Dying with End Stage Liver Disease with Cirrhosis: Insights from SUPPORT

The last 2 years of life: functional trajectories of frail older people

OBJECTIVES

To characterize the functional trajectories during the last 2 years of life of patients with progressive frailty, with and without cognitive impairment, and to assess whether it was possible to identify discrete functional indicators that signal the end of life.

DESIGN

A retrospective analysis of functional trajectories during the last 24 months of life.

SETTING

Twelve demonstration sites of the Program of All-inclusive Care for the Elderly (PACE). PACE cares for frail older people who meet criteria for nursing home placement, with the goal of keeping the patient at home.

PARTICIPANTS

Nine hundred seventeen patients who died while enrolled in PACE.

MEASURES

At PACE entry and every 3 months thereafter, data were collected about the degree of dependence (none, partial, or full) in bathing, eating, and walking and the degree of incontinence (none, bladder, or bowel). Cognitive impairment was defined as six or more errors on the Short Portable Mental Status Questionnaire. To describe the end-of-life trajectories of patients, data were analyzed from observational windows of time, beginning with the patients' dates of death and extending backward in time to 24 months before death. Each analytical window was 3 months in duration. For each of the functional measures, the probability of functional deterioration in the last 2 years of life in patients with (64%) and without (36%) cognitive impairment was also compared.

RESULTS

The mean age at death was 84; 69% of patients were women. For patients with and without cognitive impairment, a prolonged, steady increase in the rates of functional dependence that were evident at least 1 year before death, rather than sudden increases in functional dependence shortly before death, characterized the functional trajectories. It was not possible for any of the four measures to detect a time point before death at which there was an abrupt decline in function likely to signal impending death. For each measure, patients with cognitive impairment declined earlier, were more likely than patients without cognitive impairment to have the maximal level of dependence in the 0- to 3-month window before death (e.g., 56% vs 30% for mobility, P <.001), and were more likely to decline in the 2 years before death (e.g., 56% vs 36% for mobility, P <.001).

CONCLUSION

Patients with advanced frailty, with or without cognitive impairment, have an end-of-life functional course marked by slowly progressive functional deterioration, with only a slight acceleration in the trajectory of functional loss as death approaches. Patients with cognitive impairment have particularly high rates of functional impairment at the time of death. These results suggest that end-of-life care systems that are targeted toward patients with functional trajectories clearly suggesting impending death (such as the Medicare hospice benefit) are poorly suited to older people dying with progressive frailty.

Portopulmonary hypertension: a tale of two circulations

Pulmonary involvement is common in patients with portal hypertension and can manifest in diverse manners. Changes in pulmonary arterial resistance, manifesting either as the hepatopulmonary syndrome or portopulmonary hypertension (PPHTN), have been increasingly recognized in these patients in recent years. This review summarizes the clinicopathologic features, diagnostic criteria, as well as the latest concepts in the pathogenesis and management of PPHTN, which is defined as an elevated pulmonary artery pressure in the setting of an increased pulmonary vascular resistance and a normal wedge pressure in a patient with portal hypertension.

Do not resuscitate orders in different countries

Health care decision making in severely ill patients presents many difficult medical, ethical and legal problems. Physicians, including anaesthesiologists, are frequently confronted with dilemmas regarding the appropriateness of risky interventions and the balance of potential benefits versus risks. The risks include not only death and the pain and suffering that are related to the interventions, but also (and arguably more importantly) the burdens of lingering disability, loss of independence and poor quality of life. This review presents recent findings (focusing on papers published between 1999 and March 2001), and explores the background for the introduction of do not resuscitate policies and their use in clinical practice in different countries. Problems with auditing and implementing do not resuscitate policies are highlighted.

Symptom burden at the end of life: hospice providers' perceptions

To describe symptom prevalence, frequency, and severity among hospice patients, from the perspective of hospice providers, a cross-sectional study was conducted among 16 hospices participating in the Population-based Palliative Care Research Network (PoPCRN). Hospice staff estimated symptom presence, frequency, and severity, using the Memorial Symptom Assessment Scale. Among the 348 patients (median age 78 years, 55% female, 55% cancer diagnosis), the most common symptoms noted by hospice staff were lack of energy (83%), pain (76%), lack of appetite (63%), drowsiness (61%), difficulty concentrating (60%), and sadness (51%). When present, lack of energy was rated by hospice providers as both frequent (75% "frequently" or "almost constantly") and severe (46% "severe" or "very severe"). Symptoms varied by care setting and by diagnosis. Hospice staff often lacked sufficient information to rate potentially important symptoms, such as problems with sexual interest or activity (63%), change in self image (30%), and worrying (26%). This study identifies a significant burden of unrelieved symptoms among hospice patients, suggesting a need for more widespread institution of symptom management strategies with proven effectiveness and additional investigation into treatment of common symptoms for which few effective treatment strategies are known.