Prevalence of symptoms at the end of life in an acute care hospital: a retrospective cohort study

• Published in: CMAJ open 2017-01, Vol.5 (1), p.E222-E228
• Main Authors: Kobewka, Daniel, MD MSc, Mulpuru, Sunita, MD MSc, Forster, Alan, MD MSc, McIsaac, Dan, MD MPH, Ronksley, Paul, PhD
• Format: Article
• Language: English
• Subjects: Internal Medicine
• ISSN: 2291-0026; 2291-0026
• DOI: 10.9778/cmajo.20160123

Abstract Background There is currently debate over the benefits and harms of physician-assisted death. One of the factors influencing this debate is concern about symptoms in the days before death. The objective of this study was to describe the frequency of symptoms before death and determine patient characteristics associated with these symptoms. Methods We reviewed the medical record of every patient who died at a multisite academic teaching hospital over a 3-month period. We determined the number of episodes of pain, dyspnea, agitation and nausea during the final 48 hours of life and assessed the patient and encounter characteristics associated with 2 or more episodes of symptoms. Results A total of 480 patients died during the study period. Of these patients, 29.2% (140/480) had 2 or more symptoms in the final 48 hours of life. Higher Elixhauser comorbidity scores (relative risk [RR] 1.35, 95% confidence interval [CI] 1.23-1.49), having a family doctor (RR 2.33, 95% CI 1.02-5.38), being admitted to the medical oncology service (RR 1.51, 95% CI 1.11-2.05) and having a documented order for no resuscitation written early during the stay in hospital (RR 1.38, 95% CI 1.01-1.89) were independently associated with symptoms. Admission to intensive care was associated with fewer symptoms (RR 0.39, CI 95% 0.19-0.80). Interpretation Symptoms are common in the final 48 hours of life, particularly in patients with multimorbidity who want limitations on the aggressiveness of their care. An integrated palliative approach is needed for select at-risk patients.