title: Prevalence of symptoms at the end of life in an acute care hospital: a retrospective cohort study.
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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Medicine (Kobewka, Mulpuru, Forster), Division of General Internal Medicine, The Ottawa Hospital, University of Ottawa; Ottawa Hospital Research Institute (Kobewka, McIsaac, Mulpuru, Forster), Ottawa, Ont.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Department of Anesthesiology and Pain Medicine (McIsaac) - The Ottawa Hospital, University of Ottawa; Performance Measurement (Forster), The Ottawa Hospital, Ottawa, Ont.
authors.forename: Daniel
authors.initials: D
authors.lastname: Kobewka
authors.affiliation: Department of Medicine (Kobewka, Mulpuru, Forster), Division of General Internal Medicine, The Ottawa Hospital, University of Ottawa; Ottawa Hospital Research Institute (Kobewka, McIsaac, Mulpuru, Forster), Ottawa, Ont.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Department of Anesthesiology and Pain Medicine (McIsaac) - The Ottawa Hospital, University of Ottawa; Performance Measurement (Forster), The Ottawa Hospital, Ottawa, Ont.
authors.forename: Paul
authors.initials: P
authors.lastname: Ronksley
authors.affiliation: Department of Medicine (Kobewka, Mulpuru, Forster), Division of General Internal Medicine, The Ottawa Hospital, University of Ottawa; Ottawa Hospital Research Institute (Kobewka, McIsaac, Mulpuru, Forster), Ottawa, Ont.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Department of Anesthesiology and Pain Medicine (McIsaac) - The Ottawa Hospital, University of Ottawa; Performance Measurement (Forster), The Ottawa Hospital, Ottawa, Ont.
authors.forename: Dan
authors.initials: D
authors.lastname: McIsaac
authors.affiliation: Department of Medicine (Kobewka, Mulpuru, Forster), Division of General Internal Medicine, The Ottawa Hospital, University of Ottawa; Ottawa Hospital Research Institute (Kobewka, McIsaac, Mulpuru, Forster), Ottawa, Ont.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Department of Anesthesiology and Pain Medicine (McIsaac) - The Ottawa Hospital, University of Ottawa; Performance Measurement (Forster), The Ottawa Hospital, Ottawa, Ont.
authors.forename: Sunita
authors.initials: S
authors.lastname: Mulpuru
authors.affiliation: Department of Medicine (Kobewka, Mulpuru, Forster), Division of General Internal Medicine, The Ottawa Hospital, University of Ottawa; Ottawa Hospital Research Institute (Kobewka, McIsaac, Mulpuru, Forster), Ottawa, Ont.; Department of Community Health Sciences (Ronksley), University of Calgary, Calgary, Alta.; Department of Anesthesiology and Pain Medicine (McIsaac) - The Ottawa Hospital, University of Ottawa; Performance Measurement (Forster), The Ottawa Hospital, Ottawa, Ont.
authors.forename: Alan
authors.initials: A
authors.lastname: Forster