Background: Few patients with end-stage dementia are enrolled in hospice care. A palliative
care approach would nonetheless seem to be appropriate in various care settings, including
the acute care hospital.
Methods: We conducted a randomized controlled trial of palliative care in patients with advanced
dementia (Functional Assessment Staging Tool [FAST] stage 6d-7f) who were hospitalized
with acute illness. Intervention patients received recommendations by a palliative care
team with the goal of enhancing patient comfort; control patients received usual care without
these recommendations.
Results: Among 99 patients enrolled over 3 years, groups were comparable at baseline in
terms of gender, age, race, dementia stage, and advance directive status. Outcomes were similar
in terms of mean number of hospitalizations, average length of stay, and mortality. Intervention
patients were more likely than control patients to receive a palliative care plan
(23% versus 4%; p = 0.008), usually on discharge, and more decisions were made to forgo certain
medical treatments but the numbers were small. Fewer patients in the intervention group
received intravenous therapy throughout the admission (66% vs. 81%, p = 0.025). Overall, additional
interventions included daily phlebotomy for at least half of the admission (41%), systemic
antibiotics (75%), and new feeding tubes (44%). Including tubes present at the time of
randomization, a total of 69% received long-term enteral feeding.
Conclusion: It was difficult for a palliative care research team to influence the care of advanced
dementia patients in the acute hospital setting. When patients have advanced dementia,
there may be unique barriers, including perceived prognostic uncertainty, difficulty
assessing comfort level, and perceptions about tube feeding. There must be a reexamination
of treatment approaches for this severely impaired group of patients. Further study should
attempt to identify patients prior to the need for acute hospitalization so goals can be established
when there is less urgency to make life and death decisions.
