Blog | Monday, October 24, 2011

QD: News Every Day--Patients benefit knowing death is imminent

Providing information of imminent death to cancer patients does not increase pain or anxiety, but is associated with improved care and to increase the likelihood of fulfilling the principles of a good death, a Swedish study found.

Informed patients significantly more often had parenteral drugs prescribed as needed, died in his or her preferred place, and had an informed family who were offered bereavement support. There was no difference between informed and uninformed patients in control of pain, anxiety, nausea, and respiratory tract secretions, although there was a difference in management of confusion. Results appeared at the Journal of Clinical Oncology.

Since 2000, there has been an increasing focus on palliative care in Sweden, the study authors wrote. In 2001, the Swedish Government identified breakpoints for transitioning to palliative care at the end of life and starting communications when that breakpoint was reached. Adoption increased in the ensuing years, and a national quality register was established, the Swedish Register for Palliative Care, in 2005.

Data about the care delivered during the last week of life were collected from a Web-based questionnaire completed by the physician and/or nurse responsible for the patient's care during the last week of life, The questionnaire is based on the 11 principles constituting good death as defined by the British Geriatrics Society, with eight of 25 overall questions covering topics such as autonomy, information about imminent death, symptom control, parenteral prescriptions as needed, and preferred location at time of death.

This study included all cancer deaths between 2006 and 2008 for which the patient did not lose his or her decision-making capacities until hours or days before death (n=13,818, 20% of all cancer deaths in Sweden during the study period). The majority of the patients (91% (n=12,609) had been given information about imminent death; 9% (n=1,209) had not.

A matching procedure created a comparison of 1,191 informed and 1,191 uniformed patients. Symptoms of pain, anxiety, confusion, nausea, dyspnea, and respiratory tract secretions were reported as being relieved in 80% to 96% of the patients during the last week of life in both groups. There were no significant differences between the informed and uninformed groups except for the symptom of confusion. Confusion was reported as not completely relieved in 60 patients (5%) in the informed group and in 87 patients (7%) in the uninformed group.

Significantly more patients in the informed group (70%) than in the uninformed group (39%) died at their preferred location. Staff knowledge of the preferred place of death was significantly higher among the informed patients than among the uninformed patients (25% who did not know among informed, compared to 55% among uninformed patients). If a patient had been informed of possible imminent death, family members were significantly more likely to have been offered bereavement support (83% vs. 78%), the authors found.

The authors concluded, "To give information about imminent death is a conscious act that involves awareness of the fact that the patient is dying, an awareness that also implies preparedness of the [health care provider]. Such preparedness should increase the probability of a more proactive approach with respect to prescribing palliative drugs and addressing patient and family wishes and needs during the last days of life (i.e., a concept of total care)."