Impact of a treatment escalation/limitation plan on non-beneficial interventions and harms in patients during their last admission before in-hospital death, using the Structured Judgment Review Method.

OBJECTIVES: To assess the effect of using a treatment escalation/limitation plan (TELP) on the frequency of harms in 300 patients who died following admission to hospital. DESIGN: A retrospective case note review of 300 unselected, consecutive deaths comprising: (1) patients with a TELP in addition to a do-not-attempt cardiopulmonary resuscitation order (DNACPR); (2) those with DNACPR only; and (3) those with neither. Patient deaths were classified retrospectively as 'expected' or 'unexpected' using the Gold Standard Framework Prognostic Indicator Guidance. SETTING: Medical, surgical and intensive care units of a district general hospital. OUTCOMES: The primary outcome was the between-group difference in rates of harms, non-beneficial interventions (NBIs) and clinical 'problems' identified using the Structured Judgement Review Method. RESULTS: 289 case records were evaluable. 155 had a TELP and DNACPR (54%); 113 had DNACPR only (39%); 21 had neither (7%). 247 deaths (86%) were 'expected'. Among patients with 'expected' deaths and using the TELP/DNACPR as controls (incidence rate ratio (IRR)=1.00), the IRRs were: for harms, 2.99 (DNACPR only) and 4.00 (neither TELP nor DNACPR) (p<0.001 for both); for NBIs, the corresponding IRRs were 2.23 (DNACPR only) and 2.20 (neither) (p<0.001 and p<0.005, respectively); for 'problems', 2.30 (DNACPR only) and 2.76 (neither) (p<0.001 for both). The rates of harms, NBIs and 'problems' were significantly lower in the group with a TELP/DNACPR compared with 'DNACPR only' and 'neither': harms (per 1000 bed days) 17.1, 76.9 (p<0.001) and 197.8 (p<0.001) respectively; NBIs: 27.4, 92.1 (p<0.001) and 172.4 (p<0.001); and 'problems': 42.3, 146.2 (p<0.01) and 333.3 (p<0.001). CONCLUSIONS: The use of a TELP was associated with a significant reduction in harms, NBIs and 'problems' in patients admitted acutely and who subsequently died, especially if they were likely to be in the last year of life.

Death within 1 year among emergency medical admissions to Scottish hospitals: incident cohort study.

BACKGROUND: It is increasingly recognised that large numbers of hospital inpatients have entered the last year of their lives. AIM: To establish the likelihood of death within 12 months of admission to hospital; to examine the influence on survival of a cancer diagnosis made within the previous 5 years; to assess whether previous emergency admissions influenced mortality; and to compare mortality with that of the wider Scottish population. DESIGN: Incident cohort study. SETTING: 22 hospitals in Scotland. PARTICIPANTS: This study used routinely collected data from 10 477 inpatients admitted as an emergency to medicine in 22 Scottish hospitals between 18 and 31 March 2015. These data were linked to national death records and the Scottish Cancer Registry. PRIMARY OUTCOME MEASURES: 1 year cohort mortality compared with that of the general Scottish population. Patient factors correlating with higher risk of mortality were identified using Cox regression. RESULTS: There were 2346 (22.4%) deaths in the year following the census admission. Six hundred and ten patients died during that admission (5.8% of all admissions and 26% of all deaths) while 1736 died after the census admission (74% of all deaths). Malignant neoplasms (33.8%), circulatory diseases (22.5%) and respiratory disease (17.9%) accounted for almost three-quarters of all deaths. Mortality rose steeply with age and was five times higher at 1 year for patients aged 85 years and over compared with those who were under 60 years of age (41.9%vs7.9%) (p<0.001). Patients with cancer had a higher mortality rate than patients without a cancer diagnosis (55.6%vs16.6%) (p<0.001). Mortality was higher among patients with one or more emergency medical admissions in the previous year (30.1% v 15.1%) (p<0.001). Age/sex-standardised mortality was 110.4 (95% CI 104.4 to 116.5) for the cohort and 11.7 (95% CI 11.6 to 11.8) for the Scottish population, a 9.4-fold increase in risk. CONCLUSION: These data may help identify groups of patients admitted to hospital as medical emergencies who are at greatest risk of dying not only during admission but also in the following 12 months.