Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Palliative Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
J Pain Symptom Manage. 2018 Sep;56(3):337-343. doi: 10.1016/j.jpainsymman.2018.05.013. Epub 2018 May 22.
Clinicians often rely on documentation to relay information, and this remains the mainstay of interprofessional communication regarding patient care. However, there has been scant research focused on clinicians' documentation of dying in hospital and how this is communicated to other team members in patient charting.
To understand the language used to describe the deterioration and death of patients in an acute academic tertiary care center and to identify whether patient diagnoses or palliative care (PC) involvement was associated with clearer descriptions of this process.
We conducted a retrospective chart review of the final admission of 150 patients who died on an inpatient internal medicine unit. Conventional and summative content analysis was performed of the language used to describe, either directly or indirectly, that the patient's death was imminent.
Of the 150 deaths, the median age was 79.5 (range 22-101), 58% were males, and 69% spoke English. A total of 45% of deaths were from cancer, and 66% occurred with prior PC team involvement. There was no documentation of the dying process in 18 (12%) charts. In the remainder, clinicians' documentation of imminent death fell into three categories: 1) identification of the current state using specific labels; for example, dying (24.7%) or end of life (15.3%), or less specific language, unwell or doing poorly (6.0%); 2) predicting the future state using specific or more vague predictions; for example, hours to days (7.3%) or poor or guarded prognosis (26.0%); and 3) using care provided to the patient to imply patient status; for example, PC (49.3%) or comfort care (28.7%). PC involvement, but not a malignant diagnosis, was associated with more frequent use of specific language to describe the current state (P = 0.004) or future state (P = 0.02).
Death and dying in hospital is inadequately documented and often described using unclear and vague language. PC involvement is associated with clearer language to describe this process.
临床医生通常依赖记录来传达信息，这仍然是关于患者护理的跨专业交流的主要方式。然而，很少有研究关注临床医生在医院记录死亡的方式，以及如何在病历图表中向其他团队成员传达这一信息。
了解急性学术型三级保健中心描述患者恶化和死亡的语言，并确定患者的诊断或姑息治疗（PC）参与是否与更清晰地描述这一过程有关。
我们对一个内科住院病房内 150 名死亡患者的最后一次入院进行了回顾性病历审查。对直接或间接描述患者死亡迫在眉睫的语言进行了常规和总结性内容分析。
在 150 例死亡中，中位年龄为 79.5 岁（范围 22-101），58%为男性，69%讲英语。死亡原因总计 45%为癌症，66%发生于 PC 团队参与之前。18 份（12%）病历中没有记录临终过程。在其余病历中，临床医生对即将到来的死亡的记录分为三类：1）使用特定标签识别当前状态，例如临终（24.7%）或生命末期（15.3%），或使用不太特定的语言，如不适或状态不佳（6.0%）；2）使用特定或更模糊的预测来预测未来状态，例如数小时至数天（7.3%）或预后不良或预后不佳（26.0%）；3）使用提供给患者的护理来暗示患者的状态，例如 PC（49.3%）或舒适护理（28.7%）。PC 参与，而不是恶性诊断，与更频繁地使用特定语言描述当前状态（P=0.004）或未来状态（P=0.02）相关。
医院的死亡和临终记录不足，并且通常使用不明确和模糊的语言进行描述。PC 参与与更清晰的语言描述这一过程有关。
