Factors related to withholding life-sustaining treatment in hospitalized elders.
OBJECTIVE
To look for predictors in the clinical records of orders for "limitation of life sustaining treatment" (LLST) or "do not attempt resuscitation" (DNAR) in hospitalized elders and to assess the relationship between the presence of these orders and the quality of end-of-life (EOL) care.


METHODS
Retrospective clinical record review.


METHODS
Inpatients of an inner city elderly acute care unit (EACU) in Spain.


METHODS
Of 103 hospitalized patients who died in the EACU during one year, 90 dying an expected death either from acute or chronic disease were included.


METHODS
Demographic, functional, cognitive, clinical, and end-of-life (EOL) parameters. The influence of identifying closeness to death and the number of LLST suborders on the quality of EOL-management were considered simultaneously using structural equation modelling with LISREL 8.30 software.


RESULTS
LLST and specific DNAR orders were registered in 91.1% and 83.3% of patients, respectively. Failure of acute treatment, discussions with the patient/family, recognizing the presence of common EOL symptoms, and prescribing specific symptomatic treatment were recorded in 88.9%, 93.3%, 94.4%, and 86.7% of patients, respectively. LLST-orders were more likely to be documented if there was severe functional impairment prior to admission (p < 0.001), advanced organ disease criteria were met (p=0.006), or closeness to death was acknowledged in writing (p < 0.001). The quality of the EOL-management was better in patients for whom there were LLST-orders (p =0.01) and written acknowledgement of closeness to death (p < 0.001).


CONCLUSIONS
LLST-orders were more likely to be written in an EACU for patients with previous severe impairment, co-morbidity, or advanced disease. Written acknowledgement of closeness to death and LLST-orders were predictors of better EOL-management.
Esteve
A
A
Department of Geriatric Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
Jimenez
C
C
Perez
R
R
Gomez
J A
JA
D016223:Advance Directives / Q000706:statistics & numerical data*; D000369:Aged, 80 and over; D001293:Attitude to Death; D015897:Comorbidity; D003643:Death; D003657:Decision Making; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D010817:Physician-Patient Relations; D011379:Prognosis; D011788:Quality of Life; D016414:Resuscitation Orders; D013030:Spain; D013727:Terminal Care / Q000706:statistics & numerical data*; D028761:Withholding Treatment / Q000706:statistics & numerical data*