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Anne M. Walling, MD; Steven M. Asch, MD, MPH; Karl A. Lorenz, MD, MSHS; Carol P. Roth, RN, MPH; Tod Barry, MBA, CPHQ, RRT; Katherine L. Kahn, MD; Neil S. Wenger, MD, MPH

Arch Intern Med. 2010;170(12):1057-1063.

Background  Patients in American hospitals receive intensive medical treatments. However, when lifesaving treatments are unsuccessful, patients often die in the hospital with distressing symptoms while receiving burdensome care. Systematic measurement of the quality of care planning and symptom palliation is needed.

Methods  Medical records were abstracted using 16 Assessing Care of Vulnerable Elders quality indicators within the domains of end-of-life care and pain management designed to measure the quality of the dying experience for adult decedents (n = 496) hospitalized for at least 3 days between April 2005 and April 2006 at a university medical center recognized for providing intensive care for the seriously ill.

Results  Over half of the patients (mean age, 62 years; 47% were women) were admitted to the hospital with end-stage disease, and 28% were 75 years or older. One-third of the patients required extubation from mechanical ventilation prior to death, and 15% died while receiving cardiopulmonary resuscitation. Overall, patients received recommended care for 70% of applicable indicators (range, 25%-100%). Goals of care were addressed in a timely fashion for patients admitted to the intensive care unit approximately half of the time, whereas pain assessments (94%) and treatments for pain (95%) and dyspnea (87%) were performed with fidelity. Follow-up for distressing symptoms was performed less well than initial assessment, and 29% of patients extubated in anticipation of death had documented dyspnea assessments.

Conclusion  A practical, medical chart–based assessment identified discrete deficiencies in care planning and symptom palliation that can be targeted to improve care for patients dying in the hospital.

Author Affiliations: Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine (Drs Walling, Kahn, and Wenger), Health System Ethics Center (Drs Walling and Wenger), and Center for Patient Safety and Quality (Mr Barry), University of California, Los Angeles; Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles (Drs Asch and Lorenz); and RAND Health, RAND Corp, Santa Monica, California (Drs Asch, Kahn, and Wenger and Ms Roth).

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