Chart review of patients who died in the hospital was used to describe the
pattern of end-of-life decision-making and care for hospitalized dying pati
ents and to propose a structured process of assessing the suitability of pa
tients for palliative care. The setting was a large urban academic medical
center, and the sample comprised 200 of 205 consecutive adult deaths during
the first 4 months of 1996. The main outcome measures were identification
of the patient as dying, do-not-resuscitate (DNR) orders, and comfort care
plans.
Charts of 72% of the patients had evidence that they were considered dying:
DNR orders were in place for 77% of all the patients, and 46% had comfort
care plans. Presence of a health care proxy was significantly associated wi
th DNR orders and comfort care plans (P < 0.001). On average, comfort care
plans were put in place 15 days after admission, as compared with art overa
ll mean length of stay of 17 days. Substantial proportions of patients with
comfort care plans continued to receive antibiotics (41%) and blood draws
(30%). Only 13% of the patients on mechanical ventilation and 19% of those
on artificial nutrition and hydration underwent withdrawal of these interve
ntions prior to death.
These findings suggest opportunities and challenges for improving practice
patterns for hospitalized dying patients. We recommend several measurable o
bjectives for evaluating end-of-life decision-making and care and propose t
he development of a goals of care assessment tool to guide appropriate tran
sitions from life-sustaining treatment to comfort care and plan palliative
services. (C) U.S. Cancer Pain Relief Committee, 1998.