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Research

Prevalence of symptoms at the end of life in an acute care hospital: a retrospective cohort study

Daniel Kobewka, Paul Ronksley, Dan McIsaac, Sunita Mulpuru and Alan Forster
March 09, 2017 5 (1) E222-E228; DOI: https://doi.org/10.9778/cmajo.20160123
Daniel Kobewka
Department of Medicine (Kobewka, Mulpuru, Forster), Division of General Internal Medicine, The Ottawa Hospital, University of Ottawa; Ottawa Hospital Research Institute (Kobewka, McIsaac, Mulpuru, Forster), Ottawa, Ont.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Department of Anesthesiology and Pain Medicine (McIsaac) - The Ottawa Hospital, University of Ottawa; Performance Measurement (Forster), The Ottawa Hospital, Ottawa, Ont.
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Paul Ronksley
Department of Medicine (Kobewka, Mulpuru, Forster), Division of General Internal Medicine, The Ottawa Hospital, University of Ottawa; Ottawa Hospital Research Institute (Kobewka, McIsaac, Mulpuru, Forster), Ottawa, Ont.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Department of Anesthesiology and Pain Medicine (McIsaac) - The Ottawa Hospital, University of Ottawa; Performance Measurement (Forster), The Ottawa Hospital, Ottawa, Ont.
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Dan McIsaac
Department of Medicine (Kobewka, Mulpuru, Forster), Division of General Internal Medicine, The Ottawa Hospital, University of Ottawa; Ottawa Hospital Research Institute (Kobewka, McIsaac, Mulpuru, Forster), Ottawa, Ont.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Department of Anesthesiology and Pain Medicine (McIsaac) - The Ottawa Hospital, University of Ottawa; Performance Measurement (Forster), The Ottawa Hospital, Ottawa, Ont.
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Sunita Mulpuru
Department of Medicine (Kobewka, Mulpuru, Forster), Division of General Internal Medicine, The Ottawa Hospital, University of Ottawa; Ottawa Hospital Research Institute (Kobewka, McIsaac, Mulpuru, Forster), Ottawa, Ont.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Department of Anesthesiology and Pain Medicine (McIsaac) - The Ottawa Hospital, University of Ottawa; Performance Measurement (Forster), The Ottawa Hospital, Ottawa, Ont.
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Alan Forster
Department of Medicine (Kobewka, Mulpuru, Forster), Division of General Internal Medicine, The Ottawa Hospital, University of Ottawa; Ottawa Hospital Research Institute (Kobewka, McIsaac, Mulpuru, Forster), Ottawa, Ont.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Department of Anesthesiology and Pain Medicine (McIsaac) - The Ottawa Hospital, University of Ottawa; Performance Measurement (Forster), The Ottawa Hospital, Ottawa, Ont.
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    Figure 1

    Patient- and encounter-level characteristics associated with presence of 2 or more symptoms in the last 48 hours of life. *For patients' wishes for resuscitation as documented in the chart 24 hours after admission, the reference category was "not documented." CI = confidence interval, CPR = cardiopulmonary rescusitation, RR = risk ratio.

Tables

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    Table 1: The 10 most common comorbidities in the decedent cohort
    Elixhauser comorbidityPrevalence, no. (%)
    n = 479
    Hypertension196 (40.8)
    Cancer with no metastases157 (32.7)
    Arrythmia145 (30.2)
    Diabetes with complications120 (25.0)
    Cancer with metastases113 (23.5)
    Chronic heart failure105 (21.9)
    Fluid and electrolyte disorders99 (20.6)
    Chronic obstructive pulmonary disease77 (16.0)
    Diabetes without complications75 (15.6)
    Chronic kidney disease61 (12.7)
    • View popup
    Table 2: Symptoms documented in the medical record during the final 48 hours of life, n = 479
    Frequency of symptom(s)No. (%) of patients with each symptom
    n = 479
    PainDyspneaAgitationNauseaTotal with any symptom(s)
    0376 (78.5)373 (77.9)402 (83.9)459 (95.8)272 (56.8)
    149 (10.2)54 (11.3)45 (9.4)12 (2.5)67 (14.0)
    227 (5.6)32 (6.7)14 (2.9)6 (2.5)45 (9.4)
    315 (3.1)13 (2.7)10 (2.1)1 (1.3)44 (9.2)
    48 (1.7)4 (0.8)5 (1.0)0 (0)18 (3.8)
    ≥ 54 (0.8)3 (0.6)3 (0.6)1 (0.6)33 (6.9)
    • View popup
    Table 3: Characteristics of patients with and without 2 or more documented episodes of distressing symptoms in the final 48 hours of life
    Characteristic≥ 2 episodes of distressing symptoms before death, no. (%)*
    n = 140
     < 2 episodes of distressing symptoms before death, no. (%)*
    n = 339
    p value
    Age, yr, mean ± SD74.8 (13.4)73.6 (17.1)0.40
    Female sex76 (54.3)155 (45.6)0.09
    Hospital service at time of death (top 10)
        Intensive care15 (10.7)111 (32.7)< 0.001
        General medicine49 (35.0)87 (25.6)0.05
        Cardiology9 (6.4)33 (6.9)0.3
        Oncology22 (15.7)14 (4.1)< 0.001
        Neurology2 (1.4)12 (3.5)0.4
        Malignant hematology6 (4.3)6 (1.8)0.1
        General surgery5 (3.6)7 (2.1)0.3
        Radiation oncology7 (5.0)5 (1.5)0.1
        Family medicine2 (1.4)8 (2.4)0.7
        Gynecologic oncology5 (3.6)4 (1.2)0.1
    No. of inpatient encounters in the last 6 mo
        076 (54.3)231 (67.9)0.005
        136 (25.7)63 (18.5)0.08
        215 (10.7)24 (7.1)0.20
        35 (3.6)17 (5.0)0.6
        ≥ 48 (5.7)5 (1.5)0.007
    Inpatient days in the last year, mean ± SD14.4 ± 27.110.1 ± 24.10.09
    Patient has a family physician135 (96.4)299 (87.9)0.04
    LOS, median (IQR)17.6 (31.6)13.2 (19.8)0.05
    Predicted mortality0.29 (0.19)0.31 (0.20)0.3
    Elixhauser comorbidity score, mean ± SD15.5 ± 9.311.2 ± 8.5< 0.001
        Q1 -3 to 527 (19.3)103 (30.5)
        Q2 6 to 1225 (17.9)100 (29.6)
        Q3 12 to 1939 (27.9)83 (24.6)
        Q4 19 to 4849 (35.0)52 (15.4)
    Patient wishes for resuscitation documented within 24 hr of admission
        Not documented36 (25.7)100 (29.7)0.4
        Full resuscitation including CPR27 (19.3)71 (20.9)0.7
        Resuscitation but no CPR11 (7.9)51 (15.0)0.04
        No resuscitation66 (47.1)117 (34.4)0.01
    Family present in the last 24 hr of life106 (75.7)272 (80.0)0.3
    Patient wishes for no resuscitation documented in chart at time of death127 (90.7)241 (71.1)< 0.001
    Patient wishes for no resuscitation documented ≤ 24 hr before death18 (12.9)81 (23.9)< 0.001
    Palliative care consulted63 (45.0)81 (23.8)< 0.05

    Note: CPR = cardiopulmonary resuscitation, LOS = length of stay, IQR = interquartile range, SD = standard deviation.

    *Unless otherwise specified.

      • View popup
      Table 4: Representative cases of patients who experienced multiple episodes of distressing symptoms in the final 48 hours of life
      SymptomCase description
      PainDyspneaAgitationNausea
      4000A 65-year-old woman with metastatic squamous cell carcinoma of the nasopharynx admitted because of dysphagia. The patient received a percutaneous endoscopic gastrostomy tube for feeding. She experienced worsening episodic chest pain and dyspnea that worsened over the next 5 weeks that was treated with narcotics as needed and then continuous narcotics. The chart documents that the patient appeared in distress on numerous occasions, but because of a language barrier, it was difficult to know what symptoms she was experiencing. The patient died after a period of agitation and apparent distress that was treated with more narcotics.
      2500An 84-year-old man with metastatic renal cell carcinoma was admitted with delirium secondary to hypercalcemia. He was given intravenous fluids. The patient began experiencing flank pain and dyspnea. Initially, every recorded episode was treated with narcotics, but the following assessment documents that the patient was still complaining of pain. The patient was getting frustrated with the poor pain control. The patient had increasing dyspnea that was treated with benzodiazepines. He died after 3 hours of increasing dyspnea.
      3040A 62-year-old woman with metastatic esophageal cancer presented to hospital with diabetic ketoacidosis, acute kidney injury and malignant ascites. The ketoacidosis was treated, and the kidney injury resolved. The patient was waiting to go to hospice, but developed worsening abdominal pain and severe agitation that was treated with phenobarbital. The phenobarbital was titrated up until the patient was obtunded but calm. The patient passed away shortly after.
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    Prevalence of symptoms at the end of life in an acute care hospital: a retrospective cohort study
    Daniel Kobewka, Paul Ronksley, Dan McIsaac, Sunita Mulpuru, Alan Forster
    Mar 2017, 5 (1) E222-E228; DOI: 10.9778/cmajo.20160123

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    Prevalence of symptoms at the end of life in an acute care hospital: a retrospective cohort study
    Daniel Kobewka, Paul Ronksley, Dan McIsaac, Sunita Mulpuru, Alan Forster
    Mar 2017, 5 (1) E222-E228; DOI: 10.9778/cmajo.20160123
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