Q J Med 2003; 96: 777-778
© 2003 Association of Physicians
Correspondence |
Dying from heart failure in hospital
Sir,The course of heart failure (HF) is difficult to predict.1 The quality of life in patients with advanced HF is often poor, and death happens in the hospital even when the patients have already been placed in community-based, long-term care.2 Consequently, end-of-life management policies are needed to address hospitalized end-stage HF patients. We evaluated whether an educational intervention had a positive impact in the quality of the palliative care provided to elderly HF patients who die in the hospital.
In a previous observational study focused on 118 patients who died from end-stage HF in our hospital (a tertiary 1000-bed teaching centre), we reported low rates of palliative care provision.1 To address that issue, we developed an educational program whose aims and content were disseminated at a general hospital meeting, and at another meeting specifically designed for the members of the Internal Medicine Service. Both doctors and nurses received training on the basic palliative measures available for the care of all terminal HF patients. Specific training was also offered to our medical students, and our medical residents, in the setting of a post-graduate teaching course.
In the following months, patients admitted to the Internal Medicine ward because of end-stage chronic obstructive pulmonary disease, dementia or HF were systematically identified.4 The methods used have been described in detail in previous reports:3–4 briefly, we retrospectively reviewed the medical records of all consecutive elderly patients (64 years of age or older) who died from end-stage HF. Exclusion criteria were: incomplete data, sudden death, death within the first 48 h following admission, or death caused by another disease unrelated to HF. All written information concerning do-not-resuscitate (DNR) orders, graduation of therapeutic decisions, information provided to relatives about the prognosis of the disease, total withdrawal from ‘supportive’ therapy and provision of palliative care was abstracted from the medical records. Post-intervention data were tabulated and compared with pre-intervention data using conventional descriptive statistics (
2 test, and Student’s t test) All tests were two-sided, with p = 0.05 as the criterion for statistical significance.
Table 1 shows the study results. Mean age was similar in both groups, but a slightly higher prevalence of women and shorter length of stay was observed in the post-intervention cohort. These results confirm that, in the absence of specific training, only DNR orders are implemented in a substantial proportion of cases, probably meaning that doctors and nurses are most aware of this component of palliative care provision. Indeed, performance in this particular aspect of palliation increased only slightly after the educational intervention, probably implying limited room for improvement. However, the remaining components of palliative care improved significantly after the intervention. It should be noted that the rate of information provided to relatives was probably higher than reported in both groups, since this specific intervention is not usually recorded in the medical charts. To clarify how persistent the effects of this educational intervention are, will need a further evaluation.
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The competence in geriatrics of general internists should be a subject of interest in Internal Medicine Postgraduate training programs.1 Considering that many terminal HF patients die in the hospital environment, in many cases while admitted to an Internal Medicine Service, the future care procedures of these Services should include end-of-life policies aimed at the improvement of the comfort and well-being of the patients who have reached the final stages of the disease.
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Geriatric Unit Internal Medicine Service Hospital Universitari de Bellvitge L‘Hospitalet de Llobregat Barcelona Spain e-mail: fformiga{at}csub.scs.es
References
1. Jaagosild P, Dawson NV, Thomas CH, Wenger NS, Tsevat J, Knaus WA, et al. Outcomes of acute exacerbation of severe congestive heart disease. Quality of life, resource use and survival. Arch Intern Med 1998; 158:1081–9.
2. Fried TR, Pollack DM, Drickamen MA, Tinetti ME. Who dies at home? Determinants of site of death for community-base long term care patients. J Am Geriatr Soc 1999; 47:25–9.[Web of Science][Medline]
3. Formiga F, Espel E, Chivite D, Pujol R. Dying from heart failure in the hospital: palliative decision making analysis. Heart 2002; 88:187.
4. Formiga F, Vivanco V, Cuapio Y, Porta J, Gomez-Batiste X, Pujol R. Morir en el hospital por enfermedad terminal no oncológica: Análisis de la toma de decisiones. Med Clin (Barc) 2003; 121:95–7.[CrossRef][Medline]
5. Cleary LM, Lesky L, Schulz HJ, Smith L. Geriatrics in internal medicine clerkships and residencies: current status and opportunities. Am J Med 2001; 11:738–41.
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