Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2018 Oct 31;8(10):e024264.
doi: 10.1136/bmjopen-2018-024264.

Impact of a treatment escalation/limitation plan on non-beneficial interventions and harms in patients during their last admission before in-hospital death, using the Structured Judgment Review Method

Calvin J Lightbody  1 , Jonathan N Campbell  2 , G Peter Herbison  3 , Heather K Osborne  1 , Alice Radley  1 , D Robin Taylor  2   4
Affiliations

Impact of a treatment escalation/limitation plan on non-beneficial interventions and harms in patients during their last admission before in-hospital death, using the Structured Judgment Review Method

Calvin J Lightbody et al. BMJ Open. .

Abstract

Objectives: To assess the effect of using a treatment escalation/limitation plan (TELP) on the frequency of harms in 300 patients who died following admission to hospital.

Design: A retrospective case note review of 300 unselected, consecutive deaths comprising: (1) patients with a TELP in addition to a do-not-attempt cardiopulmonary resuscitation order (DNACPR); (2) those with DNACPR only; and (3) those with neither. Patient deaths were classified retrospectively as 'expected' or 'unexpected' using the Gold Standard Framework Prognostic Indicator Guidance.

Setting: Medical, surgical and intensive care units of a district general hospital.

Outcomes: The primary outcome was the between-group difference in rates of harms, non-beneficial interventions (NBIs) and clinical 'problems' identified using the Structured Judgement Review Method.

Results: 289 case records were evaluable. 155 had a TELP and DNACPR (54%); 113 had DNACPR only (39%); 21 had neither (7%). 247 deaths (86%) were 'expected'. Among patients with 'expected' deaths and using the TELP/DNACPR as controls (incidence rate ratio (IRR)=1.00), the IRRs were: for harms, 2.99 (DNACPR only) and 4.00 (neither TELP nor DNACPR) (p<0.001 for both); for NBIs, the corresponding IRRs were 2.23 (DNACPR only) and 2.20 (neither) (p<0.001 and p<0.005, respectively); for 'problems', 2.30 (DNACPR only) and 2.76 (neither) (p<0.001 for both). The rates of harms, NBIs and 'problems' were significantly lower in the group with a TELP/DNACPR compared with 'DNACPR only' and 'neither': harms (per 1000 bed days) 17.1, 76.9 (p<0.001) and 197.8 (p<0.001) respectively; NBIs: 27.4, 92.1 (p<0.001) and 172.4 (p<0.001); and 'problems': 42.3, 146.2 (p<0.01) and 333.3 (p<0.001).

Conclusions: The use of a TELP was associated with a significant reduction in harms, NBIs and 'problems' in patients admitted acutely and who subsequently died, especially if they were likely to be in the last year of life.

Keywords: advance care planning; end-of-life care; medical harms; overuse; treatment escalation / limitation; underuse.

PubMed Disclaimer

Conflict of interest statement

Competing interests: None declared.

References

    1. Clark D, Armstrong M, Allan A, et al. . Imminence of death among hospital inpatients: prevalent cohort study. Palliat Med 2014;28:474–9. 10.1177/0269216314526443 - DOI - PMC - PubMed
    1. National Records of Scotland, 2017. 2016 births, deaths and other vital events - preliminary annual figures. https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-...
    1. Taylor DR, Lightbody CJ. Futility and appropriateness: challenging words, important concepts. Postgrad Med J 2018;94:238–43. 10.1136/postgradmedj-2018-135581 - DOI - PubMed
    1. Carter HE, Winch S, Barnett AG, et al. . Incidence, duration and cost of futile treatment in end-of-life hospital admissions. BMJ Open 2017;7:e017661. - PMC - PubMed
    1. Zhang B, Wright AA, Huskamp HA, et al. . Health care costs in the last week of life: associations with end-of-life conversations. Arch Intern Med 2009;169:480–8. 10.1001/archinternmed.2008.587 - DOI - PMC - PubMed