clinical focus
A dignified end
Hospitals urged to avoid
aggressive treatments on
elderly patients if the risks
outweigh the benefits.
Magnolia Cardona interviewed
by Megan Tran
U
NSW medical researchers are
calling for restraint on the use of
aggressive life-saving treatments
for elderly patients, saying the focus
should be placed on making them
comfortable towards the end of their
lives. The study, led by Adjunct Associate
Professor Magnolia Cardona, reviewed 733
patients and found that a third of those
were subjected to aggressive procedures.
The median age was 68 years, but a third
of the patients were older than 80 years.
About 40 per cent of those aged 80-plus
were subjected to stringent procedures
such as intubation, intensive monitoring,
intravenous medications, transplants and
painful resuscitation attempts.
She said these treatments brought about
unnecessary suffering for patients by
admitting them to the ICU, and placed strain
on their families and the health system.
“Some risk factors such as a history
of presenting to the emergency room
or several hospital admissions in the
past few months, as well as not-for-
resuscitation orders, are clearly linked
with poor clinical prognosis and
impending death,” Cardona said.
“Such high-risk flags could be used as a
guide to refrain from using the emergency
team. If hospital staff were trained for
earlier recognition of when death is
inevitable, patients could be spared such
30 agedcareinsite.com.au
aggressive treatments and allowed a less
traumatic and more dignified end.”
Cardona said patients or families can
discuss their preferences before a health
crisis takes place and before they lose the
ability to make choices.
In particular, nurses and aged care
facilities can support people with writing
an advance care directive by providing the
relevant documents. She added that these
decisions are not permanent, and patients
can change their minds.
Aged Care Insite spoke with Cardona to
find out more.
ACI: What are some alternatives to
aggressive treatments?
MC: Well, when the condition is irreversible
and the end of their natural life is
approaching, what is more appropriate
is to manage patients with a transition to
comfort care. And by that I mean symptom
control, pain relief, psychosocial support
to the patient, and grief counselling to the
family. It could involve moving the patient
to another unit outside of an acute care
hospital, such as a palliative care unit, or
allowing them to die peacefully at home
surrounded by their loved ones.
What are the dangers of unnecessarily
aggressive procedures?
The main problem is the prolonged
suffering. So, when these people are
subjected to intubation or intensive care,
you need therapy for resuscitation or
even organ transplants, as happened in
this study.
Then the patient suffers longer,
especially in intensive care units, develops
delirium, and could die anyway, either
during the intensive care admission or
after discharge.
Resuscitation is very painful and is
not the successful event that we see on
television or in movies. What happens
is the patient may have broken ribs or
permanent loss of consciousness and
many other conditions that can make
the patient worse than they were before
admission.
The other thing is that, even if they
survive the resuscitation attempts, the
quality of remaining life may be very poor.
And many of them die within weeks or
months of the hospital discharge anyway.
Under what circumstances would
someone need aggressive treatment?
According to our research of many years,
only people who have a real prospect
of survival in better quality of life, or the
same as when they were admitted to
hospital, should be offered both options.
If the prognosis is not going to change,
[aggressive treatments] should not be
indicated.
In some exceptional cases, patients
are admitted to intensive care for a trial
period of about 72 hours. This is in cases
where they have, for example, family
far away and they want to be saying
their goodbyes, so it’s more about a
compassionate care approach: keeping
the person alive so the family can come
and say their goodbyes.
But it’s only a very small proportion of
patients. If the patients have had an advance
care directive or a conversation with
their family, the decision to not do those
aggressive treatments could be made earlier
and the patient is spared that suffering.
So what training should there be for
staff to recognise when death is near?
There are several prognostic tools
out there in the literature. We have
developed one at the University of NSW
called CriSTAL (Criteria for Screening
and Triaging to Appropriate aLternative
care). It’s a checklist with 19 items that
are readily available from the person’s
clinical history. So, as they come to the
emergency department, the checklist can
be completed in less than three minutes
if the person is known to the emergency
department. And that gives you a score
that tells you if the person is at high risk of
death within the next few months.
What we recommend with that checklist
is that the doctors and nurses who see
the patient start an honest conversation
with them about the true prognosis, the
possibility of recovery or their impending
death. And that honest conversation
could include the person’s values and
preferences for what they’re prepared to
endure in terms of aggressive treatments
or what they consider inappropriate,
excessive or unacceptable.