The moment of death in an Internal Medicine ward

Abstract

Background: In-hospital cardiorespiratory arrest (CRA) has a severe prognosis, but is usually preceded by alert signs. These signs
should be recognized and necessary procedures predicted.
Methods: Retrospective evaluation of alert signs and symptoms
in the 6 hours before death, decision of Do Not Resuscitate (DNR)
and attitudes chosen in deceased patients in a 3 year period.
Results: Four hundred and three patient files were reviewed
(mortality rate 11,4%). Mortality was homogeneously distributed
in respect to week day and time. Alert signs and symptoms in
the 6 hours before death were identified in 291 patients (72,2%),
specially: depressed level of consciousness (129 patients), desaturation (104) and dyspnoea (92). Doctors were called in 133
cases and their attitudes were: reversion in 70 patients, relieving
in 67, no attitude at all in 60 and assuming DNR in 40. The DNR
was present in 348 patients (86,4%) and registered in 92,0%.
Cardio-pulmonary resuscitation (CPR) was attempted in 2 patients
(0,5%) with explicit DNR and in 1 (0,2%) with implicit DNR. CPR
was not attempted in 35 patients (8,7%), although there was no
recorded indication in the patient file for DNR.
Conclusions: Alert signs and symptoms preceded most CRA,
allowing an opportunity for intervention. Mostly nurses identified
these signs. The indication for DNR was recorded in the files of
most patients. The low number of patients with indication for CPR
is a surrogate of patient’s complexity. This study reinforces the
need for intervention in recognition, evaluation and decision in
the pre-arrest patients.