Definitions of end of life and their suitability for routine use in screening
| Year | Author/reference | Definitions or potential items to include in a definition | Comments and rationale for inclusion or exclusion |
|---|---|---|---|
| 1981 | US President's Commission48 | When a terminally ill, mentally competent patient refuses resuscitative treatment and/or where treatment would be futile | Does not assist in applying terminology in a screening tool for use in routine care as it would be impractical without operational boundaries or classification of irreversible conditions or futile treatments |
| 1987 | Blackhall49 | When treatments will not be beneficial and may even be potentially harmful | This concept may be clearer for specialists but not so useful for first-line doctors/nurses at admissions in ED |
| 1989 | Stolman15 | Terminally ill patient, imminently dying (life expectancy ≤6 months) chronic debilitating irreversible condition where life-saving treatment would be futile. Coupled with competent patient with unacceptable quality of life who refuses treatment or whose family requests to not resuscitate | Life expectancy would require a prognostic table and some patients with low quality of life may refuse treatment but they are not imminently dying |
| 1990 | Tomlinson and Brody 50 | When treatment is futile, defined as intervention (such as CPR) on terminal cases that provide no physiological benefit to the patient, that is, restoring spontaneous heart beat or blood pressure | While philosophically sound, it clearly involves clinical and value judgment that could vary from one clinician to another |
| 2005 | Paterson, UK.41 | Patients expected to die within 24 hours are those who were unconscious, self-ventilating, deteriorating and having a diagnosis incompatible with survival | This framework for end-of-life care was introduced to help clinicians in the delivery of care for the acutely dying, that is, who should not be triaged if they are at that advanced stage in the dying process at the time of admission |
| 2006 | NHMRC51 | Patients requiring frequent intervention, being bed-bound, irreversible loss of appetite, profound weakness, trouble swallowing, dry mouth, weight loss, becoming semiconscious, with lapses into unconsciousness, and experiencing day-to-day deterioration that is not reversible | Combination of objective signs and symptoms and subjective considerations to be used in routine practice as indications of an imminent death; suitable for use in nursing homes and may more closely fit the needs at the hospital admission department for identification of patients dying over the next few days but does not cover the profile of those dying over weeks or months |
| 2007 | NICE, UK21 | Group 1: ‘those with advanced, progressive, or incurable conditions who are expected to die within the next 12 months’, and Group 2:‘adults with existing conditions who are at risk of dying from a sudden, acute crisis in their condition’; this group includes those with life-threatening acute conditions caused by sudden catastrophic events | Our manuscript is concerned with the first group, where the prediction of time to death is more feasible, but the definitions above are still not operative due to the uncertainty and dependency on expertise of subjective clinical or value judgements |
| 2007 | Jones et al35 | Elderly with multiple-pre-existing comorbidities and mostly designated NFR at the time of death (pre-existing or newly designated) with or without evidence of advanced care planning | This is a minimum standards definition applying to a well-defined patient group that triggers a RRT call; This represents the readily identifiable tip of the iceberg. We are also seeking to target those other patients with undiagnosed organ failures and without a documented NFR orders at the time of presentation to hospital for end-of-life screening so they can be offered end–of-life care out of acute hospitals |
| 2014 | Schmidt and Moss52 | Patients suffering from poor quality of life due to clinical deterioration that is subtle and not immediately life-threatening but in whom the burden of treatment substantially outweighs the benefit | Conceptually encapsulates the definition of dying in the short term but it is difficult to measure without a checklist or classification as it involves clinical and value judgements which leave room for interpretation among healthcare professionals |
CPR, cardiopulmonary resuscitation; ED, emergency department; NFR, not for resuscitation; RRT, rapid response team.