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.