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How We Die

August 19, 2014
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Written by Herbert R. Jalowsky M.D

An article in Journal of the American Medical Association brings both promising and disturbing information about a topic we all know and most of us are uncomfortable with: dying. Most people, when queried, say that they want to die at home. Some are even using “location of death at home” as a quality marker.

This study shows that the hospice movement, in this regard, is successful.

Comparing 2000 and 2009:

  • The number of people dying in the hospital decreased by 8%
  • Concurrent hospice use doubled from 22% to 42%.

These numbers seem reassuring.

However, if we look further, some of the trends are disturbing.

  • ICU use in the last month of life increased by 5%
  • 28 % of patients spend less than 3 days in hospice before dying.
  • 40% of the above short hospice stays were preceded by an ICU stay
  • The number of health care transitions (hospital, icu, snf, home and hospice) for the 90 days before death, and 3 days before death also rose significantly. (lots of transfers for dying patients)

What does this mean?

The authors suggest “Future research is needed to examine whether these trends are improving the quality of life and are consistent with patient preferences”

I believe that the hospice movement has been one of the most significant advances in medicine in my medical career of 30+ years. Yet it seems that it may be subverted by the medical industry.

Why? Here is how I look at it:

The primary job of hospice is to keep patients out of the hospital, AT HOME and as comfortable as possible. Hospice is pretty good at this.

Hospice provides an interdisciplinary group approach; with nursing, social services, volunteers, spiritual counselors, physicians, bereavement counselors, and pharmacy.

Indeed many patients increasingly are discharged from hospice, stronger and healthier than when admitted. Not to a mortuary, but improved, feeling better, and no longer in need of our services.

Why?

I believe hospice is providing that gold standard; coordination of care, by reducing unnecessary medications and focusing on comfort. So why is this NOT happening?

Barriers to hospice:

75% of patients who present to the ER do not have advance directives.

Misperception of what happens to you if you require CPR (cardio-pulmonary resuscitation) also known as “code”

The following are what can happen:

  • Immediate death
  • Patient does not survive the code
  • Prolonged death in the hospital
  • Survival with impairment
  • Institutionalized, dependent
  • Survival at or near baseline status

Understanding outcomes of CPR:

  • Rate of overall survival
    Your rate of surviving well is 15%
  • Relative rates
    CPR is 10 TIMES MORE LIKELY TO FAIL or leave you worse off than return you to normal
  • Goal oriented
    CPR is meant to rescue people from death, not fix any underlying problems or improve comfort/function

Bad/adverse drug side effects from CPR:

  • Trauma
    • 31% rib fractures
    • 21% chest wall fracture
    • 18% internal bleeding
    • 20% airway damage
    • 30% internal lacerations
  • Prolonged death in the hospital- Instead of dying from an arrhythmia ( heart rhythm disturbance), pt survives only to die from:
    • 59% lung failure
    • 31% heart failure
    • Many die in the ICU
      • 16% declared brain dead
      • 84% choose to withdraw care

Decision help if you don’t know what you want

Goal Full Code DNR
Longevity Longevity is still a goal
Dying peacefully is not a goal
Avoiding a prolonged death is not a goal
Longevity is no longer a goal
Dying peacefully or naturally is a goal
Avoiding a prolonged death is a goal
Comfort Not a primary goal Comfort is a primary goal
Function Low functional requisite for living High functional requisite for living
Pain Tolerance High tolerance for trauma Low tolerance for pain and trauma
Risk Tolerance A bad outcome would be okay because at least an attempt was made for longevity A bad outcome means the intervention was not worth it

Conclusion

  • Death is not a choice
  • We do have options of how we die
  • Ask your physician at Tucson Family Medicine for more information

Thank you to Dr. Shivani Ruben for her help with this article.