Article Figures & Tables
Figures
- 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
Elixhauser comorbidity Prevalence, no. (%)
n = 479Hypertension 196 (40.8) Cancer with no metastases 157 (32.7) Arrythmia 145 (30.2) Diabetes with complications 120 (25.0) Cancer with metastases 113 (23.5) Chronic heart failure 105 (21.9) Fluid and electrolyte disorders 99 (20.6) Chronic obstructive pulmonary disease 77 (16.0) Diabetes without complications 75 (15.6) Chronic kidney disease 61 (12.7) - 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 = 479Pain Dyspnea Agitation Nausea Total with any symptom(s) 0 376 (78.5) 373 (77.9) 402 (83.9) 459 (95.8) 272 (56.8) 1 49 (10.2) 54 (11.3) 45 (9.4) 12 (2.5) 67 (14.0) 2 27 (5.6) 32 (6.7) 14 (2.9) 6 (2.5) 45 (9.4) 3 15 (3.1) 13 (2.7) 10 (2.1) 1 (1.3) 44 (9.2) 4 8 (1.7) 4 (0.8) 5 (1.0) 0 (0) 18 (3.8) ≥ 5 4 (0.8) 3 (0.6) 3 (0.6) 1 (0.6) 33 (6.9) - 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 = 339p value Age, yr, mean ± SD 74.8 (13.4) 73.6 (17.1) 0.40 Female sex 76 (54.3) 155 (45.6) 0.09 Hospital service at time of death (top 10) Intensive care 15 (10.7) 111 (32.7) < 0.001 General medicine 49 (35.0) 87 (25.6) 0.05 Cardiology 9 (6.4) 33 (6.9) 0.3 Oncology 22 (15.7) 14 (4.1) < 0.001 Neurology 2 (1.4) 12 (3.5) 0.4 Malignant hematology 6 (4.3) 6 (1.8) 0.1 General surgery 5 (3.6) 7 (2.1) 0.3 Radiation oncology 7 (5.0) 5 (1.5) 0.1 Family medicine 2 (1.4) 8 (2.4) 0.7 Gynecologic oncology 5 (3.6) 4 (1.2) 0.1 No. of inpatient encounters in the last 6 mo 0 76 (54.3) 231 (67.9) 0.005 1 36 (25.7) 63 (18.5) 0.08 2 15 (10.7) 24 (7.1) 0.20 3 5 (3.6) 17 (5.0) 0.6 ≥ 4 8 (5.7) 5 (1.5) 0.007 Inpatient days in the last year, mean ± SD 14.4 ± 27.1 10.1 ± 24.1 0.09 Patient has a family physician 135 (96.4) 299 (87.9) 0.04 LOS, median (IQR) 17.6 (31.6) 13.2 (19.8) 0.05 Predicted mortality 0.29 (0.19) 0.31 (0.20) 0.3 Elixhauser comorbidity score, mean ± SD 15.5 ± 9.3 11.2 ± 8.5 < 0.001 Q1 -3 to 5 27 (19.3) 103 (30.5) Q2 6 to 12 25 (17.9) 100 (29.6) Q3 12 to 19 39 (27.9) 83 (24.6) Q4 19 to 48 49 (35.0) 52 (15.4) Patient wishes for resuscitation documented within 24 hr of admission Not documented 36 (25.7) 100 (29.7) 0.4 Full resuscitation including CPR 27 (19.3) 71 (20.9) 0.7 Resuscitation but no CPR 11 (7.9) 51 (15.0) 0.04 No resuscitation 66 (47.1) 117 (34.4) 0.01 Family present in the last 24 hr of life 106 (75.7) 272 (80.0) 0.3 Patient wishes for no resuscitation documented in chart at time of death 127 (90.7) 241 (71.1) < 0.001 Patient wishes for no resuscitation documented ≤ 24 hr before death 18 (12.9) 81 (23.9) < 0.001 Palliative care consulted 63 (45.0) 81 (23.8) < 0.05 Note: CPR = cardiopulmonary resuscitation, LOS = length of stay, IQR = interquartile range, SD = standard deviation.
*Unless otherwise specified.
- Table 4: Representative cases of patients who experienced multiple episodes of distressing symptoms in the final 48 hours of life
Symptom Case description Pain Dyspnea Agitation Nausea 4 0 0 0 A 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. 2 5 0 0 An 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. 3 0 4 0 A 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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