Non-beneficial treatments in hospital at the end of life : a systematic review on extent of the problem

Purpose To investigate the extent of objective ‘non-beneficial treatments (NBTs)’ (too much) anytime in the last 6 months of life in routine hospital care. Data sources English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995–April 2015). Study selection All study types assessing objective dimensions of non-beneficial medical or surgical diagnostic, therapeutic or non-palliative procedures administered to older adults at the end of life (EOL). Data extraction A 13-item quality score estimated independently by two authors. Results of data synthesis Evidence from 38 studies indicates that on average 33–38% of patients near the EOL received NBTs. Mean prevalence of resuscitation attempts for advanced stage patients was 28% (range 11–90%). Mean death in intensive care unit (ICU) was 42% (range 11–90%); and mean death rate in a hospital ward was 44.5% (range 29–60%). Mean prevalence of active measures including dialysis, radiotherapy, transfusions and life support treatment to terminal patient was 7–77% (mean 30%). Non-beneficial administration of antibiotics, cardiovascular, digestive and endocrine treatments to dying patients occurred in 11–75% (mean 38%). Non-beneficial tests were performed on 33–50% of patients with do-not-resuscitate orders. From meta-analyses, the pooled prevalence of non-beneficial ICU admission was 10% (95% CI 0–33%); for chemotherapy in the last six weeks of life was 33% (95% CI 24–41%). Conclusion This review has confirmed widespread use of NBTs at the EOL in acute hospitals. While a certain level of NBT is inevitable, its extent, variation and justification need further scrutiny.