Do-not-resuscitate decisions in a large tertiary hospital: differences between wards and results of a hospital-wide intervention.

BACKGROUND: Despite the advent of palliative care, the quality of dying in the hospital remains poor. Differences in quality of end-of-life practice between hospital wards are well known in clinical practice but rarely have been investigated. METHODS: A prospective observation of do-not-resuscitate (DNR) decisions was conducted in patients dying in a Belgian university hospital before (115 patients) and after (113 patients) a hospital-wide intervention consisting in informing hospital staff on the law on Patient's Rights and the introduction of a new DNR form.The new DNR form puts more emphasis on the motivation of the DNR decision and on the description of the participants in the decision-making process. RESULTS: The completion of DNR forms improved after the intervention: physicians better documented who participated in DNR decisions (for participation of family: 63% after the intervention vs. 44% before the intervention, p = 0.022, for nurses: 27% vs. 14%, p = 0.047) and the motivation for these decisions (59% vs. 32%, p = 0.001). However, there was no difference in referral to the intensive care unit (ICU) at the end of life (in 40% of patients after and 37% before the intervention). Furthermore, the number of patients dying without DNR form on the wards was similar (13% and 8%). Surgical patients and patients with non-malignant diseases were more often referred to ICU at the end of life (71% in surgical vs. 35% in medical patients, p < 0.001 and 49% in patients with non-malignant diseases vs. 23% in patients with malignancy, p < 0.001). Moreover, surgical patients less frequently received a DNR order (56% in surgical vs. 92% in medical patients, p = 0.007). CONCLUSIONS: The introduction of a new DNR form and informing hospital staff on patients' right to information did not improve physicians' end-of-life practice.Transition from life-prolonging treatment to a more palliative approach was less anticipated in surgical patients and patients with non-malignant diseases.

Factors influencing ICU referral at the end of life in the elderly.

OBJECTIVE: Referral to the intensive care unit (ICU) and frequency of do-not-resuscitate (DNR) decisions at the end of life (EOL) in adult hospitalized patients≥75 years and those<75 years were examined and influencing factors in the elderly were determined. METHODS: Data were prospectively collected in all adult patients who deceased during a 12-week period in 2007 and a 16-week period in 2008 at a university hospital in Belgium. RESULTS: Overall, 330 adult patients died of whom 33% were ≥75 years old. Patients≥75 years old were less often referred to ICU at the EOL (42% vs. 58%, p=0.008) and less frequently died in the ICU (31% vs. 46%, p=0.012) as compared to patients<75 years old. However, there was no difference in frequency of DNR decisions (87% vs. 88%, p=0.937) for patients dying on non-ICU wards. After adjusting for age, gender, and the Charlson comorbidity index, being admitted on a geriatric ward (OR 0.30, 95% CI 0.10-0.85, p=0.024) and having an active malignant disease (OR 0.39, 95% CI 0.19-0.78, p=0.008) were the only factors associated with a lower risk of dying in the ICU. CONCLUSION: Patients≥75 years are less often referred to the ICU at the EOL as compared to patients<75 years old. However, the risk of dying in the ICU was only lower for elderly with cancer and for those admitted to the geriatric ward.

Kidney in old age.

Epidemiological studies have shown that chronic kidney disease (CKD) is a major health problem especially in an older population. Given the growing segment of the elderly population and the important implication of renal disease on health care, this review discusses the structural and functional changes of the ageing kidney and the underlying mechanisms of age-dependent injury. The implications of these changes in daily clinical practice and the management of CKD is also briefly overviewed.

Renal function in the oldest-old on an acute geriatric ward.

AIM: Evaluation of renal function and relation to risk factors for renal failure in very old patients admitted to an acute geriatric ward. METHODS: Retrospective chart review of patients aged 80 years and over, admitted to the acute geriatric ward from August 1998 till August 1999. Recorded data were: age, gender, previous medical history, primary diagnosis, medication use, weight, serum creatinine, BUN, sodium, potassium, cholesterol, urine and ultrasound of the kidney. The creatinine clearance was estimated by the Cockcroft-Gault formula, the glomerular filtration rate by the MDRD equation. RESULTS: 220 (60 males/160 females) patients were included. The mean serum creatinine on admisssion and discharge was 1.17 +/- 0.45 mg/dL and 1.11 +/- 0.48 mg/dL respectively. The mean estimated creatinine clearance in the very old was 38.11 +/- 12.04 mL/min on admission and 39.00 +/- 11.01 mL/min on discharge. Renal failure arbitrarily defined as an estimated creatinine clearance on admission of less than 30 mL/min was found in 26.4% of the patients. Only a significant correlation between failure to thrive and renal failure was found (p < 0.0001). The correlation coefficient between the Cockcroft-Gault and the MDRD formula was r = 0.66 (p < 0.0001); between the Cockcroft-Gault and the reciprocal serum creatinine was r = 0.60 (p < 0.0001) and between the MDRD and the reciprocal serum creatinine was r = 0.87 (p < 0.0001). CONCLUSION: The weak correlation between the Cockcroft-Gault and other estimations of GFR in the acutely ill elderly, confirms the need to have a reliable estimation of glomerular filtration rate in the elderly. Renal failure defined as a Cockgroft-Gault <30 mL/min is found in 26.4% of the oldest-old admitted to an acute geriatric department. The elderly with renal failure is more often admitted for failure to thrive. No great differences were observed between renal function on admission and discharge.