End of life management in Internal Medicine Wards: a single-center real-life report

The burden of end of life in Internal Medicine wards is not negligible. However, literature evidence about the end-of-life care in Internal Medicine wards lacks. Therefore, this study aimed to report on end-of-life management in an Internal Medicine ward. We performed a retrospective study focusing on the characteristics and management of patients who consecutively died in an Italian Internal Medicine ward between July 1, 2018 and June 30, 2019. Demographic, co-morbidity, pharmacological treatment at hospital admission, and in the last 48-hours of life and procedures during hospital stay were collected. The study population was composed of 354 patients (190 females), corresponding to about ten percent of patients admitted to the ward, with a mean age ± standard deviation 83.5±10.6 years. Eighty-four percent of deaths was expected in the last 48 h before exitus. The main co-morbidities were blood hypertension (66.3%), solid or hematological malignancies (40.3%), arrhythmias (34.7%), pressure ulcers (31.3%), and diabetes (27.4%). The main causes of hospitalization were infectious diseases (23.1%) and cardiac or respiratory failure (20.9%). In seven percent of patients, palliative care had already been activated before the hospital admission. No patient had written living wills or advance directives. In the last 48 hours of life, the main pharmacological classes prescribed were opioids (63.2%), antibiotics (46.9%), and corticosteroids (46.3%). Compared with pharmacological classes prescribed at hospital admission, in the last 48 h of life, the prescription of antibiotics, corticosteroids, opioids, and benzodiazepines increased significantly, whereas the prescription of antihypertensive agents, proton pump inhibitors, and antithrombotic drugs resulted notably reduced. A written order to withdraw vital parameters acquisition or active treatment were found in 30.7% and 31.9%, respectively. In the last 48 h of life, 61% of patients underwent at least one blood assay, 34% arterial blood gas analysis, and about 35% at least one among radiography, computer tomography, magnetic resonance, or endoscopy. During the hospital stay, 9% of patients underwent blood transfusion. 28.1% of patients received a blood transfusion in the last 48 hours of life. Appropriate management of end of life represents a challenge in Internal Medicine wards.