title: How do patients die in a rehabilitative unit dedicated to advanced respiratory diseases?
abstract: BACKGROUND
  Evidences on how in-hospital COPD patients are cared in a Rehabilitative Respiratory Unit during the last time before death are lacking. This observational study was aimed at 1. analyzing the characteristics of respiratory patients who die in a Rehabilitative Unit dedicated to advanced care; 2. studying the available organizational support related to the dying process and quality of care in the last week of life.
  
  
  METHODS
  Medical records (MR) of patients suffering from respiratory disease admitted to a Rehabilitative Respiratory Unit during the last seven years (2005-2011) were collected retrospectively. Only MR of patients who died of respiratory complications were considered. This study describes clinical and demographic variables or information about drugs, procedures, health and unprofessional teams, intervention and interaction, habits and wishes in the last week of life.
  
  
  RESULTS
  110 patients out of 2,615 subjects (4.2%) died during the period of observation. 87 out of 110 patients fulfilled the inclusion criteria. They were aged, males, retired, severely compromised, with previous stays in an acute hospital and with a long stay in our unit. Most of them were married, lived in a small village and were cared at home by a caregiver. One third of patients came from Intensive Care Units. During the last week of life, hours spent under mechanical ventilation were extremely high both for patients under invasive (22.3 ± 3.1 hours) and non invasive ventilation (NIV) (17.5 ± 3.4 hours). The number of patients who maintained NIV was twice that of the intubated ones. Breathlessness and secretion encumbrance were the main symptoms. Secretion management was necessary in more than 50% of the cases. Communication between patient and doctor was good in the majority (67%) of the cases. Patient's and family wishes, aimed at improving their relationships, were obtained in a high percentage (63%) of the cases. Doctors prescribed sedative in a half of patients and morphine only in 40% of the cases. Patients mainly died for acute respiratory failure (55%) or infective complications (34%), almost all under mechanical ventilation. Only a minority of them (28%) reported to have had a discussion about end-of-life care with their physician; palliative/end of life decisions were taken in 13% of the cases. Sustaining figures such as psychologist (17%) or clergy (13%) were marginally required.
  
  
  CONCLUSIONS
  The current data have confirmed that, also in a Rehabilitative Respiratory setting, quality of end-of-life care and patient-physician communication need further improvement.
authors.affiliation: Pulmonary Rehabilitation Division, Salvatore Maugeri Foundation, IRCCS, Scientific Institution of Lumezzane, Via Giuseppe Mazzini, 129, 25066, Lumezzane, Brescia, Italy. michele.vitacca@fsm.it.
authors.forename: Michele
authors.initials: M
authors.lastname: Vitacca
authors.forename: Laura
authors.initials: L
authors.lastname: Comini