Dying in hospital in Germany - optimising care in the dying phase: study protocol for a multi-centre bottom-up intervention on ward level.

BACKGROUND: Hospitals are globally an important place of care for dying people and the most frequent place of death in Germany (47%), but at the same time, the least preferred one - for both patients and their relatives. Important indicators and outcome variables indexing quality of care in the dying phase are available, and various proposals to achieve corresponding quality objectives exist. However, they are not yet sufficiently adapted to the heterogeneous needs of individual hospital wards. METHODS: This multi-centre single-arm pre-post study aims at the development and implementation of context-specific measures in everyday clinical practice, followed by evaluating this approach. Therefore, (1) already existing measures regarding optimal care in the dying phase are identified applying a systematic literature review as well as an online survey and a symposium with experts. Supported by the thereby generated collection of measures, (2) a stratified sample of ten teams of different wards from two university hospitals select suitable measures and implement them in their everyday clinical practice. Circumstances of patients' deaths on the selected wards are recorded twice, at baseline before application of the self-chosen measures and afterwards in a follow-up survey. Retrospective file analysis of deceased persons, quantitative staff surveys as well as qualitative multi-professional focus groups and interviews with relatives form the data basis of the pre-post evaluation. (3) Results are reviewed regarding their transferability to other hospitals and disseminated (inter-)nationally. DISCUSSION: Measures that are easy to implement and appropriate to the specific situation are supposed to significantly improve the quality of care during the dying phase in hospitals and contribute to the well-being of dying patients and their relatives. Successful implementation of those measures requires consideration of the individual conditions and needs of patients and their relatives-but also of the health professionals-on the different hospital wards. Therefore, a bottom-up approach, in which the ward-specific situation is first analysed in detail and then the staff itself selects and implements measures to improve care, appears most promising for optimising care in the dying phase in hospitals. TRIAL REGISTRATION: The study is registered in the German Clinical Trials Register ( DRKS00025405 ).

Pharmacological treatment in the dying geriatric patient: describing use and dosage of opioids in the acute geriatric wards and palliative care units of three hospitals.

PURPOSE: The quality of dying of the older person could be optimized. One of the cornerstones to achieve better symptom control in the dying patient can be the use of opioids. However, little benchmark data concerning the use and dosage of opioids in the terminal phase in older persons are available. METHODS: In this multi-centric retrospective study, we included patients 75 years and older who died on the acute geriatric unit (AGU) and the palliative care unit (PCU) in three hospitals (during a 2-year period). Sudden deaths were excluded. Demographic and clinical variables, and data concerning use and dosage of opioids in the last 72 h before death were collected. RESULTS: Data from 556 patients were collected (38.5% from PCU, 61.5% from AGU). Older patients on the PCU were younger and suffered more frequently from end-stage malignancies. Most older patients on PCU (98.2%) received opioids with a mean dosage of 88.2 mg in 72 h. On the AGU, 75.5% of patients was treated with opioids with a mean dosage of 27.7 mg in 72 h. After adjusting for the variables age, gender and underlying pathology, use of opioids (OR 11.9; 95% CI 2.7-51.7; p = 0.022) and dosage (B 28.8; 95% CI 4.1-53.4; p = 0.001) still differed between the PCU and the AGU. Dosage of opioids was also associated with suffering from cancer or not. CONCLUSIONS: This descriptive benchmark study shows that opioids are given to 75.5% of dying older patients on the AGU at a mean dose of 27.7 mg over the last 72 h versus 98.2% and 88.2 mg, respectively, on the PCU. Further prospective studies including detailed information on symptomatology and more in-depth clinical information on trajectory of dying and cause of death are necessary.