Outcomes assessment: at what cost?

Outcomes assessment has become a major focus for evaluating managed care, but little is known about the feasibility and costs of a comprehensive outcomes assessment program. In this pilot study, more than 200 patients who were scheduled for elective hospital admissions were assessed using the Short Form 36. This instrument was mailed to patients the week before admission and three months after discharge. Cost for each complete set of pre- and post surveys was more than $60. Data from the SF-36 suggests that diagnosis-specific instruments and survey timing are necessary, which would increase the cost of outcomes assessment.     

CPR in terminally ill patients?

While limiting and foregoing therapy at the end of life is now accepted on medical, ethical, moral and legal grounds, many Americans continue to die with heroic measures being taken to prevent their death. When the patient does eventually die, attempts are frequently made to revive the patient by performing cardiopulmonary resuscitation (CPR). While CPR may result in the establishment of a perfusing pressure, in almost all instances, the patient succumbs despite advanced life support technology. The widespread adoption of do-not-resuscitate (DNR) protocols has not prevented CPR from being performed on patients, who are unlikely to survive. We present two cases, which highlight the modern American way of dying. We submit that poor end-of-life care may result from physicians discomfort with death, their poor communication skills and their failure to fully comprehend the benefits and limitations of advanced life support technology. Furthermore, we maintain that CPR should only be performed on patients, who are likely to derive benefit from this intervention.     

How do terminally ill patients at home take their medication?

Compliance with prescribed medication was assessed in 111 terminally ill patients referred to a community palliative care team using semistructured interviews and pill counting. One-hundred-and-six patients were prescribed a total of 597 drugs; of these patients, 64 (60%) were noncompliant. Thirty-five patients (33%) took less medication than prescribed, usually due to experiencing, or anxieties about, adverse events; the commonest drugs involved were analgesics. Seventeen patients (16%) took additional medication, usually purchased over the counter in response to inadequate symptom control or to adverse events from other drugs; the most common preparations were vitamins and analgesics. Twelve patients (11%) both took less medication than prescribed and also purchased medication over the counter. Most patients (90%) had two or more prescribers; patients who saw their general practitioners as their main prescriber were more likely to adhere to their prescribed medication. Patients who omitted and/or reduced their medication were more likely to see the hospital as their main prescriber. Drugs prescribed four times daily were most likely to be omitted and/or reduced.     

Are terminally ill patients dying in the ICU suitable for non-heart beating organ donation?

Objective To evaluate the feasibility of implementing a program of controlled non-heart beating organ donation, in patients undergoing the withdrawal of intensive care treatment.Design and setting Prospective observational study. Medical and Surgical ICUs in a tertiary university hospital.Patients Consecutive patients younger than 70 years dying in the ICU after treatment withdrawal for dire neurological prognosis.Measurements and results We analyzed prospectively collected data from the ICU clinical information system. Seventy-three of 516 ICU deaths (13%) were identified, equally distributed among traumatic, stroke, and anoxic brain injury. The management and the course in these three diagnostic categories were similar. All patients underwent withdrawal of mechanical ventilation and half were extubated. Median time to death was of 4.8 h (IQR 1.4–11.5). In 70% of cases the patient received analgesia and 30% sedation. Such treatment was not related to earlier death. Hypotension was observed in 50% of patients during the 30 min preceding cardiac death.Conclusions With our current management of terminal patients controlled non-heart beating organ procedure may be difficult due to the duration and variability of the dying process. This observation suggests that we can perform better by evaluating this process moreclosely.Electronic supplementary material The electronic reference of this article is . The online full-text version of this article includes electronic supplementary material. This material is available to authorised users and can be accessed by means of the ESM button beneath the abstract or in the structured full-text article. To cite or link to this article you can use the above reference.René Chioléro and Luca Imperatori are members of the SwissFoundation to Support Organ Donation.     

Publish or perish, but at what cost?

The academic scientific enterprise rewards those with the longest CVs and the most publications. Under pressure to generate voluminous output, scientists often fall prey to double publishing, self plagiarism, and submitting the "minimal publishable unit." Are these ethical gray areas, or true transgressions?     

Ten years’ activity of the first Italian public hospice for terminally ill patients

We present a review of the first 10 years of the hospice at the Geriatric Institute Pio Albergo Trivulzio of Milan, Italys first public hospice for the admission of terminally ill patients. Over 1200 patients were admitted to the nine-bed hospice between October 1991 and December 2001, most of whom (63%) were referred by the Home Palliative Care Units operating in Milan. The hospice patients are elderly (nearly 60% are 70 or more years of age, median 72 years). Admission to the hospice was until the patients death (74% of patients) after a brief time (4 weeks on average). From the very outset, we have striven to focus our attention on the daily application of the programmes of care inspired by the philosophy and practice of palliative medicine, i.e. the holistic approach and attention devoted to quality of life, multidimensional assessment, and the services of a multiprofessional team to provide, alongside medical and nursing assistance, psychosocial and spiritual support, bereavement support, etc. The continuing education of health workers and the systematic use of a clinical audit tool specifically designed for palliative care, are the two key elements which, in our judgement, have proved to be the most fruitful in reaching the objectives described above. These 10 years of the Pio Albergo Trivulzio Hospice have made a significant contribution towards defining a concrete Italian model which can be applied to the care of the terminally ill inpatient.     

At what cost care?

This paper looks at the concept of care in nursing and considers the ever-changing focus relative to the meaning of the term care and how this care is delivered by nursing staff. In the process of looking at these issues it examines the theoretical and practical issues and how these factors have changed considerably over the last twenty-five years. This examination touches upon some of the intermingled and not mutually exclusive issues which surround care and caring such as technology, stress and burnout, bureaucracy, fiscal policy, the humanness of the nurse and the ever changing nature of care delivery. Many readers will be able to relate to the issues discussed and understand how some of these factors tend to get in the way of one another and affect good patient care and outcomes.     

When to treat dehydration in a terminally ill patient?

 The need to treat dehydration in terminally ill patients has become a very controversial topic. Numerous reports in the literature illustrate opposing viewpoints from both clinical and ethical perspectives. Arguments for the maintenance of hydration in terminally ill patients have tended to come from "the traditional medical model". Many health care professionals looking after terminally ill patients have reacted to the generalized use of intravenous fluids in dying patients and the perceived negative effects of this management. Our palliative care group has argued that the viewpoint that dehydration in dying patients is not a cause of symptom distress overlooks commonly reported problems, such as agitated delirium, that can be prevented or reversed by the management of dehydration. This review presents a summary of the traditional arguments, a different perspective on the controversy, biochemical parameters reported in terminally ill cancer patients, recent dehydration research, and the use of hypodermoclysis and rectal hydration. We conclude that the data reported to date are insufficient to allow a final conclusion on the benefit or harm of dehydration in terminally ill patients. Nevertheless, it is worth considering that while some dying patients may not suffer any ill effects from dehydration, there may be others who do manifest symptoms, such as confusion or opioid toxicity, that might be alleviated or prevented by parenteral hydration.     

Death of terminally ill patients on a stretcher in the emergency department: a French speciality?

OBJECTIVES: To determine the frequency, modalities of admission and management of terminally ill patients who died on a stretcher in an emergency department (ED). DESIGN AND SETTING: Retrospective study in an ED of a university hospital. METHODS: Current place of residence, modalities of admission in ED, mortality probability scores and type of management were extracted for each patient in the terminal stage of chronic disease who died on a stretcher in our ED during a 3year period. RESULTS: Of 159 deaths observed in the ED, 56 (35%) concerned terminally ill patients. The illness was a malignancy in 22 cases, a neurological disease in 22 cases and a cardiopulmonary disease in 12 cases. Most of the patients were referred by their regular doctor. Seventy-two percent of the malignancy patients were living at home, 55% of the neurological patients came from nursing facilities and 58% of the cardio-respiratory patients came from the hospital. In 73%, 83% and 23% of the patients with malignancy, cardiopulmonary and neurological diseases, respectively, admission was related to the evolution of the chronic disease. Severity of illness on admission was similar whatever the disease. Request for compassionate end-of-life care was expressed in only 12.5%. At the ED, 91% of patients with neurological diseases received palliative support care. Supportive therapy was undertaken in one third of patients with malignancy or cardiopulmonary disease. CONCLUSION: An ED may be used as a place for dying for some terminally ill patients. This could be related to the legal opposition to withdrawal or withholding of life-support therapies as well as the absence of guidelines from scientific bodies.