To help those with terminal illness achieve the best possible experience of dying, clinicians need to know what their patients want and what they want to avoid at the very end of life. In this study, 26 men who were identified as having terminal heart disease or cancer described good and bad deaths. The interviews were tape recorded, transcribed, and analyzed using grounded theory methods. The authors found heterogeneity in responses to questions about good deaths, bad deaths, and preferred dying experiences. Participants voiced multiple reasons for why dying in one's sleep led to a good death and why prolonged dying or suffering led to a bad death. In discussing the end of life with terminally ill patients, clinicians may want to identify not only their patients' views of good and bad deaths, but also how the identified attributes contribute to a good or bad death.
Alikhan et al performed logistic regression analysis on data from patients enrolled in a medical thromboprophylaxis study to evaluate if different types of acute medical illness and patient factors were independent risk factors for venous thromboembolism. Multiple logistic regression analysis indicated that the presence of an acute infectious disease, age above 75 years, cancer, and a history of venous thromboembolism were independently associated with venous thromboembolism. These findings allow recognition of individuals at increased risk of venous thromboembolism. Currently, there is no precise patient risk profile for medical illness that would precipitate a mandatory recommendation for thromboprophylaxis, and the authors believe that these findings will facilitate the formulation of a risk-assessment model based on clinical evidence.
In this study, Rahman et al evaluated baseline renal function in 40 514 hypertensive patients 55 years or older, who were enrolled in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). The authors used the simplified Modification of Diet in Renal Disease study equation to estimate glomerular filtration rate (GFR) and examined the prevalence of cardiovascular disease (CVD) in patients with different levels of GFR. Of the patients, 57% had mild (60-89 mL/min per 1.73 m2), 17.2% had moderate (30-59 mL/min per 1.73 m2), and 0.6% had severe reductions in GFR (≤29 mL/min per 1.73 m2). Compared with patients with mildly reduced or normal GFR, patients with moderate or severe reductions were more likely to have had a prior myocardial infarction or stroke, have ischemic changes on electrocardiogram (ECG), and have left ventricular hypertrophy (LVH) on ECG. A decrease in GFR of 10 mL/min per 1.73 m2 was independently associated with a 6% higher risk for CVD and 14% higher risk for ECG-LVH. These data demonstrate that the prevalence of reduced GFR is high in older hypertensive patients. Patients with moderate or severe reduction in GFR are more likely to have a history of CVD and ECG-LVH. Even modestly low GFR levels are independently associated with a higher prevalence of CVD and ECG-LVH.
The predictive value of admission blood glucose level after acute myocardial infarction (AMI) for long-term prognosis was studied in a large number of patients with and without known diabetes mellitus, particularly in those with unknown diabetes but with blood glucose level in the diabetic range. Admission blood glucose level after AMI independently predicted long-term mortality in patients with and without known diabetes. Subjects with unknown diabetes and admission glucose level of 200 mg/dL (11.1 mmol/L) or higher after AMI had mortality rates comparable to subjects with established diabetes. Admission blood glucose level may serve to identify subjects at high long-term mortality risk, particularly among those with unknown diabetes.
Kaplan-Meier survival curves for patients without known diabetes mellitus and admission blood glucose levels less than 141 mg/dL (group 1), 141 to 199 mg/dL (group 2), and 200.0 mg/dL or higher (group 3), and patients with previously diagnosed diabetes (group 4).
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2004;164(9):929. doi:10.1001/archinte.164.9.929