Checklist to spot elderly patients most at risk of death

3 February 2015

Australian doctors have developed a checklist for identifying elderly hospital patients likely to die within three months. The list has been published in BMJ Supportive & Palliative Care.

The aim of the checklist, called Criteria for Screening and Triaging to Appropriate Alternative care, or CriSTAL for short, is to kick-start frank discussions about end of life care, and minimise the risk of further futile treatment, they say.

“Delaying unavoidable death contributes to unsustainable and escalating healthcare costs, despite aggressive and expensive interventions,” they write. “These interventions may not influence patient outcome; often do not improve the patient’s quality of life; may compromise bereavement outcomes for families; and cause frustration for health professionals.”

They scanned the published evidence to come up with definitions for the dying patient and end of life care and to search for the most likely predictors of death in the short (30 days) to medium term (12 weeks).

They came up with a checklist of 29 predictors of death, including older age (at least 65 years of age); two criteria of deterioration; at least two criteria for frailty; an early warning score of more than 4 (an assessment of acute illness); at least one other underlying health condition; nursing home residency; cognitive impairment; previous emergency admission or intensive care treatment within the preceding year; and abnormal heart monitor tracing; and protein in the urine.

The researchers emphasise that the checklist is not intended to substitute healthcare for the elderly who are terminally ill. Instead, it is meant to “provide an objective assessment and definition of the dying patient as a starting point for honest communication with patients and families about recognising that dying is part of the life cycle.”

This goes for healthcare professionals too, many of whom are under pressure to continue prolonging the life of a patient against all the odds, say the researchers.

“While there are accepted policies for de-escalating treatment in terminally ill patients, there are also inherent and societal pressures on medicine to continue utilising technological advances to prolong life even in plainly futile situations,” they write.

But they insist: “Training for nurses and doctors in the use of the screening tool and in approaching patients and families with concrete information about inevitability of death and lack of benefit of further intensive treatment are paramount.”

Most patients end up dying in hospital, even though that is not their stated preference, when asked.

By giving families and patients some options about the preferred place of death, CriSTAL could also help prompt the development of more appropriate services than hospital for managing patients at the end of their life, they suggest.

If the checklist proves accurate in the prediction of death within the next 30 days, a shortened version could be used for every hospital admission, they add.

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