Economics at the end of life: hospital and ICU perspectives

Not all feasible care is desirable care. At the end of life, aggressive interventions may not only be futile but also inappropriate because they may impair the quality of the remaining life for both the patient and the caregiver. Although it is challenging to identify patients with a poor prognosis, certain terminal conditions among the elderly, such as end-stage dementia, heart failure, and metastatic cancer, demand a more measured use of aggressive care. Frank discussions with patients and family about their desires in the context of the prognosis, as well as symptom support, can yield both economic savings and better quality of life.     

Factors important to patients' quality of life at the end of life

BACKGROUND When curative treatments are no longer options for patients dying of cancer, the focus of care often turns from prolonging life to promoting quality of life (QOL). Few data exist on what predicts better QOL at the end of life (EOL) for advanced cancer patients. The purpose of this study was to determine the factors that most influence QOL at the EOL, thereby identifying promising targets for interventions to promote QOL at the EOL. METHODS Coping With Cancer is a US multisite, prospective, longitudinal cohort study of 396 advanced cancer patients and their informal caregivers who were enrolled from September 1, 2002, through February 28, 2008. Patients were followed up from enrollment to death a median of 4.1 months later. Patient QOL in the last week of life was a primary outcome of Coping With Cancer and the present report. RESULTS The following set of 9 factors, preceded by a sign indicating the direction of the effect and presented in rank order of importance, explained the most variance in patients' QOL at the EOL: 1?=?(-) intensive care unit stays in the final week (explained 4.4% of the variance in QOL at the EOL), 2?=?(-) hospital deaths (2.7%), 3?=?(-) patient worry at baseline (2.7%), 4?=?(+) religious prayer or meditation at baseline (2.5%), 5?=?site of cancer care (1.8%), 6?=?(-) feeding-tube use in the final week (1.1%), 7?=?(+) pastoral care within the hospital or clinic (1.0%), 8?=?(-) chemotherapy in the final week (0.8%), and 9?=?(+) patient-physician therapeutic alliance at baseline (0.7%). The vast majority of the variance in QOL at the EOL, however, remained unexplained. CONCLUSION Advanced cancer patients who avoid hospitalizations and the intensive care unit, who are less worried, who pray or meditate, who are visited by a pastor in the hospital/clinic, and who feel a therapeutic alliance with their physicians have the highest QOL at the EOL.     

老年人血清白蛋白影响因素初步分析

目的 探讨老年人血清白蛋白水平可能存在的影响因素.方法 对267名60岁以上老年人进行健康体检,测量体质量,询问既往病史,并记录居住区域城乡分布、职业种类、饮食习惯、每日饮食摄入量、婚姻状况、睡眠状况、精神状态等一般情况.检测血清白蛋白、总蛋白、谷丙转氨酶、血清肌酐等生化指标.按不同影响因素分组比较.结果 与老龄组比较,高龄老人组血清白蛋白值较低[（35.6±3.4） vs （38.2±3.2） g/L,P＜0.01];与女性组相比,男性组血清白蛋白值较低[（ 36.4±3.5） vs（ 38.2± 3.2） g/L,P＜0.01];与荤食组相比,素食组血清白蛋白值较低[（34.8±2.1）vs（ 37.6±3.5） g/L,P＜ 0.01];与正常摄入组相比,低摄入组血清白蛋白值较低[（35.4±3.6） vs（ 37.7±3.3） g/L,P＜0.01];与合居组比较,独居（单身、丧偶）组血清白蛋白值较低[（35.6±3.4） vs（ 37.9±3.3） g/L,P＜ 0.01];与睡眠良好组相比,失眠组血清白蛋白值较低[（ 36.0±3.4） vs（ 38.2±3.2） g/L,P＜0.01];与精神状态良好组比较,焦虑或抑郁组血清白蛋白值较低[（ 35.7±3.8） vs（ 37.4±3.4） g/L,P＜0.01];不同地区分布,城镇组与农村组相比以及不同职业间,体力劳动组与脑力劳动组相比血清白蛋白水平未见差异.线性回归分析显示,血清白蛋白水平与年龄成负相关（r=-0.196,P＜0.01）,与体质量（r=0.133,P＜0.01）及总蛋白（r=0.282,P＜ 0.01）呈正相关.与谷丙转氨酶、肌酐未见明显相关性.结论 老年人血清白蛋白水平可能受多种因素影响,包括年龄、性别、饮食情况、每日饮食摄入量、婚姻状况、睡眠情况、精神状态等因素影响,并随年龄的增加降低,与体质量、总蛋白水平变化一致.     

Ethics at the end of life

Some of the physician’s most difficult decisions involve whether to give cardiopulmonary resuscitation (CPR). Current research, hospital policies, and case law provide little guidance for these decisions, but medical ethics offers three useful principles. All three are based on patients’ wishes. First, a victim of cardiopulmonary arrest should receive CPR unless compelling reasons indicate he would not want it. Second, a patient has the right to refuse CPR. Finally, if CPR will serve no therapeutic goals defined from the patient’s wishes, it should not be given. Applying these principles requires a sympathetic, directed history which elicits the patient’s wishes relevant to resuscitation. This article uses an actual case and a simple algorithm to show how these principles promote ethically sound resuscitation decisions. Received from the Division of General Medicine, Department of Medicine, The University of Texas Health Science Center, San Antonio, Texas.     

Quality of life at end of life

Patients with chronic kidney disease, particularly those with diabetes, often have a heavy burden of vascular comorbidity and hence a poor overall prognosis. Unfortunately, patients and their healthcare teams often have unrealistic expectations about outcomes and receive ineffective and often harmful interventions towards their end of life. We need to move away from death being perceived as a failure and realise, instead, that our goal of care at the end of life is to achieve as good a quality of life for the patient as possible. To be able to achieve this, it is important to be realistic about prognosis, be able to recognise predictors of poor outcome and then be able to discuss these with the patient and their family to ensure symptom control, avoid interventions that could do harm and then as the end approaches, determine the wishes of the patient regarding preferred place of care for their inevitable death.     

Hospice care at the end of life

Hospice care in the United States has evolved from a movement and philosophy to a new medical specialty that addresses sources of suffering at many levels. Hospice interdisciplinary teams use Maslow's hierarchy of human need to integrate the multiple domains that influence patients' well-being and assists in the development of treatment plans to prevent or alleviate suffering. Contributing to the effectiveness of this care is the Medicare Hospice Benefit, which since 1983 has served as a model and a reimbursement mechanism that has encouraged proliferation of hospices to deliver care in homes, hospitals, and long-term care facilities. The whole-person approach of hospice care may benefit all patients and can be integrated into all medical management.     

Nurturing hope at the end of life

What do older people hope for as they reach the end of their lives and how can professional careers nurture that hope? Drawing on the literature regarding end-of-life care, this paper has particular application for residential aged care but also for a variety of other aged care settings. Hope, in this paper, is not to be equated with some esoteric intangible fantasy; neither is it isolated from the need for impeccable clinical care. While hope may not be scientifically observable it can, nevertheless, be grounded in human care. To nurture hope in the face of death is to enter the dying person's story: to look behind the immediately observable, to ask what life and death mean for this particular person in this particular place at this particular time. Focussing on the everyday lived experience, contrasts will be drawn between realistic hope, wishful thinking, and false consolation. Is it humanly possible to be hope-full in a seemingly hope-less situation? While death can mean the ‘dashing’ of all hopes, this paper provides some practical examples of a ‘good death’ that fosters hope in the face of the inevitable.     

Factors influencing noncompliance with medication regimens in the elderly

Poor medication compliance is a major issue in the health care of older patients. To identify risk factors for medication noncompliance in the elderly, inpatients aged 65 years and older at Nagoya University Hospital and at Chubu National Hospital underwent a comprehensive geriatric assessment and tests for the assessment of medication compliance. The dependency of medication assistance by a caregiver is associated with low physical function activity, cognitive impairment, depression and communication inability. Medication noncompliance was not associated with the score of any component of comprehensive geriatric assessment. There was a good relationship between patient's knowledge of medications and the frequency of dosage interval, both of which were associated with the score of instrumental ADL, cognitive function and communication ability. The knowledge was also associated with the medication compliance at Nagoya University Hospital but not at Chubu National Hospital. These results may suggest that the elderly patient's understanding of a medication regimen is important but that other factors are also required to maintain their treatment regimen.     

Factors influencing prognosis of pneumonia in elderly patients

BACKGROUND AND AIMS: Polymorbidity reduces the survival of elderly patients with pneumonia. The aim of the proposed study was to identify factors determining mortality in such patients. METHODS: From January 1, 1999 to December 31, 2001, 2870 patients were admitted to the Clinic of Geriatric Medicine, Faculty of Medicine, Comenius University, Bratislava. From these, 199 patients treated for pneumonia (average age +/- SD 79.7 +/- 7.6 yr) were assigned to a retrospective study. 112 patients recovered and 87 died. The prognostic significance of the chosen factors was evaluated by comparing their incidence between the groups of surviving and non-surviving patients. RESULTS: Prognosis for patients with pneumonia is worsened significantly by: older age; immobilization syndrome; incontinence of urine and feces; presence of some clinical and laboratory characteristics at the time of diagnosis of pneumonia (respiratory insufficiency, absence of fever, leukocytosis); pneumonia acquired in hospital; immunosuppressive therapy and comorbid conditions (congestive heart failure, chronic renal insufficiency, anemia, hepatic, psychiatric and neoplastic diseases). According to multivariate analysis, the most significant mortality-predicting characteristics were: immobilization (odds ratio (OR) 9.36; 95% confidence interval (CI) 3.92-22.33); congestive heart failure (OR 8.26; 95% CI 3.08-22.14); immunosuppressive therapy (OR 7.47; 95% CI 2.54-21.98) and psychiatric diseases (OR 4.53; 95% CI 1.94-10.58). CONCLUSIONS: Patients with immobilization, congestive heart failure, immunosuppressive therapy, or psychiatric diseases run a high risk of death and require intensive medical care.