BMJ. UK: Australian doctors have come up with a
checklist designed to spot elderly hospital patients likely to die
within the next three months, it is reported in BMJ Supportive & Palliative Care. The
aim of Critera for Screening and Triaging to Appropriate aLternative
care, or CriSTAL for short, is to kick-start frank discussions about end
of life care, and minimise the risk of further futile treatment, they
say.
“Delaying
unavoidable death contributes to unsustainable and escalating
healthcare costs, despite aggressive and expensive interventions,” they
write. “These interventions may not influence patient outcome; often do
not improve the patient’s quality of life; may compromise bereavement
outcomes for families; and cause frustration for health professionals.”
They
scanned the published evidence to come up with definitions for the
dying patient and end of life care and to search for the most likely
predictors of death in the short (30 days) to medium term (12 weeks).
They
came up with a checklist of 29 predictors of death, including older age
(at least 65 years of age); two criteria of deterioration; at least two
criteria for frailty; an early warning score of more than 4 (an
assessment of acute illness); at least one other underlying health
condition; nursing home residency; cognitive impairment; previous
emergency admission or intensive care treatment within the preceding
year; and abnormal heart monitor tracing; and protein in the urine.
The
researchers emphasise that the checklist is not intended to substitute
healthcare for the elderly who are terminally ill. Instead, it is meant
to “provide an objective assessment and definition of the dying patient
as a starting point for honest communication with patients and families
about recognising that dying is part of the life cycle.”
This
goes for healthcare professionals too, many of whom are under pressure
to continue prolonging the life of a patient against all the odds, say
the researchers.
“While
there are accepted policies for de-escalating treatment in terminally
ill patients, there are also inherent and societal pressures on medicine
to continue utilising technological advances to prolong life even in
plainly futile situations,” they write.
But
they insist: “Training for nurses and doctors in the use of the
screening tool and in approaching patients and families with concrete
information about inevitability of death and lack of benefit of further
intensive treatment are paramount.”
Most patients end up dying in hospital, even though that is not their stated preference, when asked.
By
giving families and patients some options about the preferred place of
death, CriSTAL could also help prompt the development of more
appropriate services than hospital for managing patients at the end of
their life, they suggest.
If
the checklist proves accurate in the prediction of death within the
next 30 days, a shortened version could be used for every hospital
admission, they add.
http://spcare.bmj.com/lookup/doi/10.1136/bmjspcare-2014-000770