Vol. 33 No.

6 June 2007 Journal of Pain and Symptom Management 711

Original Article

End-of-Life Care in Hospital: Current Practice

and Potentials for Improvement
Gerhild Becker, MD, MTh, Robert Sarhatlic, MSc, Manfred Olschewski, MSc,
Carola Xander, MSc, Felix Momm, MD, and Hubert E. Blum, MD
Departments of Medicine II (G.B., R.S., H.E.B.), Medical Biometry and Statistics (M.O.),
and Radiotherapy (C.X., F.M.), University Hospital Freiburg, Freiburg, Germany

Abstract
From July until September 2004, all deaths were registered prospectively in all departments of
Freiburg University Hospital, Germany, a large teaching hospital with approximately 55,000
inpatient admissions per year. A retrospective chart review was done for all patients who died
during this time period using a tool validated in two American and Australian projects.
Main outcome measures were patients’ identification as dying by medical staff, Do-Not-
Resuscitate (DNR) orders, and the presence of comfort care plans. The cohort comprised 226
consecutive death events. Seven percent of patients had a written advance directive. DNR
orders were available for 65% of patients and were entered into the charts on average 5.9
days prior to death. Thirty-eight percent of charts had evidence that staff recognized that the
patients were dying. This prognosis was noted on average 3.8 days prior to death. According
to chart notes, clinicians documented cancer patients as dying more frequently than patients
with cardiovascular disease (P ¼ 0.029). In the chart entries, comfort care plans were
completed fully for 14% and partially for 27% of patients. On average, comfort care plans
were put in place nine days prior to death. Cancer patients had significantly more frequent
comfort care plans than patients with cardiovascular diseases (P < 0.001). In 59% of
medical charts, there was no evidence of a comfort plan. Approximately one-third of dying
patients received active life-sustaining treatment at time of death. These data highlight the need
for systematic strategies to monitor patients’ needs and to improve quality of care, especially
during the last four days before death. J Pain Symptom Manage 2007;33:711e719.
Ó 2007 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

Key Words
Terminal care, end-of-life decisions, DNR, advance directives

Introduction who choose to be cared for at home may end

Approximately half of all patients who die in
Germany do so in the hospital.1 Even patients
Address reprint requests to: Gerhild Becker, MD, MTh,
Department of Medicine II, University Hospital
Freiburg, Hugstetter Str. 55, D-79106 Freiburg, Ger-
many. E-mail: becker@med1.ukl.uni-freiburg.de
Accepted for publication: September 28, 2006.
up in a hospital when a sudden complication
arises, or the family is no longer able to cope
with caregiving demands. There have been
some studies that describe the circumstances
of dying in the acute care setting.2e11 However,
whereas the Study to Understand Prognoses
and Preferences for Outcomes and Risks of
Treatments5 investigated a large sample of crit-
ically ill patients in the United States, there
is little systematic information about such

Ó 2007 U.S. Cancer Pain Relief Committee 0885-3924/07/$esee front matter

Published by Elsevier Inc. All rights reserved. doi:10.1016/j.jpainsymman.2006.09.030
712
patients in acute hospitals in Europe, and
nearly no systematic information about such
patients in Germany.
In Germany, palliative care is a relatively new
and developing specialty. The German Associa-
tion for Palliative Care was founded in 1994.12
Additionally, Germany has a guilt-burdened
history, with physician-assisted euthanasia of
disabled patients during the Nazi regime be-
tween 1933 and 1945.13,14 Given these factors,
our hypothesis was that, in Germany, health
care is particularly dominated by a therapeutic
imperative toward life-prolonging interven-
tions. Therefore, we investigated the patterns
of medical and nursing practice in the care
of patients dying in Freiburg University Hospi-
tal, a large urban teaching hospital, using
a modified version of two recently published
chart abstraction instruments.2,3
Patients and Methods
Research Question and Sample Size
The study was guided by the research ques-
tion: What are the patterns of medical and
nursing practice in the care of patients dying
in the acute care setting of a large hospital in
Germany? The study was designed to replicate
two previously described projects: an American-
based project by Fins et al., which analyzed the
consecutive deaths of 200 patients,2 and an
Australian-based project by Middlewood et al.,
which analyzed the deaths of 100 cancer
patients.3 Based on this experience, we assumed
that our study would be adequately powered with
a sample size of 220 consecutive deaths.
Statistics for hospital deaths in 2003 showed
441 cancer deaths per year in our hospital. The
corresponding estimate of overall deaths at
Freiburg University Hospital was 80 patients
per month. Therefore, we selected an obser-
vation period of three months. The medical
records of 252 consecutive deaths occurring
between July and September 2004 in all de-
partments of Freiburg University Hospital
were studied. Twenty-six medical records
were excluded from analysis because the time
period between admission and death was less
than 24 hours (23 records) or notes were not
complete (3 records). In total, 226 medical re-
cords were analyzed. The study protocol was
Becker et al. Vol. 33 No. 6 June 2007
approved by the Ethics Committee of Freiburg
University Hospital.
Data Collection
The documentation system used for the
medical records in our hospital is OptiplanÒ
(Optiplan Inc., Duesseldorf, Germany)15 and
is the same in all departments. To analyze
the charts, permission was obtained to use
the chart abstraction tool of Fins et al., which
was validated in two previous studies.2,3 Only
small changes were made to accommodate
the Germany-specific health service elements.
The original instrument developed by Fins
et al.2 was modified as follows:
1. The following items were eliminated be-
cause this information is not routinely
documented in medical records in Ger-
many: race, attending coverage for the
primary care physician, and if family or
significant others were involved in the
admission.
2. A differentiation was made between a writ-
ten advance directive and an ‘‘indirect’’
advance directive (i.e., oral information
about patient’s preferences obtained by
a spouse), because patients in Europe
rarely have written advance directives.16
3. The charts were surveyed for documented
conflicts concerning end-of-life decision
making and how potential conflicts were
resolved.
4. A differentiation was also made between
intravenous and oral administration of
antibiotics and between parenteral nutri-
tion and hydration.
Consistent with trends in health service re-
search,17,18 data triangulation was used, and
qualitative data were also included in the anal-
ysis of the medical records.
In total, our chart abstraction tool contained
93 items and was pilot tested on 10 charts of
deaths occurring in different medical depart-
ments in April 2004 to determine user friend-
liness. It was determined whether information
for items asked was documented in the charts
and could be found in a reasonable time (de-
fined as not exceeding two hours per chart).
Additionally, 10 randomly chosen charts out
of the first 50 charts investigated in the study
period were reviewed independently by two
doctors to determine percentage agreement
Vol. 33 No. 6 June 2007 End-of-Life Care in Hospital 713

on survey items. Inter-rater reliability was bleeding, or stroke. The remaining 20% showed
94.8%, as compared to 91% in the study by a great variety of diseases, for example, end-
Fins et al.2 and 96% in the study by Middle- stage chronic obstructive pulmonary disease or
wood et al.3 infections like pneumonia; these were charac-
terized as ‘‘other’’ causes of death. Most patients
Statistics (56.2%) entered the hospital via the emergency
Data were analyzed using SPSS (SPSS for room; 44% of the patients were living at home
Windows, Version 13.0, SPSS Inc., Chicago, prior to their terminal admissions, 39% were
USA). Chi-square tests and logistic regression transferred from another hospital, and 2%
were conducted to analyze relationships be- were transferred from a nursing home. The
tween the dependent variables of Do-Not- majority of patients (81%) had compulsory
Resuscitate (DNR), identification of patient health insurance and 19% had a private health
as dying, comfort care plans, and the indepen- insurance.
dent variables of age, sex, insurance status, pri-
mary diagnosis, presence of advance directive, Life-Sustaining Treatment
patient preferences, department of admission, Seventy-four percent of patients were admit-
and length of stay. ted or transferred to an intensive care unit
(ICU). The mean duration of stay in an ICU
was 11 days (median 6 days). Most (52%)
Results deaths occurred in an ICU and 7.5% of pa-
Patient Characteristics tients were transferred to the ICU in the last
Patient characteristics are shown in Table 1. 48 hours prior to death. Table 2 summarizes
The mean age of patients was 68.3 (range use of life-sustaining treatment.
7e93) years. Patients had a broad range of dis-
eases, with approximately 60% suffering from
cancer or cardiovascular diseases and 20% Advance Directives and DNR Orders
suffering from head trauma, intracerebral On admission, 65% of the patients had
decision-making capacity, but 58% of these
Table 1 lost capacity during their hospital stay (exclud-
Patient Characteristics ing terminal agony during the last 48 hours.).
Characteristic n % Within the last 48 hours prior to death, 79.2%
Age (years)
of all patients had lost consciousness. A written
0e20 2 0.9
21e40 5 2.2
41e60 41 18.1 Table 2
61e80 141 62.4 Life-Sustaining Treatment
>81 37 16.4 n %
Gender
Male 145 64.2 Ventilator 120 53.1
Female 81 35.8 Mean time on ventilator [days], 8.7 (5)
(median)
Primary diagnosis Withdrawn from ventilator 38/120 31.7
Cancer 80 35.4 prior to death
Cardiovascular 56 24.8 Mean time off ventilator prior to 2.8 (1.4)
HCS (Head trauma or intracerebral 45 19.9 death [days] (median)
bleeding or stroke) Artificial nutrition and hydration 123 54.4
Other 45 19.9 Mean time on artificial nutrition and 11.9 (8.0)
Religion hydration [days], (median)
No documentation 185 81.9 Reduction or withdrawn from artificial 22/123 17.9
Protestant 14 6.2 nutrition prior to death
Roman Catholic 22 9.7 Mean time off artificial nutrition 1.97 (2.0)
Moslem 1 0.4 prior to death [days], (median)
Orthodox 1 0.4 Patients on antibiotics 168 74.3
Jewish 1 0.4 Antibiotics stopped prior to death 51/168 30.3
No religion 2 0.9 Mean time off antibiotics prior to 2.9 (2.0)
death [days], (median)
Language All medication stopped prior to death 26 11.5
German 214 94.7 Patients with cancer receiving 26/80 32.5
Other 12 5.3 chemotherapy
714 Becker et al. Vol. 33 No. 6 June 2007

advance directive was completed by 6.6% of tells that he is waiting for his death now’’
patients, and 22.1% had a health care proxy. (note from a nurse four days prior to death)
Seventy-six percent of these health care prox- or ‘‘Miss S. has no will to live and said this
ies were completed during the patient’s last ad- morning explicitly that she wants to die, there-
mission. According to the notes, an ‘‘indirect’’ fore no escalation of therapy’’ (note from
advance directive (i.e., oral information about a physician, one day prior to death). Patients
patient’s preferences obtained by asking with preferences other than a living will had
a spouse) was used in 70.3% of patients. Con- DNR orders significantly more often than
tact person and date of this information were other patients (78.9% vs. 61.7%, P ¼ 0.043).
explicitly specified in the notes in 19.5% of Concerning end-of-life ethical decision mak-
these patients. ing, there was no evidence for ethical conflicts
DNR orders were documented in the charts in 97.8% of charts. Conflicts in 5/226 patients
for 64.6% of patients (Table 3) and were fixed were resolved by hierarchical decision (e.g., se-
on average 5.9 days prior to death (median 3.0 nior physician or head physician decided) in
days). Regarding the patients who had DNR or- three patients (1.3%), by informal conversa-
ders at the time of death, there was no statisti- tions in one patient (0.4%) and by an Ethics
cally significant difference between patients Committee in another patient (0.4%).
with short hospital stays (2e4 days) and patients Advance care planning and evidence of pa-
with long hospital stays (>21 days, P ¼ 0.366). tient preferences were significantly associated
DNR orders were authorized in 15.4% by pa- with end-of-life decision making (Table 4). Pa-
tients and in 11.8% by health care agents. In tients with written advance directives more fre-
41.3%, DNR was discussed with the patient’s quently had comfort care plans than patients
family but not with the patient. There was no without a written advance directive (P ¼ 0.049).
evidence of a discussion in 30.8% when the There was a trend that patients with written
patient was documented DNR. advance directives also more often had a DNR
order, but this difference did not reach statistical
Qualitative Analysis significance (P ¼ 0.104). Regarding DNR orders
Notations in the medical records were exam- and comfort care plans, there was no statistical
ined for key issues, concepts, and themes difference between the compulsory health insur-
according to the qualitative framework ap- ance and a private health insurance.
proach method.19 All analyses were conducted
in conjunction with a second reviewer. Agree- Patients Identified as Dying and Comfort
ment regarding coding and development of Care Plans
themes was reached through independent re- As in the studies by Fins et al.2 and Middle-
view of coded material and discussion of any wood et al.,3 the question as to whether the
discrepancies. Qualitative analysis of the chart
notes indicated that in 16.8% of patients
Table 4
(38/226), preferences were other than a will End-of-Life Decisions According to Primary
to live. This was illustrated by notes like ‘‘Pa- Diagnosis
tient talks much about death and dying and Cancer HCS Others
(n ¼ 80) Cardiovascular (n ¼ 45) (n ¼ 45)
(%) (n ¼ 56) (%) (%) (%)
Table 3
End-of-Life Decisions by Advance Planning Identified as 41.3 23.2 53.3 28.9
dyinga
Health Care
Comfort care 26.3 3.6 11.1 6.7
Proxy No Advance
planb
Advance Directive (n ¼ 47) Planning
Advance 6.3 5.4 2.2 8.9
(n ¼ 15) (%) (%) (n ¼ 147) (%)
directive
DNR 80 59.6 64.6 DNR orderc 66.3 58.9 66.7 64.4
ordera HCS ¼ head trauma, cerebral bleeding, or stroke.
Comfort 33.3 6.4 14 a
Cancer vs. cardiovascular P ¼ 0.029, cancer vs. HCS: P ¼ 0.193, (c2
care test).
planb
b
Cancer vs. cardiovascular P # 0.001, cancer vs. HCS: P ¼ 0.045, (c2
test).
a
Advance directive vs. no advance planning: P ¼ 0.104, (c2 test). c
Cancer vs. cardiovascular P ¼ 0.383, cancer vs. HCS: P ¼ 0.962, (c2
b
Advance directive vs. no advance planning: P ¼ 0.049, (c2 test). test).
Vol. 33 No. 6 June 2007 End-of-Life Care in Hospital
patient was considered dying was answered
with yes if the following terms or synonyms ap-
peared in the notes: end stage, dying, moribund,
situation hopeless, and prognosis grim. Whether
a palliative care plan was in place was deter-
mined by the presence of expressions like com-
fort care, supportive care, and palliative care.
For 36.7% of patients, there was evidence in
the records that they were considered dying
by the clinicians responsible for care. This prog-
nosis was noted on average 3.8 days (median 2
days, range 1e34 days) prior to death. Accord-
ing to chart notes, comfort care plans were com-
pleted fully for 13.7% of patients and partially
for 27.0% of patients. The threshold for desig-
nation was very low. If the named terms comfort
care, supportive care, palliative care, or other
synonyms, appeared in the notes, it was rated
as ‘‘partial palliative care plan.’’ Clear goals of
palliative care or a holistic concept of support
were rated as ‘‘full palliative care plan.’’ In
59.3%, there was no evidence of a comfort
plan in the medical records. Comfort plans
were put in place on average 9 days prior to
death (median 3 days, range 1e45 days).
In the majority of patients with comfort care
plans, blood tests and life-sustaining treatment
continued: 71% received blood tests, 61% re-
ceived antibiotics, 48% received artificial nutri-
tion, 19% received blood transfusions, 16%
continued to receive mechanical ventilation,
and 16% continued to receive catecholamines.
Additionally, 70.8% of all patients were placed
on an opioid infusion prior to death. The
mean length of time on an opioid infusion
was 130 hours (5.4 days, median 46.5 hours,
range: 1 houre52.9 days).
Influence of Primary Diagnosis
End-of-life decisions according to primary
diagnosis are presented in Table 4. Clinicians
identified cancer patients more frequently as
dying than patients with cardiovascular disease
(P ¼ 0.029). Patients diagnosed with cancer
had significantly higher proportions of com-
fort care plans than patients diagnosed with
cardiovascular diseases (P # 0.001) or patients
with HCS (head injury, cerebral bleeding, or
stroke) P ¼ 0.045.
Timing of Decisions
Patients were stratified according to dura-
tion of stay from admission to death. Mean
715
days from admission to decision points and be-
tween decision points were analyzed. Table 5 il-
lustrates that sequence of end-of-life decisions
was different in nearly all strata and no con-
stant pattern could be identified. For patients
with lengths of stay between 2 and 9 days, the
sequence of end-of-life decisions was comfort
care plan, identification as dying, and admis-
sion to DNR. For patients with lengths of stay
between 10 and 21 days, the sequence was
DNR, comfort care plan, and identification as
dying. For patients with lengths of stay over
21 days, sequence of end-of-life decision was
comfort care plan, DNR, and identification as
dying.
Discussion
Our study illustrates the patterns of medical
and nursing practice in the care of patients dy-
ing in an acute care hospital. Because of the
comparatively small sample size, this study nei-
ther provides a comprehensive analysis of the
palliative care standard in German acute care
hospitals nor a substantiated comparison
between palliative care standards in the United
States, Australia, and Germany. In Germany,
palliative care is a very young and just develop-
ing specialty. Although Freiburg University
Hospital is one of the largest hospitals in Eu-
rope, with more than 1,700 beds and over
55,000 inpatients per year, there is no special-
ized palliative care service and neither a pallia-
tive care unit nor a specialist palliative care
team that sees patients in a consultative capac-
ity. The study was designed to assess the cir-
cumstances of dying in a German acute care
hospital without a palliative care service. Our
findings suggest that the transition from acute
care to a palliative approach is problematic.
Patients Identified as Dying
and Comfort Care Plans
Improving terminal care for hospitalized pa-
tients depends on the ability of clinicians to
recognize that patients are dying and their
readiness to limit aggressive treatment and
plan comprehensive palliative care.2 In our
study, 36.7% of patients were considered dying
by the attending physician. Similar to previous
reports,2 in our study, significantly more cancer
patients were considered dying than patients
716 Becker et al.
Table 5
Mean Days from Admission to Decision Points and Between Decision Points by Lengths of Stay (n ¼ 226)
Admission to Identification as Dying Admission to DNR
Length of Stay [days] n Median SD n Mean
2e4 (n ¼ 57) 32 0.34 0.56 36
5e9 (n ¼ 44) 14 2.17 2.53 26
10e21 (n ¼ 67) 24 10.33 4.09 40
>21 (n ¼ 58) 13 39.77 22.12 37
Total 83 139
ID-CC ¼ length of time from patient identified as dying to comfort care plan.
with cardiovascular disease. This is expected,
because cancer patients have a more predict-
able clinical course,20 while cardiovascular dis-
eases have a very variable course. Additionally,
physicians are possibly not very well experi-
enced in diagnosing when the process of dying
starts in cardiology patients.21
In Germany, there is still confusion concern-
ing the definition of the term palliative care.
Although palliative care encompasses a holistic
concept, including physical, psychosocial, and
spiritual care, the term is often mixed up
with supportive care or even aggressive but
noncurative chemotherapy. Taking this into
account, we intentionally defined a very low
threshold. Even if terms like supportive care
or palliative care appeared in the chart notes,
this was rated as ‘‘partial palliative care plan.’’
Although a ‘‘conservative estimation’’ using
a very low threshold was performed, there
was no evidence for even a rudimentary pallia-
tive care plan in 60% of the charts.
Life-Sustaining Treatment
In our sample, 52% of all deaths occurred in
an ICU and the median duration of hospital
stay was 11 days. Our findings further show
that a substantial proportion of dying hospital-
ized patients has active life-sustaining treat-
ment in progress at time of death. Even in
patients designated to comfort care plans,
blood tests and life-sustaining treatment with
antibiotics, artificial nutrition, or other proce-
dures continued. Undoubtedly, blood tests
and procedures like blood transfusions may
contribute to better management of distress-
ing symptoms. Further, in some cases the
uncertainty about short-term prognosis of pa-
tients with progressive terminal conditions
may recommend a ‘‘mixed management
Vol. 33 No. 6 June 2007
Admission to Comfort
Care Plan ID-CC
SD n Mean SD n Mean SD
0.67 0.83 12 0.17 0.39 9 0.0 0.0
3.42 2.49 5 1.0 1.23 3 0.0 0.0
8.63 5.62 5 9.6 6.07 4 3.25 3.2
29.03 20.59 9 23.11 19.57 3 4.33 7.51
31 19
strategy’’ involving both life prolonging and
palliative measures.2,22 On the other hand,
subjecting dying patients to medical inter-
ventions can add to suffering, and so-called
‘‘routine’’ procedures, such as taking blood,
placing intravenous lines, or nasogastric tubes,
can be very traumatic for seriously ill patients.3
Overall, our findings indicate that patients
possibly are infrequently withdrawn from non-
comfort measures prior to death. Fins et al.2
and Middlewood et al.3 report similar results.
A recent Italian study by Toscani et al. reports
that even in patients highly expected to die,
57% received routine blood tests in the last
24 hours of life.11
It has to be kept in mind that our study was
based on a retrospective chart review. There-
fore, the detailed reasons for blood tests, trans-
fusions, or other procedures cannot be
defined clearly and it cannot be differentiated
unambiguously how many of these procedures
were for comfort, for curative attempts, or for
sustaining life as long as possible. Additionally,
our investigation was an analysis ‘‘ex post,’’
knowing that the patient has died. It is easier
to criticize a treatment retrospectively than to
reach a decision while currently caring for
a patient.
End-of-Life Decisions
Only in 7% of records did the patient have
a completed, written advance directive. This
confirms the findings of Vollmann et al.,16
who reported that only 8% of Germans have
a written advance directive (living will). DNR
orders were in place in 64.5% of our patients,
similar to the finding of Fins et al.,2 who ob-
served about 77% DNR orders in their sample.
According to notes, DNR orders were explicitly
authorized by 15% of patients compared to
Vol. 33 No. 6 June 2007 End-of-Life Care in Hospital
32% reported by Fins et al.2 Different from the
American study,2 our data show a minor em-
phasis on advance care planning and patient
involvement in decision making. In the United
States, since 1991, the so-called Patient Self-
Determination Act has been established, a fed-
eral law requiring hospitals and other care
providers to give adult individuals certain infor-
mation about the right to participate in health
care decisions, including the right to accept or re-
fuse medical treatment and the right to prepare
an advance directive. This may explain why in
the U.S. study2 only 5% of DNR orders were au-
thorized by the physician alone. In our study,
69% of DNR orders were discussed with the pa-
tients, health care agents, or the family.
Table 5 shows that patients received comfort
care plans rather late during their hospital stay.
Although there was evidence in 36.7% of the
records that they were considered dying by
the clinicians responsible for care, a compre-
hensive management plan with defined goals
of care for the dying patient could not be
found in any of the 226 surveyed medical re-
cords. Our results suggest that the transition
from acute care to a palliative care approach
is problematic. In many cases, diagnosing dy-
ing is a complex process. In the setting of an
acute care hospital, the culture is often fo-
cused on life-supporting and life-prolonging
activities. There may be a reluctance to make
a diagnosis of dying if any hope of improve-
ment exists.21 In a culture focused on ‘‘cure,’’
death may be perceived as a failure by patients
and physicians.23,24 Continuation of invasive
procedures and treatments, therefore, may
be pursued at the expense of the comfort of
the patient.2,3,21 Although most patients die
in hospital, only a minority of patients cared
for in acute hospitals are patients who die.
Roughly 50% of all 880,000 patients who annu-
ally die in Germany do so in the hospital, but
these patients are only approximately 2% of
the 17 million patients annually cared for in
German hospitals.1 This may explain why
only little attention has been devoted to the
process of clinicians arriving at a terminal
prognosis, communicating this to patients
and families, and planning palliative care.2
To integrate life-sustaining treatment and
palliative care, it is important to address the
misconception that forgoing life-sustaining
treatment means ‘‘giving up’’ and ‘‘doing
717
nothing’’ for the patient.24 Keeping in mind
the paradox that the majority of patients die
in acute hospitals but only a minority of pa-
tients cared for in acute hospitals are dying pa-
tients, clinicians might benefit from a directed
process that would help them plan timely,
comprehensive and coherent end-of-life care
strategies. In this context, integrated care path-
ways (ICPs) are a successful method of incor-
porating accepted guidelines and protocols
into health care settings.25 The ICPs could pro-
vide a flow sheet of care, which has been lo-
cally developed by a multiprofessional team
based on clinical experience, empirical data
regarding hospitalized dying patients, and
the evidence in literature concerning end-of-
life decisions and palliative care.2,26 The devel-
opment of an ICP for dying hospitalized pa-
tients has been described in the literature.27
It includes three sections: 1) an initial assess-
ment, 2) ongoing care, and 3) care after death.
Each section contains physical, psychosocial,
and spiritual care.26 Another option to im-
prove the care for dying patients is the integra-
tion of palliative care services into the acute
care setting to assist the transition of goals
from life-sustaining therapy to improving qual-
ity of life.3
In summary, the findings from this study for
the first time illustrate the situation of dying
patients in one of the large university hospitals
in Germany. There is a need for a change in
the management of patients who are dying in
the acute care setting. Medical staff need to
be educated and supported in provision of pal-
liative care, helping patients to die with com-
fort and dignity even in an acute care setting.
Additionally, there is a need for appropriate
documentation systems, which monitor best
practice in the treatment of incurably ill and
dying patients, like the HOPE system for Ger-
man-speaking countries.12 In the investigated
sample of 226 dying patients, for example,
more than 70% were placed on an opioid infu-
sion prior to death, but it was rarely docu-
mented in the charts if the goals for this
treatment were pain or dyspnea therapy, seda-
tion, or other reasons.
Limitations
Although our study was prospective and in-
cluded consecutive deaths, we only took a ret-
rospective look at the care of patients who died
718
in our hospital. The data were derived from
chart review, which may not fully reflect clini-
cal practice.28 Although this method was
validated in other studies,2,3 our findings con-
cerning ‘‘comfort care plans’’ need to be inter-
preted with caution, because the judgment was
derived only from key words and notes in the
medical records. As the study was a retrospec-
tive investigation using medical records, it
was reliant upon the quality of notes and the
inclinations of medical staff making these
notes. Therefore, discussions may have taken
place but not been charted. This has to be
kept in mind interpreting the results (e.g.,
the observation that 97.8% of charts showed
no evidence for ethical conflicts). Another lim-
itation of the study is that the detailed reasons
for blood tests, transfusions, or other proce-
dures in a retrospective analysis cannot be de-
fined clearly and it cannot be differentiated
unambiguously how many of these procedures
were for comfort, for curative attempts, or for
sustaining life as long as possible. Due to its
retrospective design, this study is no more
and not less than a description of the situation
of dying patients in one of the large university
hospitals in Germany. A recommendation for
further research is a prospective study collect-
ing comparable data from critically ill patients
who die and who survive to hospital discharge.
Conclusions
Our results identified shortcomings in the
palliative care of patients who died in a Ger-
man acute care hospital. Comfort care plans,
even rudimentary, are implemented rarely
and late. Coordination of therapeutic goals is
lacking. In the United Kingdom, one strategy
to improve the care of dying patients has
been the use of an ICP for dying patients.26,27
Clinical pathways encourage regular monitor-
ing and anticipatory prescribing of drugs for
the treatment of symptoms, such as pain, agita-
tion, and breathlessness, and set out goals for
adequate communication regarding patient
and caregiver insight, increasing awareness of
the current clinical situation, and providing
psychosocial and spiritual support both before
and after the patient’s death.10 Our study
shows that patients were identified as dying
on average 3.8 days prior to actual death.
Becker et al. Vol. 33 No. 6 June 2007
Therefore, to improve the quality of care for
patients who die in an acute care hospital,
one should develop systematic strategies to
identify patients’ needs and to improve the
quality of care especially during the last four
days prior to death.
Acknowledgments
The authors gratefully acknowledge Joseph
J. Fins, MD, The New York Hospital-Cornell
Medical Center, USA, and Sue Middlewood,
RN BA, Palliative Care Service, The Canberra
Hospital, Australia, for permission to use and
modify their chart abstraction tools and for
their helpful advice.
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