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The Liverpool Care Pathway – are patients suffering unnecessarily due to media criticism?

1 Mar, 13 | by Assistant Editor

 

The overwhelming majority (89%) of senior palliative care doctors who responded to a survey carried out for the BMJ and Channel 4’s Dispatches think the Liverpool care pathway (LCP) is the right approach for caring for patients in their final hours, and they would choose it for themselves.

However, almost three quarters (74%) think that recent criticism in the media and elsewhere has led to less use of the LCP. Of these, two-thirds (67%) said patients and relatives had asked them not to use it and 84% said staff were apprehensive about relatives’ complaints.

The results, published on bmj.com today (http://press.psprings.co.uk/bmj/march/Finalresults.xls) – and due to be aired on Channel 4 Dispatches on Monday 4 March – support concerns already made by palliative medicine leaders.

One specialist said the controversy around the LCP “has caused additional distress for relatives at an already distressing time when their loved one is dying.” Another said that that it was “putting end of life care back about twenty years, where dying patients were hidden inside rooms and not seen by a consultant.”

The Liverpool care pathway was introduced to help doctors and nurses provide quality care for patients during their final hours and days of life, but it has recently been criticised after accounts of patients having food and fluids withdrawn and the use of financial incentives. Some families are claiming that their relatives could, and should, have lived longer.

As a result, the Department of Health and the NHS National End of Life Care Programme are currently reviewing the pathway.

In February, in conjunction with Channel 4 Dispatches, the BMJ emailed 3,021 hospital doctors for an anonymous online survey of the Liverpool care pathway. The results are based on answers from 563 doctors who responded and had used the pathway in their practice (185 palliative medicine consultants, 168 in other grades in palliative medicine, and 210 doctors in another specialty). The respondents included about 40% of all palliative medicine consultants in the UK.

Overall, 91% (514) thought that the pathway represented best practice for care of the dying patient, including 89% (164) palliative care specialists. If used properly, 98% (551) thought it allowed patients to die with dignity, with only two respondents (0.4%) disagreeing.

When asked if they would want the pathway during a terminal illness, 90% (509) said yes and 3% (16) said no. And despite media reports, almost all (98%) did not think that pressure on beds or other resources had influenced decisions to use the pathway.

However, only 13% (75) respondents agreed that hospitals should be offered financial incentives for using the pathway, with over half (58%) disagreeing.

Concerns about lack of training in the use of the pathway were also raised, in particular around recognising a dying patient and communicating this to patients and relatives.

Other respondents pointed to “damaging misconceptions” about the pathway, such as it precludes nutrition, hydration or antibiotics, that it is a one way process with no further patient review, and that it is an active intervention to hasten death.

Dr Fiona Godlee, BMJ Editor in Chief, said: “This survey gives overwhelming support for the LCP from doctors who have experience in using the pathway when caring for patients in the last few days of life. The fact that most of these doctors said they would choose the LCP for themselves is doubly reassuring. The recent adverse media coverage of the LCP has been misleading and has damaged patient care. I hope this survey goes some way to restoring public confidence in the LCP as a reasonable and compassionate choice for patients and their families when making decisions about end of life care.”

Death on the Ward: Channel 4 Dispatches (Monday 4 March, 8pm) interviews leading specialists, terminally ill patients and families to explore the simple question at the heart of this controversy: can doctors accurately tell when someone is dying?

Proposal for the development of community end of Life Care: A guest post by Julian Abel

12 Feb, 13 | by Assistant Editor

 

Background

Over the last 45 years the hospice movement has set the standard for caring for people who are approaching the end of life.  The levels of services have been developing steadily and the quality of care has been of the highest standard.  An unintentional consequence of the development of end of life services has been that the care has become professionalised.  Families naturally look for professional care as their loved one becomes increasingly unwell.  In addition, although healthcare professionals look to see what care the family can deliver, the main focus of supporting people at home is the addition of a variety of professional care.  Culturally, we have lost something of the traditional role of the community caring for people who are dying.

Proposal

There are two components to this proposal.  The first part relates to involving the network of family and friends supporting the dying person and carer at home.  The second part aims to build compassionate communities who can help to support end of Life Care in their own community.

 

  1. Developing family and friends networks

 

Caring for the terminally ill relies heavily on the support of family and friends.  Often there is a very natural reluctance to ask for help from even close family members.  Even if people offer to help, it is not always clear whether help can be given.  Furthermore close carers may feel a sense of value in maintaining their role without asking others to help.

There are a wide variety of tasks that need to be completed in order to keep someone at home.  These include cooking, cleaning, shopping, washing, dressing, visits to clinics, feeding, medication, collecting prescriptions, and toileting.  Some of these tasks may be small in themselves part in combination add up to a large burden for one person.

We propose that developing a network has two phases.

Firstly, for each patient a map is drawn of close family members and friends.  If possible a person who would be prepared to be the main coordinator is identified on this map.

The second phase is that a chart of the week is drawn up with all the tasks listed down one side.  The coordinator then decides with the main carer and the patient of the acceptability of asking people for help, in a regular and organised fashion.  An explanation that can work well in this circumstance is that caring for somebody with a terminal illness is more of a marathon rather than a sprint.  Keeping the carer has supported as possible is a key component to maintaining the patient at home. Even small amount of input can help significantly.  For example the lift to the shops once a week may be very helpful.  Somebody sitting with the patient whilst the shopping is done can help to give the carer a break.  Sharing the tasks out in an agreed way can help to spread the load of care.  The coordinator maps family and friends on to the chart.

The ideal time to start thinking about these kind of arrangements is when the discussion of advance care planning is started.  At the hospice, advance care planning discussions are usually started by the specialist palliative care community nurse. Planning for care fits easily into thoughts about the future.  The advantage of starting at this point is that care can be increased as the patient becomes less well.

A common experience for many people once the patient has died here is that everyone disappears after the funeral, leaving the care and feeling lonely and unsupported.  However, in this arrangement regular contact can be maintained and gradually withdrawn as the sense of loss and loneliness lessens.  The Healthcare professionals involved in which support the coordinator in drawing up a plan and look to see where there are gaps.  These gaps could then be filled by existing professional Care Services.

  1. The second phase of the project is the development of compassion in communities.  Each time a family network looks after their terminally ill loved-one, they develop skills and expertise on how to do this.  These skills are a resource for communities.  The closest Health Care professional to the patient could ask the developed network if individuals would like to volunteer to help other people in their locality who may be in a similar situation either now or in the future.  For those people who are prepared to do this the details could be kept as a resource and they could be offered more formal training as a volunteer.  For people who have a small network, it is much easier to ask whether they would accept help from somebody who lives in the locality who has been through a similar experience.  They may well be a neighbour who already knows the family concerned.

Over a period of time, communities could build up a large network of you who are prepared to support their neighbours in the end of Life Care.  In this way, end of Life Care is handed back to the community in which it belongs, supported and aided by Health Care professionals.

 

Project proposal

We propose that Weston Hospicecare run a project on developing compassionate communities.  We think that the community specialist palliative care nurse is the ideal person to start the process of identifying the key coordinator and providing supportive documentation.  This would follows naturally from starting advance care planning discussions.  We know from our records that these take place on average three months before the patient dies.  If there is no obvious person to do the coordinating, the palliative care nurse could fulfil this role.

We think that there will be, particularly initially, a significant time input which will have an impact on the palliative care nurses job.  For this reason we would like to employ another specialist palliative care nurse who can act as backfill.

We think that the volunteer carer programme would be ideal in developing volunteers for particular neighbourhoods.  We intend to start the project apply targeting the small number of GP practices so that we can build up a neighbourhood resource.  When a new patient within that locality needs support, the hospice could then use the resources held by the volunteer carer programme.

 

Julian Abel

Do ‘humorous’ references to murder and euthanasia reflect societal beliefs about palliative care?

13 Sep, 12 | by Assistant Editor

A recent survey of palliative care doctors published in the Mayo Clinic Proceedings investigates the role that gallows humour plays in the relationships between palliative care physicians and their patients and colleagues.

The online survey, developed by Lewis Cohen MD and colleagues from Tufts University School of Medicine, found that nearly three-quarters of doctors interviewed have been ‘humorously’ accused of promoting death. Most of the comments came from fellow physicians and health care workers.

Parallel to this, results indicated that 25 out of the 633 respondents reported having been formally investigated for hastening a patient’s death. One third of cases were initiated by fellow health care workers.

The study concludes that whether real or in jest, accusations of murder are part of a wider issue. The survey highlights that the presence of gallows humour into the medical environment is representative of conflicting beliefs about end-of-life care, specifically hastening death. The article cites global examples of palliative care cases that have been brought to court, emphasising the international scale of the issue.

Although caring for dying patients is always a serious matter, it would be a mistake to suggest that physicians ought to cease joking about death with their colleagues. Cohen reiterates that, “Levity must remain an acceptable defense mechanism in medicine for coping with the weightiest of medical duties: helping patients to die with grace and dignity”. In Cohen’s opinion, rather than curbing humorous references, it is more important for medical professionals to address the underlying conflicts that exist both globally and within their own community. Accusations from health care professionals clearly indicate that there are strong disagreements over end-of-life care that must be discussed.

Should palliative care play a role in the management and treatment of diabetes?

8 Aug, 12 | by Assistant Editor

New research published this week in the Journal of General Internal Medicine indicates that palliative care could play an important role in the management of type 2 diabetes.

The study, conducted by a team of researchers in California, analysed the symptom burden and survival times of over 13,000 diabetic adults aged 30-75. The results indicated high prevalences of pain and discomfort, with 42% of participants reporting acute pain and 40% reporting chronic pain.

Psychosocial symptoms were also common amongst those surveyed, with a quarter reporting experiencing either fatigue, depression or insomnia. Interestingly, younger individuals (aged under 60) were more likely to report psychosocial symptoms, whilst those over 60 were more likely to experience painful symptoms.

The American Diabetes Association estimates that over 25 million people have diabetes in the US alone. The global prevalence of the disease is thought to be over 285 million and rising. With palliative care being incorporated more and more often into the management of non-cancer diseases including heart disease and kidney failure, this study highlights an important issue – could palliative care be used to alleviate painful symptoms amongst diabetic patients, and is there a place for palliative medicine in standard diabetes care?

Results of the UK’s first National Bereavement Survey released

3 Jul, 12 | by Assistant Editor

Today saw the publication of the results from the UK’s first National Bereavement Survey. The questionnaire, which was administered in November 2011, aimed to establish what the standard of end-of-life care was, as seen through the eyes of people who had lost a loved-one.

The responses of over 22,000 people were collated and the results highlight geographical disparities in perceived quality of care. Residents of Bournemouth, Poole and Dorset gave the highest ratings for end-of-life care, whilst the quality of care in Bedfordshire and Luton was considered the worst.

Overall, 75% of respondents rated the quality of care as good or better. People were more likely to rate the quality of care as outstanding if their loved-one died in a hospice or at home as opposed to in a hospital. In fact, hospice care was considered the best setting for end-of-life care, with 92% of respondents who had experienced hospice care rating it as good or better.

There was a large disparity between the numbers of people reporting ‘complete pain relief’ according to setting, with 62% of hospice deaths reporting this but only 17% of home deaths.

Care quality for people who died of cancer was more likely to be perceived as outstanding than care for people who died from cardiovascular disease – indicating that there are ongoing problems with integrating palliative care services into cardiovascular disease management.

Only 44% of respondents reported that the person had expressed a wish about where they would like to die. This is at odds with other surveys which have suggested that the majority of people would like to die at home.

The report highlights several causes for concern in terms of the provision of end-of-life care in the UK. Most notably, it appears that people who die at home are still not receiving adequate pain relief, that people dying from non-cancer disease continue to be neglected by the end-of-life care services and that the wishes of people who are dying are not being adequately communicated to their loved ones.

 

The transition from childhood to adult palliative care: A time for action

27 Jun, 12 | by Assistant Editor

Young people with palliative care needs from across the UK are today lobbying the government to change the way that the transition from childhood to adult palliative care services is handled.

Currently, support for children with life-limiting conditions comes to an abrupt end at the age of either 16 or 18. Services for adults – provided jointly by the National Health Service and other government bodies – are far less extensive, and the sudden loss of support leaves many families in a state of shock.

The issue is particularly timely as, due to rapid medical advancement in the last few decades, more and more people born with life-limiting conditions are surviving to 18 and beyond. In the last ten years alone in the UK the number of young people living with long-term health conditions which may require palliative care has risen by 30%.

Over the next two days a group of young people facing this difficult transition are gathering in London to meet with ministers and other healthcare professionals. Their aim is to explain the major failings of the current system and encourage policy-makers to take action. Today the issue is being raised in the House of Lords, and tomorrow it will be discussed at a conference at the Oval Cricket Ground.

The event is accompanied by a report entitled ‘Don’t Let Me Down’ by Marie Curie, which outlines how the current system could be improved and urges the Prime Minister to spearhead the new initiative.

The BMJ’s new stance on assisted dying

18 Jun, 12 | by Assistant Editor

The BMJ recently expressed its support for the notion that the UK’s leading medical bodies, including the BMA and Royal Colleges, abandon their opposition to assisted dying in favour of a neutral stance.

The move comes as a recent poll undertaken by Dignity in Dying revealed that of 1000 GPs surveyed, 62% supported a shift to neutrality. This, accompanied by the finding that over 80% of the general public support the legalisation of assisted dying, means that the BMJ’s stance had become increasingly untenable.

Dr Fiona Godlee, Editor-in-Chief of the BMJ, highlighted similarities with prior opposition to the legalisation of abortion and suggested that whilst doctors would have to carry out the procedure, the decision regarding the concept ‘rests with society and its representatives in parliament.’ In order for society’s views to be expressed adequately, the Healthcare professionals for Assisted Dying (HPAD) ask for the BMA and certain opposing Royal Colleges to move their position to neutrality. At the BMA’s annual conference later this month, a debate on whether to assume a neutral position will ensue.

The proposition of neutrality is supported by HPAD’s Chair and Emeritus Professor of Geriatric Medicine, Raymond Tallis who states that opposition to assisted dying hinders the principle of specific patient-centred care. This view is – at least in part – an acknowledgment of the fact that medical bodies’ opposition to assisted dying is in conflict with the wishes of the general public, the overwhelming majority of whom seem to support it. Thus he states that ‘the proper stance of healthcare professional bodies is one of neutrality’.

In response to the BMJ’s new bearing, Dr Peter Saunders, director of the pro-life group Care Not Killing stated that the call “is a carefully orchestrated move by a small minority of doctors with extreme views aimed at neutralising medical opposition and softening up public and parliamentary opinion in advance of new pressure to change the law.”

He maintains that a change in the law on assisted dying “would place pressure on vulnerable sick, elderly and disabled people to end their lives for fear of being a financial or emotional burden on loved ones” which is “the very last thing we need” at a time when scores of families “are already under considerable financial pressure”.

Whilst this shift towards neutrality may not actively support a case for legal reform on the matter, some have speculated that it may lay the foundations for the legalisation of assisted dying in the UK. However, the case of Belgium shows that in order for legal reform to occur, there must be overwhelming public, as well as institutional, support for it. The fundamental question is whether or not this is currently the case in the UK.

 

__________________________________________________

 

Medical bodies’ stances on assisted dying

Opposed

BMA

Royal College of Physicians of London

Royal College of Surgeons of England

Royal College of General Practitioners

Association of Palliative Medicine

No position

General Medical Council

Royal College of Anaesthetists

Royal College of Obstetricians and Gynaecologists

Royal College of Paediatrics and Child Health

Royal College of Physicians of Edinburgh

Royal College of Surgeons Edinburgh

Neutral

Royal Society of Medicine

Royal College of Nursing

Royal College of Nursing Scotland

Royal College of Psychiatrists

New NICE guidelines aim to address patient concerns about the use of opioids in advanced disease.

24 May, 12 | by Assistant Editor

The UK’s Institute for Clinical Excellence has released new guidelines which aim to standardize the use of opioids in advanced disease pain management.

It is estimated that each year in the UK some 300,000 people are diagnosed with cancer and 900,000 have heart failure. As well as this, thousands live with long-term chronic conditions such as kidney disease and COPD.

Despite the fact that opioids offer the most effective pain control in advanced disease, both patients and doctors seem unwilling to use them.

Often, it seems, patients worry about the side-effects of opioid painkillers, as well as the possibility of becoming addicted. According to Dr Damien Longson, Chair of the Guideline Development Group,  “Because opioids are powerful medicines people worry they can become addicted, particularly if opioids are prescribed over an extended period of time”.

As well as this, many doctors seem unsure about when strong opioids are an effective and appropriate treatment option.

The new guidelines aim to combat both patient and doctor aversion to opioid prescribing.

The guidelines recommend more clear and effective communication with patients, including asking them about their concerns and discussing these with them. Also, NICE recommends that patients be given access to out of hours contacts and frequent reviews of pain control and side effects.

Regular oral sustained-release or immediate-release preparations are recommended for patients beginning strong opioid treatment for chronic disease, with rescue doses of oral immediate-release preparations for breakthrough pain.

Read the full guidelines here: http://www.nice.org.uk/CG140

The Working of an Integrated Community Palliative Care Team

18 May, 12 | by Assistant Editor

Guest writers Anna MacPherson and Louise Forman of St Catherine’s Hospice, Preston, discuss the experience of working within a community palliative care team in light of recent changes to the structure of community palliative care.

 

Community based palliative care services are growing in importance. As surveys repeatedly tell us most people want to die at home[i], and policy shifts towards enabling that, services based in patients’ homes become more prominent.

Traditionally, district nursing services have mainly provided palliative care for people in their home environment, with medical input from GPs. These services have and continue to provide generalist palliative care. In support, specialist palliative care services have grown over recent years, offering a variable combination of practical care and advice, often led by community specialist palliative care nurses.

Over the past fifteen years there has been increasing medical specialist palliative care input into the care of community patients. As with most aspects of palliative care, this has varied, with practices developing locally, different teams finding different ways of working, with little evidence as to what the best model is.

This article presents one community palliative care team’s experiences of this development, and how one team integrated medical and nursing palliative care. This is not a statement of best practice, but aims to share how one team has developed over a relatively long time of having a dedicated community palliative care consultant in post.

 

Team Structure

The community palliative care team based at St Catherine’s Hospice, Preston covers a mixture of urban and semi-rural areas of Preston, Chorley and South Ribbleand a population of roughly 370,000.[ii] There has been a community palliative care team in this area for many years, comprised of specialist nurses, managed by a nurse manager from 2003, and under the umbrella of the hospice, with GP and hospice physician support. In 2002 a full-time Consultant in Palliative Medicine was appointed to work solely with this team.

There are now 7 full-time equivalent nurse specialists, each responsible for a group of GP practices. Patients referred from any source are the responsibility of the clinical nurse specialist attached to the patient’s GP practice.

 

Integrated medical and nursing clinical working

There are several ways in which patient management is integrated to facilitate input from both medical and nursing staff.

A major component of joint working is via twice weekly multi-disciplinary team meetings in which all newly referred and complex patients are discussed, allowing the full team to be aware and have some input into the care of these patients. Monthly, a larger MDT meeting is attended in addition by an occupational therapist, physiotherapist and social worker. This format will need to be adjusted to fit with the NICE quality standards[iii] and peer review measures,[iv] for example involving a second consultant, but this adjustment is relatively minor.

On a regular basis the clinical nurse specialists have “clinical supervision” sessions, consisting of a day of joint visits by the nurse and consultant, with the nurse leading, followed by discussion and feedback. This enables additional input for complex patients, as well as an opportunity to raise any concerns or queries. Twice weekly consultant-led out-patient clinics are attended by the consultant in addition to a nominated clinical nurse specialist, allowing joint review and education.

 

Integration with other services

Gold-Standard Framework[v] type meetings are seen as key opportunities to engage with local primary care teams, and are attended where possible by the designated clinical nurse specialist. This enables an awareness and discussion of a wider range of patients as well as a chance to build working relationships.

Initial assessments follow a structure, including a period of information gathering and liaison prior to seeing any newly referred patient. Referrals are accepted from various sources, and consulting the patient’s primary care team before the first assessment makes this process more efficient and better informed. This liaison continues throughout; the clinical nurse specialists are not nurse prescribers, which has the benefit of encouraging discussion and liaison about management plans with the patient’s primary care team.

In addition, there has been work with local prisons to build relationships and create structures to enable the management of palliative patients within prison environments.

The community-based, hospice and hospital palliative care teams meet weekly using video-conferencing to discuss jointly managed patients. This involves three consultants, so may provide an opportunity to fulfil the peer review measure on MDT meetings. Again, as well as liaison, this is a chance to improve working relationships.

 

Education and audit

There is a structured education programme involving monthly sessions covering topics chosen by the team. These are in addition to mandatory training, and provide a chance for tutorial-type discussion of complex cases or subjects. Clinical supervision sessions and joint clinics enable informal case-based discussion and teaching.

The community team participates in several education delivery projects. This includes structured education courses, such as programmes providing education to nursing home staff, district nurses and social workers, as well as clinical teaching to various people who shadow the nurse specialists, including medical students and student nurses. This has been a source for additional funding for the hospice.

The community team have held an annual conference for the past fifteen years, involving outside speakers from different backgrounds about mostly clinical topics. This has attracted attendees from local primary care teams, hospitals, other local hospices as well as staff from settings such as nearby prisons. Again, this has been a source of funding.

The team take part in hospice-wide audits and regional palliative medicine audits as well as audits of topics identified by the team.

 

Management structure

A nurse manager is the direct line manager of the clinical nurse specialists. She holds monthly one-to-one meetings with each nurse specialist to ensure they have adequate support and opportunity to highlight any concerns.

The team as a whole has a monthly business meeting, in which non-clinical projects are discussed as well as any proposed changes to ways of working. Non-clinical projects were previously allocated to certain allocated nurse specialists (e.g. audit leads, education leads), but more recently have been taken on by whichever nurse has capacity and interest in that project.

 

Recent developments

Over the past two years the hospice has introduced and developed a twenty-four hour advice line, available for professionals, patients and carers. This is provided by the hospice inpatient unit, although the community team are regularly involved in follow up of issues raised. Local palliative care teams share electronic records, so patients can access 24-hour specialist palliative care advice from staff with full background information about them.

During the past six months the community team has started seven-day working. A clinical nurse specialist is available 9-5, seven days each week, and during the weekends answers the advice line as well as being available for face-to-face consultations. This change in working practice has led to more “days-in-lieu” during the week, and so increased strain due to less continuity of care, but has also led to clear benefits in service delivery at weekends. This does now comply with NICE quality standards (ref.2, quality statement 10).

The need to be able to measure results is becoming increasingly important, and audits now focus more on measureable outcomes. The proportion of deaths in each location, whether the LCP was used and whether the preferred place of death was met is recorded, and annual statistics for each nurse specialist looked at by the team. Overall the results for the team compare favourably with other local and national statistics (table 1).

 

Table 1:

Deaths of patients known to community palliative care team Aug-Oct 2011

Place of death Team audit statistics Local average 2008-2010[vi] England 2008-2010 (ref. 4)
Hospital 19.1% 57.14% 54.7%
Home 41.1% 19.17% 20.33%
Care home 14.2% 15.73% 17.8%
Hospice 24.1% 5.95% 5.21%
Other 1.4% 2.00% 2.19%

 

Future challenges

NICE quality standards as well as peer-review guidance have recently been published, with specific recommendations for community palliative care teams. Local palliative care services will need to consider how best to meet these measures, which within the above model will require adjustments to existing practice rather than major changes.

These service developments, and the expectation of increasing deaths and care at home, are on a background of increasing financial pressures. The models of care delivery may need to adjust to enable input to greater numbers of patients from a smaller service. This will provide challenges over coming years.

Given the new financial structure, budget constraints and quality standards, it is becoming increasingly important to provide proof of effectiveness of care. Time and effort will need to be invested into trying to accurately measure effects, along with obtaining service user opinions, to be able to bid for even the same amount of funding.

The delivery of palliative care in the community is highly dependent on teamwork with professionals in primary care and allied health professionals, as well as the provision of social care. These areas are all also subject to rising pressures from increasing expectations and demand, along with increasing financial pressure. This will undoubtedly impact on how much effective palliative care can be provided in the community, and models will need to continually develop to provide high-quality palliative care at home with measureable benefits.


[i] Higginson IJ, Sen-Gupta GJ “Place of care in advanced cancer: a qualitative systematic literature review of patient preferences.” J Palliat Med 2000;3:287300

 

[ii] Lancashire Teaching Hospitals Foundation trust website http://www.lancsteachinghospitals.nhs.uk/services/services.html

 

[iii] National Institute for Health and Clinical Excellence “Quality Standard for end of life care for adults” November 2011

 

[iv] National Cancer Peer Review Programme “Manual for Cancer Services: draft specialist palliative care measures” Department of Health; Dec 2011

 

Dialysis patients receive aggressive treatment during last month of life

10 May, 12 | by Assistant Editor

A research letter published in the journal Archives of Internal Medicine has reported that patients with end stage renal disease tend to receive very aggressive treatment during their last month of life.

The researchers from the University of Washington analysed data on almost 100,000 Medicare patients who were treated with dialysis, and found that during the last month of life 76% of patients were hospitalized (compared to 61% of cancer patients). The data also showed that the average hospital stay for those with end stage renal disease was double that of cancer patients (10 days compared to just 5 in the cancer group).

Not only were dialysis patients more likely to be hospitalized, they were also three times more likely to receive intrusive procedures (including the placement of feeding tubes and mechanical ventilation).

Interestingly, the authors found that amongst the study population, those who lived in areas with a high end-of-life care spending capacity, were more likely to receive aggressive treatment. This suggests that budgetary factors, rather than patient preferences, may well be driving the end of life care decisions of healthcare workers.

These findings offer a useful insight into the experiences of end-stage renal disease patients, an area in which little research has been published.

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