Checklist May Help Identify Patients for End-of-Life Care

Neil Osterweil

January 23, 2015

A checklist based on multiple clinical and demographic factors may help identify hospital patients who are likely to die soon and are unlikely to benefit from additional costly interventions.

Results of the screening tool could help clinicians and families discuss and better plan for end-of-life care, investigators say.

"This tool does not intend to preclude access to healthcare for the terminal elderly, but to provide an objective assessment and definition of the dying patient as a starting point for honest communication with patients and families, about recognizing that dying is part of the life cycle," write Magnolia Cardona-Morrell, MPH, PhD, and Ken Hillman, MD, from the Simpson Centre for Health Services Research at the University of New South Wales in Kensington, Australia. "Dignified withdrawal of intensive and inappropriate treatment and triage into alternative care in non-acute facilities is an area where there is still ample room for improvement," they continue in an article published online January 5 in BMJ Supportive & Palliative Care.

They note that although most patients express a preference for dying at home, the majority will die in a hospital, and that care of patients at or near the end of life often involves high use of medical transportation, emergency services, hospitalization, and intensive care.

"While there are accepted policies for de-escalating treatment in terminally ill patients, there are also inherent and societal pressures on medicine to continue utilising technological advances to prolong life even in plainly futile situations," the authors write.

Therefore, they designed a clinical decision aid to help clinicians identify patients who are close to death and unlikely to benefit from aggressive interventions when they present to an emergency department or when seen by an emergency response team on an urgent call.

CriSTAL Clear

The tool is dubbed CriSTAL, an acronym for Criteria for Screening and Triaging to Appropriate Alternative Care.

The authors searched the medical literature to find "explicit and practical" definitions of the term "end of life" and to identify screening tools and instruments, and they scanned the published evidence to come up with definitions for the dying patient and end-of-life care and to search for the most likely predictors of death in the short term (30 days) to medium term (12 weeks).

They came up with a checklist of 29 predictors of death, including:

  • Age 65 years or older, plus either emergency admission for the current hospitalization (associated with 25% mortality within 1 year) or two or more deterioration criteria, including change on the Glasgow Coma Score, low systolic blood pressure, slow or rapid respiration, low or high pulse rate, need for oxygen therapy or oxygen saturation less than 90%, hypoglycemia, or repeat or prolonged seizures.

  • Additional risk factors or predictors of short- to medium-term death, including personal history of active disease (advanced malignancy, chronic kidney disease, chronic heart failure, chronic obstructive pulmonary disease, new cerebrovascular disease, myocardial infarction, moderate or severe liver disease, cognitive impairment), as well as previous hospitalization within the last year, or repeat intensive care unit admission at the previous hospitalization.

  • Other factors, such as evidence of frailty, residence in a nursing home or supported-living facility, proteinuria, and abnormal electrocardiogram findings.

The authors plan to test the checklist against a retrospective data review, using a case–control study design in which the cases are deaths reported from an emergency response system in a teaching hospital, using controls matched by age, sex, and hospital unit.

If the checklist proves to be an accurate predictor of 30-day mortality, the authors suggest it could be implemented in a short form for use during every appropriate hospital admission.

The work is supported by a grant from the National Health and Medical Research Council of Australia. Dr Hillman has disclosed serving as an advocate for dying with dignity and writing books and articles on the subject.

BMJ Support Palliat Care. Published online January 5, 2015. Full text

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