Differences in end of life care in patients who died with dementia during acute hospital admissions
SIR—We have read with great interest the study of Sampson et al. [1] focusing on the care received by dying patients with and without dementia on acute medical wards to identify differences between them. This issue has also been our concern [2], and we welcome other studies about this poorly analysed problem. Nevertheless, we suggest that next prospective studies should include only terminal patients (i.e. patients who fulfil the criteria of National Hospice Organization Medical Guidelines Task Force to refer patients with selective non-cancer diseases to palliative care programs) [3]. Neoplastic patients must be analysed separately, because they have, usually, a different specific approach. In our opinion, patients who had died suddenly or because of another condition should be excluded, although the main diagnosis is dementia, when palliative care is the ‘item’ to be assessed.With this idea, we have evaluated the circumstances of death in 293 patients aged >64 years, who died consecutively in a tertiary teaching hospital from terminal dementia (46%), terminal heart failure (31%) and terminal chronic obstructive pulmonary disease (COPD) (23%) [4]. All patients met the criteria to refer patients to palliative care programs [3]. The cause of hospital admission was a medical problem in the totality of patients. Patients were excluded if they had died suddenly or because of another condition. To evaluate palliative care decision-making, we recorded the medical chart records of each patient and collected written information on: do not resuscitate (DNR) instructions, graduation of therapeutic decisions and information provided to relatives on the prognosis of the disease. Withdrawal of unnecessary drug treatment for the control of symptoms and provision of terminal care were also assessed. In demented patients, DNR orders were specified in 35% of cases, graduation of therapeutic decisions in 11% and knowledge of the prognosis by relatives in 67%. Drug withdrawal was carried out in 70% and palliative care in 69% patients. DNR orders were present with equal frequency in all groups. In the dementia subgroup, the compliment of the graduation of therapeutic decisions was lower, but the percentage of information to relatives higher (P < 0.002), and also, drug withdrawal was more frequent (P < 0.005) with respect to heart failure patients (P < 0.002). When compared with COPD, in dementia patients, the percentage of drug withdrawal (P < 0.01) was higher.
Both studies [1, 4] suggest that provision of palliative care to elderly patients, in acute care hospitals, at their last admission before death because of dementia and other non-oncological end-stage diseases must be improved. Randomised controlled trials are necessary to determine the most appropriate interventions and most effective method of delivery of care of non-malignant diseases such as dementia [5].
Geriatric Unit, Internal Medicine Service, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
* To whom correspondence should be addressed at: Email: fformiga{at}csub.scs.es
References
- Sampson EL, Gould V, Lee D, Blanchard MR. Differences in care received by patients with and without dementia who died during acute hospital admissions: a retrospective case note study. Age Ageing 2006; 35: 187–9.
[Free Full Text] - Formiga F, Olmedo C, Lopez-Soto A, Pujol R. Dying from severe dementia in the hospital: palliative decision making analysis. Aging Clin Exp Res 2004; 16: 420–1.[ISI][Medline]
- National Hospice Organization. Medical Guidelines Task Force. Medical Guidelines for Determining Prognosis in Selected Noncancer Diseases, 2nd edition. Arlington, VA: National Hospice Organization, 1996.
- Formiga F, Vivanco V, Cuapio Y, Porta J, Gómez-Batiste X, Pujol R. Morir en el hospital por enfermedad terminal no oncológica: análisis de la toma de decisiones. Med Clin (Barc) 2003; 121: 95–7.[CrossRef][Medline]
- Bayer A. Death with dementia-the need for better care. Age Ageing 2006; 35: 101–2.
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