Caring for dying patients needs better physician communication

by Michael Smith

Clinicians treating dying patients did well in managing pain but fell short on communicating with patients and their loved ones, researchers said.

The findings, from a single-institution study, suggest that those who care for terminal patients also often failed to assess shortness of breath in a dying patient whose mechanical ventilation was withdrawn, according to Anne Walling, MD, of the University of California Los Angeles, and colleagues.

But overall those caring for dying patients met 16 quality indicators 70% of the time, Walling and colleagues said in the June 28 issue of Archives of Internal Medicine.

While aggressive medical care is the rule in U.S. hospitals, “when lifesaving treatments are unsuccessful, patients often die in the hospital with distressing symptoms while receiving burdensome care,” the authors said.

But there has been no systematic and clinically detailed measurement of the quality of care planning, palliation, and symptom management among dying inpatients, Walling and colleagues said.

To begin to fill that gap, they used 16 quality indicators from the Assessing Care of Vulnerable Elders set of measures and medical records to assess how almost 500 dying patients were treated at the University of California Los Angeles Medical Center, a 600-bed quaternary care university hospital.

The 16 quality indicators were divided into three domains — goals of care, pain, and dyspnea — and for each patient, the score was one if the recommended care process was undertaken and zero otherwise. Since some quality indicators could be triggered several times by the same patients, a score between zero and one was possible.

All told, for the 496 patients, the 16 indicators were triggered 3,046 times and the treating clinicians performed correctly 70% of the time, the researchers said.

But they dropped the ball on several indicators, Walling and colleagues said. Specifically:

* Within 48 hours of intensive care unit admission, the quality indicators suggest, the record should show that the patient’s preferences for care were considered or that an attempt was made to identify them. The indicator applied to 396 patients, but was met just 40% of the time.
* If a patient had an implantable cardioverter/defibrillator and was either in hospice care or died an expected death the device should have been deactivated or the record should show why it wasn’t. That only applied to 12 patients, but was only followed 25% of the time.
* When a non-comatose patient is not expected to survive and a mechanical ventilator is withdrawn or withheld, the chart should document whether the patient has dyspnea and the patient should get (or have orders available for) an opiate/benzodiazepine/barbiturate infusion. That was the case for 83 patients, but only 29% were assessed. On the other hand, 99% got the appropriate treatment for shortness of breath.
* A patient with chronic pain treated with opioids should be offered treatment for possible constipation or the record should show why not. That applied to 460 patients but was followed only 61% of the time.

On the other hand, Walling and colleagues said, the clinical teams were on the ball with regard to treatment and follow-up assessment of pain, at 95% and 81% respectively.

The findings suggest that “while many areas of measured care are good, key aspects of care need improvement,” Walling and colleagues argued.

However, the analysis is subject to some limitations, they noted. For one thing, they said, the patients in the sample all died; it is possible that those who recover and leave hospital receive different levels of care, especially with regard to goals of care.

As well, they said, the evaluation took place at a single center, using medical records that were three or four years old, and needs to be repeated elsewhere.

Michael Smith is a MedPage Today North American Correspondent.

Originally published in MedPage Today. Visit MedPageToday.com for more geriatrics news.

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