Dying in Internal Medicine Wards: The Last Hours of Life
DOI:
https://doi.org/10.24950/rspmi/original/90/4/2018Keywords:
Hospitalization, Internal Medicine, Medical Futility, Palliative Care, Patient Care Management, Terminal CareAbstract
Introduction: Introduction: The increasing longevity and number of chronic diseases justify the number of patients with palliative needs in Internal Medicine services. The internist should be able to ensure comfort care at the end of life of the patients he is attending. The study objective was to analyze the therapy performed and complementary diagnostic tests (CDT) requested within 48 hours before death. Methods: Retrospective observational study with 100 consecutive deaths (from patients with “do not resuscitate indication”) occurring in the Internal Medicine Service for a year. Results: The length of stay was 9.4 ± 7.9 days, the age 86.5 ± 9.9 years, with no gender differences. It was found that 71.0% of patients had at least one CDT application. CDTs included blood tests (54.0%), blood cultures (17.0%), radiographs (19.0%), ultrasound scans (8.0%) or computerized axial tomography (2.0%). They were prescribed: nebulizations (76.0%), antibiotic therapy (74.0%, being 44.6% broad spectrum), low molecular weight heparin (71.0%), nonopioid analgesics (53.0%), among others. In 28.0% of cases there was no prescribed analgesia. The opioid prescription rate was 19.0%. Conclusion: There is an urgent need for a paradigm shift in the care of vulnerable patients. Medicine should not always have a healing glow, but it must always take care, respecting the cultural, clinical and ethical values of the doctor-patient relationship. The internist should in end-of-life patients improve their symptomatic control and avoid the use of inappropriate CDTs without any added benefit to the human person.
Downloads
References
Reis-Pina P. Da Filosofia do Cuidar e da Ética do Cuidado. In: Barbosa A, Reis Pina P, Tavares F, Neto IG, editores. Casos Clínicos em Cuidados Paliativos. Lisboa: Faculdade de Medicinca, Universidade de Lisboa; 2015.p. 239-51.
Gomes B, Sarmento VP, Ferreira PL, Higginson IJ. Epidemiological study of place of death in Portugal in 2010 and comparison with the preferences of the Portuguese population. Acta Med Port. 2013;26:327-34.
Sarmento VP, Higginson IJ, Ferreira PL, Gomes B. Past trends and projections of hospital deaths to inform the integration of palliative care in one ofthe most ageing countries in the world. Palliat Med. 2016;30:363-73. doi: 10.1177/0269216315594974.
Murtagh FE, Bausewein C, Verne J, Groeneveld EI, Kaloki YE, Higginson IJ. How many people need palliative care? A study developing and comparing methods for population-based estimates. Palliat Med. 2014;28:49- 58. doi: 10.1177/0269216313489367.
Maja de Brito SB, Sapeta P, Simões C, Gomes B. Ficha técnica para os perfis regionais de cuidados paliativos do Observatório Português dos Cuidados Paliativos. Lisboa: Observatório Português dos Cuidados Paliativos; 2016.
Associação Portuguesa De Cuidados Paliativos. Cuidados paliativos: o que são? [cited 2017 30.07.2017]; Available from: http://www.apcp.com. pt/cuidados-paliativos/o-que-sao.html.
Código Deontológico da Ordem dos Médicos. Regulamento n.º 14/2009, Diário da República, 2.ª série - N.º 8 - 13 de janeiro de 2009.
Carneiro R, Freire E, Alves J, Rocha N. Gestos e atitudes em medicina centrada no doente num Serviço de Medicina Interna. Acta Med Port 2010;23:1035-42.
Pulido I, Baptista I, Brito M, Matias T. Como morrem os doentes numa enfermaria de Medicina Interna. Med Interna 2010;17:222-6.
Furuno JP, Noble BN, Horne KN, McGregor JC, Elman MR, Bearden DT, et al. Frequency of outpatient antibiotic prescription on discharge to hospice care. Antimicrob Agents Chemother. 2014;58:5473-7. doi: 10.1128/ AAC.02873-14.
Burns JP, Truog RD. Futility. Chest. 2007;132:1987-93. doi: 10.1378/ chest.07-1441.
Bailey FA, Burgio KL, Woodby LL, Williams BR et al. Improving Processes of Hospital Care during last hours of life. Arch Intern Med. 2005;165:1722-7.
Monteiro PH, da Silva MJ, Fraga M, Mota C, Suarez A, Ponte C, et al. Necessidade de cuidados paliativos num Serviço de Medicina Interna. Med Interna 2013;20:7-20.
Albrecht JS, McGregor JC, Fromme EK, Bearden DT, Furuno JP. 2013. A nationwide analysis of antibiotic use in hospice care in the final week of life. J. Pain Symptom Manage. 46:483– 490. http://dx.doi.org/10.1016/j. jpainsymman.2012.09.010
Mitchell SL, Shaffer ML, Loeb MB, Givens JL, Habtemariam D, Kiely DK, et al. Infection Management and Multidrug-Resistant Organisms in Nursing Home Residents With Advanced Dementia. JAMA Intern Med. 2014;174:1660-7. doi: 10.1001/jamainternmed.2014.3918.
Juthani-Mehta M, Malani PN, Mitchell SL.. Antimicrobials at the end of life an opportunity to improve palliative care and infection management. JAMA. 2015;314:2017-8. doi: 10.1001/jama.2015.13080.
Toscani F, Di Giulio P, Brunelli C, Miccinesi G, Laquintana D; End-of-Life Observatory Group. How people die in hospital general wards: a descriptive study. J Pain Symptom Manage. 2005;30:33-40.
Ribeiro AS. Controlo de sintomas em cuidados paliativos num serviço de medicina interna.[Dissertação de Mestrado]. Lisboa: Faculdade de Medicina da Universidade de Lisboa; 2012.
Silva MJ. Cuidados paliativos: caracterização assistencial e identificação de necessidades num serviço de medicina interna. [Dissertação de Mestrado]. Lisboa: Faculdade de Medicina da Universidade de Lisboa; 2011.
Murray SA, Boyd K, Sheikh A. Palliative care in chronic illness. BMJ. 2005; 611-2.
Carneiro R, Sousa E, Guerreiro T, Rocha N. Qualidade e satisfação com a prestação de cuidados na patologia avançada em Medicina Interna. Arq Med. 2009, 23:95-101.
Henk Verloo EKM, Maria Ferreira, Charles-Henri Rapin and Philippe Chastonay. Morphinofobia: the situation among the general population and health care professionals in North-Eastern Portugal. BMC Palliat Care. 2010;9:15. doi: 10.1186/1472-684X-9-15.
Lanken PN, Terry PB, Delisser HM, Fahy BF, Hansen-Flaschen J, Heffner JE,et al. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med. 2008;177:912-27.
Mahler DA. Opioids for refractory dyspnea. Expert Rev Respir Med. 2013;7:123-34. doi: 10.1586/ers.13.5.
Lindqvist O, Lundquist G, Dickman A, Bükki J, Lunder U, Hagelin CL, et al. Four essential drugs needed for quality care of the dying: a Delphi-study based international expert consensus opinion. J Palliat Med. 2013;16:38-43. doi: 10.1089/jpm.2012.0205.
Alves FI. Cuidar o doente terminal em Serviço de Medicina Interna: um olhar fenomenológico sobre as experiências dos enfermeiros. [ Dissertação de Mestrado]. Porto: Faculdade de Medicina da Universidade do Porto; 2012.
Beckstrand RL, Callister LC, Kirchhoff KT. Providing a “good death”: critical care nurse’ suggestions for improving end-of-life care. Am J Crit Care. 2006 15: 38-45..
Beernaert K, Smets T, Cohen J, Verhofstede R, Costantini M, Eecloo K, et al. Improving comfort around dying in elderly people: a cluster randomised controlled trial. Lancet. 2017 8;390:125-134. doi: 10.1016/ S0140-6736(17)31265-5.
Sigurdardottir K, Haugen D. Prevalence of distressing symptoms inhospitalised patients on medical wards: a cross sectional study. BMC Palliat Care. 2008; 23:7-16. doi: 10.1186/1472-684X-7-16.
Gott CM, Ahmedzal SH, Wood C. How many inpatients in an acute hospital have palliative care needs? Comparing the perspectives of medical and nursing staff. Palliat Med. 2001;15:451-60. doi: 10.1191/026921601682553932.
Riechelmann RP, Krzyzanowska MK, Zimmermann C. Futile medication use in terminally ill cancer patients. Support Care Cancer.2009;17:745-8. doi: 10.1007/s00520-008-0541-y.
Adeline Tan AS, Gerald Chua, Tow Keang Lim and Jason Phua. Impact of a palliative care initiative on end-of-life care in the general wards: A before-and-after study. Palliat Med. 2014; 28 34–41. doi: 10.1177/0269216313484379.
Downloads
Published
How to Cite
Issue
Section
License
This work is licensed under a Creative Commons Attribution 4.0 International License.
Copyright (c) 2023 Medicina Interna
Open Access
