criteria.ConclusionThe biology of dying is an important area for future research, with the evidence focused on signs, symptoms and prognostic factors. This review identifies a number of common themes shared amongst advanced cancer patients and highlights candidate biomarkers which may be indicative of a common biological process to dying.
| S-EPMC5383239 | biostudies-literature
Project description:We explore how and why the Liverpool Care Pathway (LCP) for the dying patient was transferred to 20 countries beyond the UK, and with what consequences for policy and practice. Our paper synthesises findings from 95 publications contained in a historical narrative literature review on the implementation of the LCP outside the United Kingdom, alongside data from 18 qualitative interviews with 19 key actors involved with the LCP in 14 countries. We use the review to explore the timelines and patterns of development and implementation in the specific countries, to consider what forms of research and evaluation about the LCP were undertaken to establish its effectiveness, and to summarise the resulting findings and their consequences. We use the interviews to gain insights into the elements, processes and dynamics that shaped the transfer and translation of the LCP from one location to another, across national boundaries. Using six questions from the policy transfer literature we then explain who were the key actors involved; what was transferred; from where lessons were drawn; the different degrees of transfer that took place; what restricted or facilitated transfer; and how transfer was related to 'success' or 'failure'. We conclude that the spread of the LCP took place mostly in prosperous countries, and was sustained over around 15 years. It took in differing geographies and cultures, and a variety of linguistic, policy and practice contexts. If it did not succeed in a wider transformational goal, it appears to have been well received and perceived as beneficial in many contexts, largely avoiding accusations of mis-use and harm that had occurred in the UK, and in some cases fostering a sustained international collaboration and ongoing use of local variants, even after withdrawal in its country of origin in 2014.
| S-EPMC7726848 | biostudies-literature
Project description:BackgroundThe Care Programme for the Last Days of Life has been developed to improve the quality of end-of-life care in acute geriatric hospital wards. The programme is based on existing end-of-life care programmes but modeled to the acute geriatric care setting. There is a lack of evidence of the effectiveness of end-of-life care programmes and the effects that may be achieved in patients dying in an acute geriatric hospital setting are unknown. The aim of this paper is to describe the research protocol of a cluster randomized controlled trial to evaluate the effects of the Care Programme for the Last Days of Life.Methods and designA cluster randomized controlled trial will be conducted. Ten hospitals with one or more acute geriatric wards will conduct a one-year baseline assessment during which care will be provided as usual. For each patient dying in the ward, a questionnaire will be filled in by a nurse, a physician and a family carer. At the end of the baseline assessment hospitals will be randomized to receive intervention (implementation of the Care Programme) or no intervention. Subsequently, the Care Programme will be implemented in the intervention hospitals over a six-month period. A one-year post-intervention assessment will be performed immediately after the baseline assessment in the control hospitals and after the implementation period in the intervention hospitals. Primary outcomes are symptom frequency and symptom burden of patients in the last 48 hours of life.DiscussionThis will be the first cluster randomized controlled trial to evaluate the effect of the Care Programme for the Last Days of Life for the acute geriatric hospital setting. The results will enable us to evaluate whether implementation of the Care Programme has positive effects on end-of-life care during the last days of life in this patient population and which components of the Care Programme contribute to improving the quality of end-of-life care.Trial registrationClinicalTrials.gov Identifier: NCT01890239. Registered June 24th, 2013.
| S-EPMC4340777 | biostudies-literature
Project description:OBJECTIVES:The aims of this study were (1) to document the clinical condition of patients considered to be in the last 2?weeks of life and (2) to compare patients who did or did not survive for 72?hours. DESIGN:A prospective observational study. SETTING:Two sites in London, UK (a hospice and a hospital palliative care team). PARTICIPANTS:Any inpatient, over 18 years old, English speaking, who was identified by the palliative care team as at risk of dying within the next 2?weeks was eligible. OUTCOME MEASURES:Prognostic signs and symptoms were documented at a one off assessment and patients were followed up 7 days later to determine whether or not they had died. RESULTS:Fifty participants were recruited and 24/50 (48%) died within 72?hours of assessment. The most prevalent prognostic features observed were a decrease in oral food intake (60%) and a rapid decline of the participant's global health status (56%). Participants who died within 72?hours had a lower level of consciousness and had more care needs than those who lived longer. A large portion of data was unavailable, particularly that relating to the psychological and spiritual well-being of the patient, due to the decreased consciousness of the patient. CONCLUSIONS:The prevalence of prognostic signs and symptoms in the final days of life has been documented between those predicted to die and those who did not. How doctors make decisions with missing information is an area for future research, in addition to understanding the best way to use the available information to make more accurate predictions.
| S-EPMC6624101 | biostudies-literature