UNSW (Australia) researchers have developed an assessment tool that helps doctors
and caregivers more accurately identify elderly patients whose death is
imminent and unavoidable at the time of hospital admission. The CriSTAL
(Criteria for Screening and Triaging to Appropriate aLternative care)
tool identifies patients who are likely to die within a three-month
period.
Elderly people with chronic, age-related illness commonly
endure repeated admissions to hospital in the last months of life and
may be subject to distressing, expensive and futile medical procedures.
The new tool provides more certainty in prognosis and enables an
end-of-life care plan to be developed that best meets patients’ needs.
A paper describing the assessment procedure is published today in the BMJ Supportive & Palliative Care.
“Most
terminally ill people want to die at home, but in fact three quarters
end up dying in acute hospitals, often after intrusive, expensive and
ultimately pointless medical procedures,” says Dr Magnolia
Cardona-Morrell, who led the research at UNSW Medicine’s Simpson Centre
for Health Services Research, alongside UNSW professor of intensive care
Ken Hillman*.
“Current acute hospital systems often fail to
recognise or cater to the needs of people for whom death is imminent and
unavoidable. They are geared for aggressive treatment and emergency
resuscitation, not peaceful, harm-free transitions,” Dr Cardona-Morrell
says.
“Elderly people who are dying need to be protected from
heroic but intrusive live-saving hospital interventions that often only
prolong suffering rather than enhance quality of remaining life.”
CriSTAL
consists of a 29-item screening list that can be completed by a nurse
or a doctor before hospital admission and takes account of factors such
as vital signs, cognitive impairment, recent hospitalisations, measures
of frailty and the presence of active disease such as cancer or chronic
kidney or liver disease.
The process is informed by an extensive
review of the strengths and weaknesses of medical literature that
attempts to “diagnose dying” or devise an end-of-life assessment tool
for clinical use. Most of the existing tools rely on clinical judgment
or subjective assessments and value judgments. Others are unacceptably
inaccurate.
The authors say developing a more objective and
accurate way of identifying patients near the end of life is crucial to
prevent inappropriate hospital admission and unnecessary treatments.
“It
can be difficult to reach a decision that balances the rights of
patients to die with dignity and the expectations of families about
satisfactory end-of-life care, while considering the limitations of
health resources,” they write.
“Delaying unavoidable death through
aggressive and expensive interventions may not influence patient
outcome; may compromise the bereavement process for families; and cause
frustration for health professionals.”
Dr Cardona-Morrell says the
research is not about dictating the withdrawal of treatment, but about
minimising uncertainty and establishing objective criteria for imminent
death.
“It’s about coming to terms with the fact that death from
old age and multiple chronic conditions is part of a natural process and
that medicine cannot work miracles. And it’s about ensuring that people
at the end of their lives have the best possible care and support, in
line with their wishes,” she says.
Professor Hillman emphasises
that “the management of elderly frail patients at the end of life in
acute hospitals is one of the greatest challenges facing health care.
Most patients and their carers do not wish to be admitted to a hospital
at the end of their life and this is a major contributor to the
unsustainable costs of health care.”
CrisTAL will be trialled in
selected hospital emergency departments in Sydney this year. It will
include communication training for medical staff, so they can ably and
comfortably discuss with dying patients and their carers the limitations
of medical treatment and the most appropriate place and process of
dying.
The paper, “Development of a tool for defining and
identifying the dying patient in hospital: Criteria for Screening and
Triaging to Appropriate aLternative care (CriSTAL)” is an Open Access publication.
The research was funded by a grant from the National Health and Medical Research Council of Australia.
*Professor Hillman is a well-known advocate for dying with dignity and has written books and articles on the subject.