In the largest systematic review of the care of elderly patients hospitalized at the end-of-life, researchers have found that more than one third of elderly people hospitalized at the end of their life receive unnecessary and potentially harmful medical treatments. The study highlights the need for improved training for doctors and more community education to minimize the number of non-beneficial treatments in patients nearing the end of their life.
Whether a patient is at their natural end of life or has a condition that is reversible, admission to an acute hospital and prevention of death by means of medical interventions is usually the default option. When patients are at their natural end of life, however, it is difficult to reach a balance between doing everything that is technically practical and doing everything that is clinically appropriate in order to improve quality of care. Clinical judgment on its own does not always correctly predict patients who may not benefit from further treatment.
Researchers have defined “non-beneficial treatments” as those medical treatments and procedures administered to people who are elderly in terminal stages of disease which extend suffering instead of survival, that can potentially cause harm, are sometimes given against wishes of patients and are not likely to enhance the health or quality of remaining life of the patient. To examine the extent of non-beneficial treatments given to elderly patients hospitalized at the end of their life, researchers conducted a systematic review; they examined data from 38 studies involving non-beneficial treatments over the past 20 years, using information from 1.2 million patients, nurses and doctors, and bereaved relatives in 10 countries around the world (Australia, Canada, England, the USA, France, Holland, Brazil, Taiwan, South Korea and Israel). Studies included in the review examined non-beneficial treatments including operations, complex medications, invasive procedures and costly actions that were administered in the last 6 months of life to the last days of life (a period that qualifies ‘terminal illness’).
The study, published in the International Journal for Quality in Health Care, provides evidence to suggest that the practice of doctors administering unnecessary or excessive medical treatment on elderly patients in the last six months of their end of life holds in hospitals worldwide. The researchers found that approximately 33% to 38% of elderly patients with irreversible, advanced chronic conditions received non-beneficial treatments including chemotherapy or intensive care, while others with do-not-resuscitate orders were still given CPR (cardiopulmonary resuscitation) near the end of life. Moreover, up to 10% of elderly patients were admitted to non-beneficial intensive care at the end of their life, and about half of imaging and blood tests were conducted unnecessarily on older patients, and around one third received non-beneficial administration of antibiotics, chemotherapy (in the last six weeks of life), digestive and endocrine and cardiovascular treatments to dying patients. Another 30% of elderly patients were found to unnecessarily undergo radiotherapy, blood transfusions, dialysis and other life support in the last days of life and 33-50% received non-beneficial CPR when they had do-not-resuscitate orders.
According to the researchers, a possible explanation for why excessive and unnecessary treatments and procedures are often performed is that rapid advancements in medical technology have led to unrealistic expectations of the healing power of doctors and their ability to ensure survival of patients. Furthermore, doctors are often torn by the ethical problem of doing what they were trained to do — to save lives — in contrast with respecting the right of the patient to die with dignity. The culture of ‘doing everything possible’, even if it is in disagreement with patients’ expressed wishes, sustains the practice of aggressive, and costly care at the end of life. The researchers note that these behaviours have consequences not only on the financial sustainability of the health services, and maintain the unrealistic high social expectation of survival no matter what, but also more importantly demonstrate a disregard for quality end of life and human dignity.
The overall findings of this study indicate widespread use of non-beneficial treatments at the end of life in hospitals. The emerging conclusion is that it seems that a certain degree of non-beneficial treatments must always be present given the unpredictability of prognosis on time to death, the ethical and social pressures, and the compassionate recommendation for intensive care admissions while families come to accept the inevitable; this does not mean that its widespread presence should not be reduced.
As the population of elderly and frail people rises and the number of admissions to hospitals are rapidly increasing, doctors and nurses must be able to better identify when death is impending and inevitable in order to reduce non-beneficial treatments. A good start to prevent non-beneficial treatments is to have an honest and open dialogue with patients or their families. The researchers also add that additional training will help doctors let go of their fear of a wrong prognosis and better identify patients near the end of their lives. More community education is also encouraged to enhance awareness and reduce the demand for non-beneficial treatments at the end of life.
Written By: Nigar Celep, BASc