Numerous factors associated with rapid death after admission to palliative care service

Image: CC/F. Gardener

Key findings:

1. For patients who are rapidly dying, early referral to palliative care services is important as there is evidence that the overall satisfaction of patients, families, and even staff is higher with longer palliative care admissions
2. Factors associated with patient death in 24 hours include admission from neurosurgery, admission with a vascular or infective pathology, commencing a syringe driver as part of treatment prior to or at admission, and the following validated scores: PCOC phase ≥ 3 and modified Karnofsky score ≤ 20%

Primer: In the classical sense, palliative care services aim to improve the overall quality of life in patients where death is imminent and to sooth the effects of the process of dying on those close to the patient. Admissions to palliative care that have been blunted do not provide enough time for symptom assessment and relationship formation and are, therefore, more disruptive to the patient and family. In order to maximize the time spent in palliation when needed, factors should be identified that affect the palliative care length of stay. Standard clinical assessment tools that measure outcome in the palliative care setting include the Australian Palliative Care Outcomes Collaboration (PCOC), which places patients in a “phase” (from 1 to 5) as determined by standardized definitions (i.e., stable, unstable, deteriorating, terminal, and post-death support, respectively) and the modified Karnofsky score (from 0 to 100%) that assesses activity, work, and self-care.

For further reading, please see the following studies:

1. Kapo J, Harrold J, Carroll JT, et al. Are we referring patients to hospice too late? Patients’ and families’ opinions. Journal of Palliative Medicine 2005;8:521–527.
2. Frantz TT, Lawrence JC, Somov PG, et al. Factors in hospice patients’ length of stay. American Journal of Hospice and Palliative Care 1999;16:449–454.

This [retrospective] study: An audit of patient files referred to the palliative care unit of St. Vincent’s Hospital Melbourne in Australia in 2011 resulted in 256 patients being involved in this study. Patients were divided into two groups: 1) those who died within 24 hours of admission (n = 42) and 2) those who died after 24 hours (n = 214).  Univariate analysis was performed, and five factors were determined to be significantly associated with a greater rapidity of death (P=0.0001). Age, outside country of birth, preferred language, and whether an emergency code was called or not were all not associated.

In sum: The study found several factors that were significantly associated with a quicker death following admission to palliative care: 1) admission from neurosurgery, 2) admission with an infectious or vascular pathology, 3) a PCOC phase ≥ 3, 4) a modified Karnofsky score ≤ 20%, and 5) the commencement of a syringe driver before or at admission.

It's somewhat apparent that each of these factors, on their own, correlates with a patient who is clinically unwell, especially the PCOC and Karnofsky scores that, by their definitions, infer a rapidly dying patient. The limited sample size and the fact that the study was carried out at a single centre makes it difficult to generalize these factors to all palliative care settings. Nevertheless, these findings suggest that physicians need to be cognisant of patient characteristics that may expedite death, in order to make the appropriate transition to palliation.

Click to read in IMJ

Written by JDP and AC