- Email: [email protected]
Issues at the End of Life
Issues at the End of Life Anthony Breu,
MD*,
Joseph Ming Wah Li,
MD, SFHM
KEYWORDS End of life Inpatient mortality Advance directives Code status
HOSPITAL MEDICINE CLINICS CHECKLIST
1. Most Americans die outside their homes, with a wide variation in the location of death depending on region. 2. Only 18.3% of patients 65 years and older who undergo cardiopulmonary resuscitation (CPR) survive to hospital discharge. 3. Between 60% and 70% of those placed on mechanical ventilation survive to discharge. 4. Rapid-response teams are associated with a reduction in cardiopulmonary arrests outside intensive care units (ICUs) but not with reduction in inpatient mortality. 5. Only 10% of hospitalized patients have been engaged in a code discussion within 24 hours of hospitalization. 6. In patients with advance directives, most physicians are still unaware of their preferences. The Physician Order for Life-Sustaining Treatment (POLST)/ Medical Order for Life-Sustaining Treatment (MOLST) form can help inform providers of patient wishes.
EPIDEMIOLOGY OF INPATIENT MORTALITY
1. Where do patients die? Although many patients prefer to die at home,1 many do not. One trial examining patients with congestive heart failure showed that 58% died in the hospital and just 29% died at home.2 Similar numbers are seen for patients who have cancer and, although there have been some shifts over time, there have been no substantial
Division of General Internal Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Span 221, Boston, MA 02115, USA * Corresponding author. E-mail address: [email protected] Hosp Med Clin 1 (2012) e124–e131 doi:10.1016/j.ehmc.2011.10.003 2211-5943/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
End of Life
changes in the last 6 decades; studies dating back to the 1950s to 1980s show that 60% to 70% of patients with cancer died in acute and chronic care hospitals.3,4 For the population as a whole, the percentage of those dying in hospital decreased from 54% to 41% between 1980 and 1998.5 Hospital and nursing homes combined account for 67% of the sites of patients’ death, leaving less than 40% dying at home.6 The percentage of patients dying in hospital varies depending on region,5,7 with some states (eg, Utah, Colorado, Arizona, Idaho, Oregon) having less than the national average and others (eg, New York, New Jersey, Mississippi, South Carolina, Hawaii) having more.8 2. What are the most common admission diagnoses and most common causes of death in hospitals? According to the most recent data from the Healthcare Cost and Utilization Project,9 as of 2007, the 10 most common admission diagnoses are: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Pneumonia (3% of diagnoses) Congestive heart failure (2.6%) Coronary artery disease (2.4%) Osteoarthritis (2.1%) Nonspecific chest pain (2.0%) Depression and bipolar disorder (2.0%) Cardiac dysrhythmias (1.8%) Septicemia (1.7%) Disorders or the intervertebral discs and bones in the spinal column (1.6%) Acute myocardial infarction (1.6%).
The same data show that pneumonia is the most common cause of death in adults, followed by septicemia, myocardial infarction, congestive heart failure, stroke, and respiratory failure. The 10 conditions with the highest number of in-hospital deaths by age group are listed in Table 1. 3. What percentage of hospitalized patients die in the hospital and what conditions have the highest inpatient mortality? Approximately 2% to 3% of patients admitted to the hospital do not survive to discharge.10 The inpatient mortality is depends largely on the admitting diagnosis and age. Although medicine has made great progress in the last century, with the average life expectancy increasing from to 49.2 years of age at the turn of the century to 77.9 years of age in 2007,11 many conditions remain morbid despite the best efforts. According to the most recent data from the Healthcare Cost and Utilization Project,12 the 10 conditions with the highest inpatient mortality are: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Cardiac arrest (53.6% inpatient mortality) Shock (51.5%) Intrauterine hypoxia and birth asphyxia (27.6%) Cancer, unspecified (24.2%) Adult respiratory failure or arrest (22.5%) Aspiration pneumonitis (18.3%) Septicemia (17.6%) Cancer, liver and bile duct (16.3%) Leukemia (16.1%) Cancer, lung (14.6%).
e125
e126
Breu & Li
Table 1 The 10 conditions with the highest number of in-hospital deaths (by age group) Age-Related Rank (y) Diagnosis
18–44
45–65
65–84
85D
Pneumonia
6
5
1
1
Septicemia
4
2
4
2
Myocardial infarction
—
6
2
3
Congestive heart failure
—
8
6
4
Stroke
3
1
3
5
Respiratory failure
7
4
5
6
Fluid and electrolyte disorders
—
—
10
7
Hip fracture
—
—
—
8
Gastrointestinal bleeding
—
—
—
9
Intestinal obstruction
—
—
—
10
Aspiration pneumonitis
—
—
7
—
Metastasis
5
3
8
—
Cancer, lung
—
7
9
—
Brain injury
1
—
—
—
AIDS/HIV
2
—
—
—
Crush injury or internal injury
8
—
—
—
Liver disease, other
10
9
—
—
Alcoholic liver disease
9
10
—
—
Abbreviations: AIDS, acquired immune deficiency syndrome; HIV, human immunodeficiency virus.
Both cardiac arrest and respiratory failure are among the 5 diagnoses with the highest mortality, which highlights the importance of both CPR and intubation with mechanical ventilation in modern medicine. Understanding the basis of these interventions, both historically and for their success rates, improves the hospitalist’s ability to guide patients and their families during the discussion about the role of these interventions. CPR AND MECHANICAL VENTILATION
1. When were cardiopulmonary respiration and intubation with mechanical ventilation introduced? Defibrillation and CPR were introduced in the 1950s and early 1960s respectively.13,14 Until the introduction of CPR, open chest cardiac massage was the only option available to aid an arrested heart. The implementation of these techniques, especially as the coordinated maneuvers now used, allowed physicians (and later the lay public) the opportunity to alter the end of life, often for good, but sometimes to the medical community’s shock and dismay.15 For those more than 65 years of age, the rate of CPR is 2.73 per 1000 admissions.16 The use of external devices to aid those with respiratory failure has a longer history, with the twentieth century seeing the necessity for negative pressure ventilation (socalled iron lungs) to support scores of polio victims. Around the middle of the century, positive pressure ventilation administered via endotrachial intubation became the standard of care.
End of Life
2. What percentage of patients undergoing in-hospital CPR and mechanical ventilation survive to discharge? Just 18.3% of patients more than 65 years old who undergo in-hospital CPR survive to discharge, with less than half of those being discharged to home,16 and this meager success rate has not changed in the last 2 decades, despite the best efforts.17 Moreover, there is a discrepancy between outcomes for ventricular tachycardia and fibrillation compared with either pulseless electrical activity or asystole. Pulseless electrical activity and asystole portend a worst chance of survival. Overall, 4.2% of all hospital deaths are preceded by CPR.16 The in-hospital mortality for patients with respiratory failure requiring mechanical ventilation are varied, but slightly better than for CPR. Approximately 60% to 70% of patients survive to discharge, with a wide variety of diagnoses.18,19 On average, patients whose cause for acute respiratory failure is trauma, postoperative effects, aspiration, or congestive heart failure have higher survival rates compared with those with sepsis, acquired respiratory distress syndrome, and cardiac arrest.18 3. Have either rapid-response or code-blue teams affected the outcomes in patients undergoing CPR? Rapid-response teams (RRTs) appeared in the early 2000s in response to a recognition that many patients display physiologic clues to deterioration before cardiac arrest. RRTs are typically composed of a multidisciplinary team of medical, nursing, and respiratory therapy staff. Many have hypothesized that RRTs could reduce mortality through increased attention to patients in the critical window before a cardiac arrest. A 2010 meta-analysis examined 18 studies of RRTs and found that their use was associated with a 33.8% reduction in rates of cardiopulmonary arrest outside the intensive care unit. There was no difference in-hospital mortality.20 Although more common, traditional code-blue teams have been less rigorously studied. One single-center trial showed an improvement in the percentage of patients with a recorded return in spontaneous circulation (58% vs 30%) and survival to discharge (6% vs 18%).21 CODE STATUS, DO NOT RESUSCITATE/DO NOT INTUBATE ORDERS, AND ADVANCE DIRECTIVES
1. What does code status entail and when was the concept introduced? In most circumstances, a patient’s code status is an enumerated description of a patient’s wishes in the event of cardiac or respiratory arrest. Patients are often designated as being either Full Code or Do Not Resuscitate (DNR)/Do Not Intubate (DNI), with the former indicating that all life-saving interventions are expected, up to and including CPR and mechanical ventilation. Alternatively, patients may request that these maneuvers not be done; in such circumstances, a DNR or DNI order may be placed. After the introduction of CPR and mechanical ventilation, some patients were subjected to these interventions despite their requests that they be withheld.15 A response to this development was the emergence of DNR orders, first appearing in the 1970s.22–26 As described by Burns and colleagues,25 these orders “marked a pivotal change in the delivery of medical care, for instead of instructing others to deliver treatment, it was the first order to direct the withholding of treatment.” Largely the result of an increasing awareness that CPR often led to increased patient suffering and that
e127
e128
Breu & Li
hospitals were using their own informal systems to ensure that patients were not subjected to these interventions despite their wishes, these orders have become commonplace. Most of the initial orders did not distinguish between intubation with mechanical ventilation and the use of CPR and included both decisions into a particular order not to resuscitate. The first appearance of separate orders for DNR and DNI was in 1985,26 with the increasing use of both of these terms continuing to the present day. 2. What percentage of patients have a code status discussion and order while in hospital? Despite the importance of ensuring that patient preferences are acknowledged and enforced, as few as 10% are engaged in code status discussions within 24 hours of admission to the hospital.27 Even in patients who had undergone a cardiac arrest, a retrospective analysis showed that less than 20% had a discussion before the arrest.28 The landmark SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) trial showed that only 47% of physicians knew when their patients preferred to avoid CPR.29 Independent of these discussions, approximately 60% of patients have specific code status orders, with 10% of those orders delineated as DNR.30,31 3. What is the Patient Self-Determination Act and what is the prevalence of advance directives? Passed by Congress in 1990, the Patient Self-Determination Act (PSDA) became law in 1991. It requires hospitals to give patients written notice, on admission, of their decision-making rights and policies regarding advance directives.32 Advance directives have existed in some form since the 1970s and are designed to further patient autonomy. The importance of planned decision making is noted by a study of nearly 4000 patients more than 60 years of age showing that 29.8% required decision making at the end of life but lacked decision-making capacity.33 Those without previously defined wishes require some version of surrogate decision making. The percentage of elderly patients with advanced directives has increased since their first usage, with up to 70% of community-dwelling elders having completed them, according to some studies.34,35 However, survey data suggest that advance directives remain underused, with some finding that less than 30% of patients have living wills.35 FUTURE DIRECTIONS
1. What is a POLST (MOLST)? The POLST (sometimes known MOLST) was developed in Oregon in the 1990s to address concerns that preferences for life-sustaining treatments were not conveyed adequately between health care settings.36 Designed for patients with progressive illness or frailty, these forms expand on traditional code status orders to include a range of life-sustaining treatments (eg, use of artificial nutrition, dialysis, antibiotics) and are meant to have the weight of a physician’s order. As of early 2011, more than 30 states either have endorsed or are developing versions of the POLST.37 Although their merits have not been fully evaluated, early studies suggest that they facilitate documentation of a range of treatments and are associated with lower rates of unwanted hospitalizations.38–40
End of Life
ETHICS AT THE OF END OF LIFE
1. What is the current legal status of physician-assisted suicide and euthanasia? Physician-assisted suicide (PAS) is currently legal in 2 states. Oregon passed the Death with Dignity Act in 1994, followed in 2009 by Washington State’s version of the same. These laws allow patients with less than 6 months to live to have access to a lethal dose of medications, prescribed by their physician, so that the patient may end his or her life. The Supreme Court has ruled in this issue 3 times. In 1997, it ruled that states could ban PAS41 and that “the distinction between assisting suicide and withdrawing life sustaining treatment, a distinction widely recognized and endorsed in the medical profession and in our legal traditions, is both important and logical.”42 However, the Court did not overturn the Oregon law allowing PAS in the 2006 case Gonzalez v. Oregon.43 In essence, states are currently afforded the freedom to pass laws for or against the practice. Euthanasia is currently not legal in any state. 2. What are physicians’ opinions regarding the use of PAS and euthanasia? Many physicians are placed in the position of being asked to participate in either PAS or euthanasia.44 Opinions regarding the ethical justification, proposed legality, and personal participation in PAS and euthanasia vary widely. One review suggested that fewer than 50% think that either PAS or euthanasia is morally justified. Although there is inconsistency regarding the support for legalization, few physicians report that they would participate in either if they were legal.45 GUIDELINES AND STATEMENTS American College of Physicians
Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2008;148:141–6. American Medical Association
http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/about-ethicsgroup/ethics-resource-center/end-of-life-care.shtml. REFERENCES
1. Higginson IJ, Sen-Gupta GJ. Place of care in advanced cancer: a qualitative systematic literature review of patient preferences. J Palliat Med 2000;3:287–300. 2. Olshansky B, Wood F, Hellkamp AS, et al. Where patients with mild to moderate heart failure die: results from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT). Am Heart J 2007;153:1089–94. 3. Flynn A, Stewart DE. Where do cancer patients die? A review of cancer deaths in Cuyahoga County, Ohio, 1957–1974. J Community Health 1979;5(2):126–30. 4. McCusker J. Factors affecting place of death of hospice and non-hospice cancer patients. Public Health Rep 1983;98:170–6. 5. Flory J, Young-Xu Y, Gurol I, et al. Place of death: U.S. trends since 1980. Health Aff (Millwood) 2004;23(3):194–200. 6. Teno JM, Clarridge BR, Casey V, et al. Family perspectives on end-of-life care at the last place of care. JAMA 2004;291(1):88–93.
e129
e130
Breu & Li
7. Pritchard RS, Fisher ES, Teno JM, et al. Influence of patient preferences and local health system characteristics on the place of death. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Risks and Outcomes of Treatment. J Am Geriatr Soc 1998;46:1242–50. 8. The Dartmouth Atlas of Health Care. Available at: http://www.dartmouthatlas.org/ data/. Accessed October 26, 2011. 9. Facts and Figures 2007. Healthcare Cost and Utilization Project (HCUP). Rockville (MD): Agency for Healthcare Research and Quality; 2009. Available at: www.hcup-us.ahrq.gov/reports/factsandfigures/2007/exhibit2_1.jsp. Accessed October 26, 2011. 10. Shahian D, Wolf RE, Iezzoni LI, et al. Variability in the measurement of hospitalwide mortality rates. N Engl J Med 2010;363:2530–9. 11. Xu JQ, Kochanek KD, Murphy SL, et al. no 19. Deaths: final data for 2007. National vital statistics reports, vol. 58. Hyattsville (MD): National Center for Health Statistics; 2010. 12. Merrill CT, Elixhauser A. Hospitalization in the United States, 2002. Rockville (MD): Agency for Healthcare Research and Quality; 2005. HCUP fact book no. 6. AHRQ publication no. 05–0056. ISBN 1-58763-217-9. 13. Kouwenhoven WB, Milnor WR, Knickerbocker GG, et al. Closed chest defibrillation of the heart. Surgery 1957;42:550–61. 14. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA 1960;173(10):1064–7. 15. Symmers WS Sr. Not allowed to die. Br Med J 1968;1(5589):442. 16. Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med 2009;361:22–31. 17. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003;58:297–308. 18. Esteban A, Anzueto A, Frutos F. Characteristics and outcomes in adult patients receiving mechanical ventilation. JAMA 2002;287:345–55. 19. Behrendt CE. Acute respiratory failure in the United States. Chest 2000;118:1100–5. 20. Chan PS, Jain R, Nallmothu BK, et al. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med 2010;170(1):18–26. 21. Henderson S, Ballesteros D. Evaluation of a hospital-wide resuscitation team: does it increase survival for in-hospital cardiopulmonary arrest? Resuscitation 2001;48(2):111–6. 22. Clinical Care Committee of the Massachusetts General Hospital. Optimum care for hopelessly ill patients: a report of the Clinical Care Committee of the Massachusetts General Hospital. N Engl J Med 1976;295:362–4. 23. Rabkin MT, Gillerman G, Rice NR. Orders not to resuscitate. N Engl J Med 1976; 295:364–6. 24. Fried C. Terminating life support: out of the closet! N Engl J Med 1976;295:390–1. 25. Burns JP, Edwards J, Johnson J, et al. Do-not-resuscitate order after 25 years. Crit Care Med 2003;31(5):1543–50. 26. Miles SH, Crimmins TJ. Orders to limit emergency treatment for an ambulance service in a large metropolitan area. JAMA 1985;254:525–7. 27. Auerbach AD, Katz R, Pantilat SZ, et al. Factors associated with discussion of care plans and code status at the time of hospital admission: results from the Multicenter Hospitalist Study. J Hosp Med 2008;3:437–44. 28. Bedell SE, Delbanco TL. Choices about cardiopulmonary resuscitation in the hospital. N Engl J Med 1984;310:1089–93.
End of Life
29. SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients: the study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA 1995;274:1591–8. 30. Calam B, Andrew R. CPR or DNR? End-of-life decision making on a family practice teaching ward. Can Fam Physician 2000;46:340–6. 31. Wenger NS, Pearson ML, Desmond KA, et al. Epidemiology of do-not-resuscitate orders. Disparity by age, diagnosis, gender, race, and functional impairment. Arch Intern Med 1995;155(19):2056–62. 32. Brown BA. The history of advance directives: a literature review. J Gerontol Nurs 2003;29:4–14. 33. Silveira M, Kim S, Langa K. Advance directives and outcomes of surrogate decision making before death. N Engl J Med 2010;362:1211–8. 34. Teno JM, Gruneir A, Schwartz Z, et al. Association between advance directives and quality of end-of life care: a national study. J Am Geriatr Soc 2007;55:189–94. 35. More Americans Discussing – and Planning – End-of-Life Treatment. The Pew Research Center. Available at: http://people-press.org/reports/pdf/266.pdf. 2006:1–45. Accessed October 26, 2011. 36. Dunn PM, Schmidt TA, Carley MM, et al. A method to communicate patient preferences about medically indicated life-sustaining treatment in the out-of-hospital setting. J Am Geriatr Soc 1996;44(7):785–91. 37. National POLST Paradigm Programs. Available at: http://www.ohsu.edu/polst/ programs/state1programs.htm. Accessed October 26, 2011. 38. Hickman SE, Tolle SW, Brummel-Smith K, et al. Use of the Physician Orders for Life-Sustaining Treatment program in Oregon nursing facilities: beyond resuscitation status. J Am Geriatr Soc 2004;52:1424–9. 39. Hickman SE, Nelson CA, Moss AH, et al. Use of the Physician Orders for Life Sustaining Treatment (POLST) Paradigm Program in the hospice setting. J Palliat Med 2009;12:133–41. 40. Lee MA, Brummel-Smith K, Meyer J, et al. Physician orders for life-sustaining treatment (POLST): outcomes in a PACE program. J Am Geriatr Soc 2000;48: 1219–25. 41. Washington v Glucksberg, 117 S. Ct. 2258 (1997). 42. Vacco v Quill, 117 S. Ct. 2293 (1997). 43. Gonzalez v Oregon, 126 S. Ct. 904 (2006). 44. Meier DE, Emmons CA, Wallenstein S, et al. A national survey of physicianassisted suicide and euthanasia in the United States. N Engl J Med 1998;338: 1193. 45. Emanuel EJ. Euthanasia and physician-assisted suicide: a review of the empirical data from the United States. Arch Intern Med 2002;162(2):142–52.
e131
MD*,
Joseph Ming Wah Li,
MD, SFHM
KEYWORDS End of life Inpatient mortality Advance directives Code status
HOSPITAL MEDICINE CLINICS CHECKLIST
1. Most Americans die outside their homes, with a wide variation in the location of death depending on region. 2. Only 18.3% of patients 65 years and older who undergo cardiopulmonary resuscitation (CPR) survive to hospital discharge. 3. Between 60% and 70% of those placed on mechanical ventilation survive to discharge. 4. Rapid-response teams are associated with a reduction in cardiopulmonary arrests outside intensive care units (ICUs) but not with reduction in inpatient mortality. 5. Only 10% of hospitalized patients have been engaged in a code discussion within 24 hours of hospitalization. 6. In patients with advance directives, most physicians are still unaware of their preferences. The Physician Order for Life-Sustaining Treatment (POLST)/ Medical Order for Life-Sustaining Treatment (MOLST) form can help inform providers of patient wishes.
EPIDEMIOLOGY OF INPATIENT MORTALITY
1. Where do patients die? Although many patients prefer to die at home,1 many do not. One trial examining patients with congestive heart failure showed that 58% died in the hospital and just 29% died at home.2 Similar numbers are seen for patients who have cancer and, although there have been some shifts over time, there have been no substantial
Division of General Internal Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Span 221, Boston, MA 02115, USA * Corresponding author. E-mail address: [email protected] Hosp Med Clin 1 (2012) e124–e131 doi:10.1016/j.ehmc.2011.10.003 2211-5943/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
End of Life
changes in the last 6 decades; studies dating back to the 1950s to 1980s show that 60% to 70% of patients with cancer died in acute and chronic care hospitals.3,4 For the population as a whole, the percentage of those dying in hospital decreased from 54% to 41% between 1980 and 1998.5 Hospital and nursing homes combined account for 67% of the sites of patients’ death, leaving less than 40% dying at home.6 The percentage of patients dying in hospital varies depending on region,5,7 with some states (eg, Utah, Colorado, Arizona, Idaho, Oregon) having less than the national average and others (eg, New York, New Jersey, Mississippi, South Carolina, Hawaii) having more.8 2. What are the most common admission diagnoses and most common causes of death in hospitals? According to the most recent data from the Healthcare Cost and Utilization Project,9 as of 2007, the 10 most common admission diagnoses are: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Pneumonia (3% of diagnoses) Congestive heart failure (2.6%) Coronary artery disease (2.4%) Osteoarthritis (2.1%) Nonspecific chest pain (2.0%) Depression and bipolar disorder (2.0%) Cardiac dysrhythmias (1.8%) Septicemia (1.7%) Disorders or the intervertebral discs and bones in the spinal column (1.6%) Acute myocardial infarction (1.6%).
The same data show that pneumonia is the most common cause of death in adults, followed by septicemia, myocardial infarction, congestive heart failure, stroke, and respiratory failure. The 10 conditions with the highest number of in-hospital deaths by age group are listed in Table 1. 3. What percentage of hospitalized patients die in the hospital and what conditions have the highest inpatient mortality? Approximately 2% to 3% of patients admitted to the hospital do not survive to discharge.10 The inpatient mortality is depends largely on the admitting diagnosis and age. Although medicine has made great progress in the last century, with the average life expectancy increasing from to 49.2 years of age at the turn of the century to 77.9 years of age in 2007,11 many conditions remain morbid despite the best efforts. According to the most recent data from the Healthcare Cost and Utilization Project,12 the 10 conditions with the highest inpatient mortality are: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Cardiac arrest (53.6% inpatient mortality) Shock (51.5%) Intrauterine hypoxia and birth asphyxia (27.6%) Cancer, unspecified (24.2%) Adult respiratory failure or arrest (22.5%) Aspiration pneumonitis (18.3%) Septicemia (17.6%) Cancer, liver and bile duct (16.3%) Leukemia (16.1%) Cancer, lung (14.6%).
e125
e126
Breu & Li
Table 1 The 10 conditions with the highest number of in-hospital deaths (by age group) Age-Related Rank (y) Diagnosis
18–44
45–65
65–84
85D
Pneumonia
6
5
1
1
Septicemia
4
2
4
2
Myocardial infarction
—
6
2
3
Congestive heart failure
—
8
6
4
Stroke
3
1
3
5
Respiratory failure
7
4
5
6
Fluid and electrolyte disorders
—
—
10
7
Hip fracture
—
—
—
8
Gastrointestinal bleeding
—
—
—
9
Intestinal obstruction
—
—
—
10
Aspiration pneumonitis
—
—
7
—
Metastasis
5
3
8
—
Cancer, lung
—
7
9
—
Brain injury
1
—
—
—
AIDS/HIV
2
—
—
—
Crush injury or internal injury
8
—
—
—
Liver disease, other
10
9
—
—
Alcoholic liver disease
9
10
—
—
Abbreviations: AIDS, acquired immune deficiency syndrome; HIV, human immunodeficiency virus.
Both cardiac arrest and respiratory failure are among the 5 diagnoses with the highest mortality, which highlights the importance of both CPR and intubation with mechanical ventilation in modern medicine. Understanding the basis of these interventions, both historically and for their success rates, improves the hospitalist’s ability to guide patients and their families during the discussion about the role of these interventions. CPR AND MECHANICAL VENTILATION
1. When were cardiopulmonary respiration and intubation with mechanical ventilation introduced? Defibrillation and CPR were introduced in the 1950s and early 1960s respectively.13,14 Until the introduction of CPR, open chest cardiac massage was the only option available to aid an arrested heart. The implementation of these techniques, especially as the coordinated maneuvers now used, allowed physicians (and later the lay public) the opportunity to alter the end of life, often for good, but sometimes to the medical community’s shock and dismay.15 For those more than 65 years of age, the rate of CPR is 2.73 per 1000 admissions.16 The use of external devices to aid those with respiratory failure has a longer history, with the twentieth century seeing the necessity for negative pressure ventilation (socalled iron lungs) to support scores of polio victims. Around the middle of the century, positive pressure ventilation administered via endotrachial intubation became the standard of care.
End of Life
2. What percentage of patients undergoing in-hospital CPR and mechanical ventilation survive to discharge? Just 18.3% of patients more than 65 years old who undergo in-hospital CPR survive to discharge, with less than half of those being discharged to home,16 and this meager success rate has not changed in the last 2 decades, despite the best efforts.17 Moreover, there is a discrepancy between outcomes for ventricular tachycardia and fibrillation compared with either pulseless electrical activity or asystole. Pulseless electrical activity and asystole portend a worst chance of survival. Overall, 4.2% of all hospital deaths are preceded by CPR.16 The in-hospital mortality for patients with respiratory failure requiring mechanical ventilation are varied, but slightly better than for CPR. Approximately 60% to 70% of patients survive to discharge, with a wide variety of diagnoses.18,19 On average, patients whose cause for acute respiratory failure is trauma, postoperative effects, aspiration, or congestive heart failure have higher survival rates compared with those with sepsis, acquired respiratory distress syndrome, and cardiac arrest.18 3. Have either rapid-response or code-blue teams affected the outcomes in patients undergoing CPR? Rapid-response teams (RRTs) appeared in the early 2000s in response to a recognition that many patients display physiologic clues to deterioration before cardiac arrest. RRTs are typically composed of a multidisciplinary team of medical, nursing, and respiratory therapy staff. Many have hypothesized that RRTs could reduce mortality through increased attention to patients in the critical window before a cardiac arrest. A 2010 meta-analysis examined 18 studies of RRTs and found that their use was associated with a 33.8% reduction in rates of cardiopulmonary arrest outside the intensive care unit. There was no difference in-hospital mortality.20 Although more common, traditional code-blue teams have been less rigorously studied. One single-center trial showed an improvement in the percentage of patients with a recorded return in spontaneous circulation (58% vs 30%) and survival to discharge (6% vs 18%).21 CODE STATUS, DO NOT RESUSCITATE/DO NOT INTUBATE ORDERS, AND ADVANCE DIRECTIVES
1. What does code status entail and when was the concept introduced? In most circumstances, a patient’s code status is an enumerated description of a patient’s wishes in the event of cardiac or respiratory arrest. Patients are often designated as being either Full Code or Do Not Resuscitate (DNR)/Do Not Intubate (DNI), with the former indicating that all life-saving interventions are expected, up to and including CPR and mechanical ventilation. Alternatively, patients may request that these maneuvers not be done; in such circumstances, a DNR or DNI order may be placed. After the introduction of CPR and mechanical ventilation, some patients were subjected to these interventions despite their requests that they be withheld.15 A response to this development was the emergence of DNR orders, first appearing in the 1970s.22–26 As described by Burns and colleagues,25 these orders “marked a pivotal change in the delivery of medical care, for instead of instructing others to deliver treatment, it was the first order to direct the withholding of treatment.” Largely the result of an increasing awareness that CPR often led to increased patient suffering and that
e127
e128
Breu & Li
hospitals were using their own informal systems to ensure that patients were not subjected to these interventions despite their wishes, these orders have become commonplace. Most of the initial orders did not distinguish between intubation with mechanical ventilation and the use of CPR and included both decisions into a particular order not to resuscitate. The first appearance of separate orders for DNR and DNI was in 1985,26 with the increasing use of both of these terms continuing to the present day. 2. What percentage of patients have a code status discussion and order while in hospital? Despite the importance of ensuring that patient preferences are acknowledged and enforced, as few as 10% are engaged in code status discussions within 24 hours of admission to the hospital.27 Even in patients who had undergone a cardiac arrest, a retrospective analysis showed that less than 20% had a discussion before the arrest.28 The landmark SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) trial showed that only 47% of physicians knew when their patients preferred to avoid CPR.29 Independent of these discussions, approximately 60% of patients have specific code status orders, with 10% of those orders delineated as DNR.30,31 3. What is the Patient Self-Determination Act and what is the prevalence of advance directives? Passed by Congress in 1990, the Patient Self-Determination Act (PSDA) became law in 1991. It requires hospitals to give patients written notice, on admission, of their decision-making rights and policies regarding advance directives.32 Advance directives have existed in some form since the 1970s and are designed to further patient autonomy. The importance of planned decision making is noted by a study of nearly 4000 patients more than 60 years of age showing that 29.8% required decision making at the end of life but lacked decision-making capacity.33 Those without previously defined wishes require some version of surrogate decision making. The percentage of elderly patients with advanced directives has increased since their first usage, with up to 70% of community-dwelling elders having completed them, according to some studies.34,35 However, survey data suggest that advance directives remain underused, with some finding that less than 30% of patients have living wills.35 FUTURE DIRECTIONS
1. What is a POLST (MOLST)? The POLST (sometimes known MOLST) was developed in Oregon in the 1990s to address concerns that preferences for life-sustaining treatments were not conveyed adequately between health care settings.36 Designed for patients with progressive illness or frailty, these forms expand on traditional code status orders to include a range of life-sustaining treatments (eg, use of artificial nutrition, dialysis, antibiotics) and are meant to have the weight of a physician’s order. As of early 2011, more than 30 states either have endorsed or are developing versions of the POLST.37 Although their merits have not been fully evaluated, early studies suggest that they facilitate documentation of a range of treatments and are associated with lower rates of unwanted hospitalizations.38–40
End of Life
ETHICS AT THE OF END OF LIFE
1. What is the current legal status of physician-assisted suicide and euthanasia? Physician-assisted suicide (PAS) is currently legal in 2 states. Oregon passed the Death with Dignity Act in 1994, followed in 2009 by Washington State’s version of the same. These laws allow patients with less than 6 months to live to have access to a lethal dose of medications, prescribed by their physician, so that the patient may end his or her life. The Supreme Court has ruled in this issue 3 times. In 1997, it ruled that states could ban PAS41 and that “the distinction between assisting suicide and withdrawing life sustaining treatment, a distinction widely recognized and endorsed in the medical profession and in our legal traditions, is both important and logical.”42 However, the Court did not overturn the Oregon law allowing PAS in the 2006 case Gonzalez v. Oregon.43 In essence, states are currently afforded the freedom to pass laws for or against the practice. Euthanasia is currently not legal in any state. 2. What are physicians’ opinions regarding the use of PAS and euthanasia? Many physicians are placed in the position of being asked to participate in either PAS or euthanasia.44 Opinions regarding the ethical justification, proposed legality, and personal participation in PAS and euthanasia vary widely. One review suggested that fewer than 50% think that either PAS or euthanasia is morally justified. Although there is inconsistency regarding the support for legalization, few physicians report that they would participate in either if they were legal.45 GUIDELINES AND STATEMENTS American College of Physicians
Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2008;148:141–6. American Medical Association
http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/about-ethicsgroup/ethics-resource-center/end-of-life-care.shtml. REFERENCES
1. Higginson IJ, Sen-Gupta GJ. Place of care in advanced cancer: a qualitative systematic literature review of patient preferences. J Palliat Med 2000;3:287–300. 2. Olshansky B, Wood F, Hellkamp AS, et al. Where patients with mild to moderate heart failure die: results from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT). Am Heart J 2007;153:1089–94. 3. Flynn A, Stewart DE. Where do cancer patients die? A review of cancer deaths in Cuyahoga County, Ohio, 1957–1974. J Community Health 1979;5(2):126–30. 4. McCusker J. Factors affecting place of death of hospice and non-hospice cancer patients. Public Health Rep 1983;98:170–6. 5. Flory J, Young-Xu Y, Gurol I, et al. Place of death: U.S. trends since 1980. Health Aff (Millwood) 2004;23(3):194–200. 6. Teno JM, Clarridge BR, Casey V, et al. Family perspectives on end-of-life care at the last place of care. JAMA 2004;291(1):88–93.
e129
e130
Breu & Li
7. Pritchard RS, Fisher ES, Teno JM, et al. Influence of patient preferences and local health system characteristics on the place of death. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Risks and Outcomes of Treatment. J Am Geriatr Soc 1998;46:1242–50. 8. The Dartmouth Atlas of Health Care. Available at: http://www.dartmouthatlas.org/ data/. Accessed October 26, 2011. 9. Facts and Figures 2007. Healthcare Cost and Utilization Project (HCUP). Rockville (MD): Agency for Healthcare Research and Quality; 2009. Available at: www.hcup-us.ahrq.gov/reports/factsandfigures/2007/exhibit2_1.jsp. Accessed October 26, 2011. 10. Shahian D, Wolf RE, Iezzoni LI, et al. Variability in the measurement of hospitalwide mortality rates. N Engl J Med 2010;363:2530–9. 11. Xu JQ, Kochanek KD, Murphy SL, et al. no 19. Deaths: final data for 2007. National vital statistics reports, vol. 58. Hyattsville (MD): National Center for Health Statistics; 2010. 12. Merrill CT, Elixhauser A. Hospitalization in the United States, 2002. Rockville (MD): Agency for Healthcare Research and Quality; 2005. HCUP fact book no. 6. AHRQ publication no. 05–0056. ISBN 1-58763-217-9. 13. Kouwenhoven WB, Milnor WR, Knickerbocker GG, et al. Closed chest defibrillation of the heart. Surgery 1957;42:550–61. 14. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA 1960;173(10):1064–7. 15. Symmers WS Sr. Not allowed to die. Br Med J 1968;1(5589):442. 16. Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med 2009;361:22–31. 17. Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003;58:297–308. 18. Esteban A, Anzueto A, Frutos F. Characteristics and outcomes in adult patients receiving mechanical ventilation. JAMA 2002;287:345–55. 19. Behrendt CE. Acute respiratory failure in the United States. Chest 2000;118:1100–5. 20. Chan PS, Jain R, Nallmothu BK, et al. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med 2010;170(1):18–26. 21. Henderson S, Ballesteros D. Evaluation of a hospital-wide resuscitation team: does it increase survival for in-hospital cardiopulmonary arrest? Resuscitation 2001;48(2):111–6. 22. Clinical Care Committee of the Massachusetts General Hospital. Optimum care for hopelessly ill patients: a report of the Clinical Care Committee of the Massachusetts General Hospital. N Engl J Med 1976;295:362–4. 23. Rabkin MT, Gillerman G, Rice NR. Orders not to resuscitate. N Engl J Med 1976; 295:364–6. 24. Fried C. Terminating life support: out of the closet! N Engl J Med 1976;295:390–1. 25. Burns JP, Edwards J, Johnson J, et al. Do-not-resuscitate order after 25 years. Crit Care Med 2003;31(5):1543–50. 26. Miles SH, Crimmins TJ. Orders to limit emergency treatment for an ambulance service in a large metropolitan area. JAMA 1985;254:525–7. 27. Auerbach AD, Katz R, Pantilat SZ, et al. Factors associated with discussion of care plans and code status at the time of hospital admission: results from the Multicenter Hospitalist Study. J Hosp Med 2008;3:437–44. 28. Bedell SE, Delbanco TL. Choices about cardiopulmonary resuscitation in the hospital. N Engl J Med 1984;310:1089–93.
End of Life
29. SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients: the study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA 1995;274:1591–8. 30. Calam B, Andrew R. CPR or DNR? End-of-life decision making on a family practice teaching ward. Can Fam Physician 2000;46:340–6. 31. Wenger NS, Pearson ML, Desmond KA, et al. Epidemiology of do-not-resuscitate orders. Disparity by age, diagnosis, gender, race, and functional impairment. Arch Intern Med 1995;155(19):2056–62. 32. Brown BA. The history of advance directives: a literature review. J Gerontol Nurs 2003;29:4–14. 33. Silveira M, Kim S, Langa K. Advance directives and outcomes of surrogate decision making before death. N Engl J Med 2010;362:1211–8. 34. Teno JM, Gruneir A, Schwartz Z, et al. Association between advance directives and quality of end-of life care: a national study. J Am Geriatr Soc 2007;55:189–94. 35. More Americans Discussing – and Planning – End-of-Life Treatment. The Pew Research Center. Available at: http://people-press.org/reports/pdf/266.pdf. 2006:1–45. Accessed October 26, 2011. 36. Dunn PM, Schmidt TA, Carley MM, et al. A method to communicate patient preferences about medically indicated life-sustaining treatment in the out-of-hospital setting. J Am Geriatr Soc 1996;44(7):785–91. 37. National POLST Paradigm Programs. Available at: http://www.ohsu.edu/polst/ programs/state1programs.htm. Accessed October 26, 2011. 38. Hickman SE, Tolle SW, Brummel-Smith K, et al. Use of the Physician Orders for Life-Sustaining Treatment program in Oregon nursing facilities: beyond resuscitation status. J Am Geriatr Soc 2004;52:1424–9. 39. Hickman SE, Nelson CA, Moss AH, et al. Use of the Physician Orders for Life Sustaining Treatment (POLST) Paradigm Program in the hospice setting. J Palliat Med 2009;12:133–41. 40. Lee MA, Brummel-Smith K, Meyer J, et al. Physician orders for life-sustaining treatment (POLST): outcomes in a PACE program. J Am Geriatr Soc 2000;48: 1219–25. 41. Washington v Glucksberg, 117 S. Ct. 2258 (1997). 42. Vacco v Quill, 117 S. Ct. 2293 (1997). 43. Gonzalez v Oregon, 126 S. Ct. 904 (2006). 44. Meier DE, Emmons CA, Wallenstein S, et al. A national survey of physicianassisted suicide and euthanasia in the United States. N Engl J Med 1998;338: 1193. 45. Emanuel EJ. Euthanasia and physician-assisted suicide: a review of the empirical data from the United States. Arch Intern Med 2002;162(2):142–52.
e131