Death in the hospital

To examine symptoms and treatments among hospitalized adults in the last 2 days of life.

Review of 72 consecutive medical records of patients who died at an academic medical center and 32 consecutive medical records of patients who died at an affiliated Veterans Affairs hospital. Medical records were examined for documentation of symptoms, treatment, and orders to limit the use of life-sustaining interventions.

The 104 patients who died had an average age of 68.9 years and 70 (68%) were men. The majority had neoplasms or acquired immunodeficiency syndrome, cardiovascular disease, and end-stage lung disease; the remainder died of other acute or chronic illnesses. In the last 2 days of life, pain was noted in 49 patients (46%). Dyspnea (n=53) and restlessness or agitation (n=50) were documented in 51% of the patients. In the last 48 hours of life 12 patients (12%) underwent an attempt at resuscitation, 26 patients (27%) were receiving ventilatory support, and 18% were restrained. Nearly half of the patients (48%) had an order or progress note specifying "comfort measures only" (CMO). Patients with CMO, compared with those without such orders, had similar levels of pain, agitation, and dyspnea. Patients with CMO were less likely to be in an intensive care unit (P=.001), receive ventilatory support (P=.001), receive antibiotics (P=.009), or be weighed (P=.001).

Baseline information with which to begin improvement of care for dying individuals was obtained through a brief retrospective chart review. While patients with CMO receive less aggressive care, no specific process was used to provide comfort care. The evaluation and testing of processes of care for dying patients are necessary to begin the improvement of care. We provide baseline data about processes and outcomes of care in our hospitals.