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Researchers examine factors affecting the quality of end-of-life care

Despite the ideal of dying at home surrounded by loved ones, most people in the United States die in hospitals. Hospitalized patients and their families want alleviation of symptoms such as pain and shortness of breath, the opportunity to talk with doctors and others about death and dying, and knowledge that they will be attended to and comforted by their doctors as they approach death. Two recent studies that were supported in part by the Agency for Healthcare Research and Quality focus on end-of-life care and are summarized here.

Auerbach, A.D., and Pantilat, S.Z. (2004, May). "End-of-life care in a voluntary hospitalist model: Effects on communication, processes of care, and patient symptoms." (AHRQ grant K08 HS11416).  American Journal of Medicine 116, pp. 669-675.

In many hospitals, hospitalists (hospital-based internists) now assume responsibility for the care of hospitalized patients, while primary care physicians resume care after discharge. This study found that hospitalists at a community-based teaching hospital documented substantial efforts to communicate with dying patients and their families. This approach may have resulted in improved end-of-life care, conclude the researchers. They examined the charts of 148 patients who had died at a community-based urban teaching hospital to compare the end-of-life care provided by community physicians and hospitalists to similar patients.

After patients were admitted to the hospital, hospitalists discussed care with them or their families more often than community physicians (91 vs. 73 percent), and the hospitalists were more likely to document these discussions themselves. Among patients who were "full code" at admission (that is, there were no do-not-resuscitate or other advanced directives to withhold care), there was a trend toward patients of hospitalists receiving comfort care more often at the time of death (50 vs. 37 percent) than patients of community physicians. Although there were no differences in the use of medication such as long-acting opioids, patients of hospitalists were more likely to have no symptoms in the 48 hours prior to death than patients of community-based physicians (47 vs. 31 percent).

These results suggest that there are advantages to the availability of hospitalists to discuss end-of-life care with patients. In addition, the greater inpatient experience of hospitalists with acute illness may have enabled them to better recognize when patients were nearing death, prompting more frequent discussions about their care.

Bryce, C.L., Loewenstein, G., Arnold, R.M., and others (2004, May). "Quality of death: Assessing the importance placed on end-of-life treatment in the intensive-care unit." (HS11620). Medical Care 42(5), pp. 423-431.

Hospital intensive care unit (ICU) patients value the end-of-life care they receive in the ICU, according to a recent survey. Three-fourths of 104 community respondents surveyed were prepared to shorten a healthy life for better end-of-life ICU care. Survey scenarios described the experiences of six hypothetical patients. Each patient lived for 80 years in good health before becoming ill and being admitted to the ICU, and each patient died after 30 days in the ICU.

While in the ICU, patients received different end-of-life care. Mr. A's care was poor in all four domains: he experienced moderate pain, he could not alter his surroundings or environment while in the ICU, he was not consulted about his medical care preferences, and his family was not provided with counseling or support services. In contrast, the other patients had better ICU experiences.

Those surveyed were willing to trade a median time of 8.3 months of good health for improvement in all domains of end-of-life care. Respondents who were older, minority, or had children traded significantly less time, whereas those who did not perceive the ICU to be a caring environment traded more time. There was considerable variation among respondents in the time they were willing to trade, highlighting the importance of soliciting individual preferences about end-of-life care. That most respondents were willing to trade a substantial duration of healthy life for better end-of-life ICU care supports the contention that end-of-life care matters. It also suggests that traditional methods to calculate quality-adjusted life years may underestimate the true value of this care to society.

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