Non-sudden Death Research Articles

Final transitions to place of death: patients and families wishes.

This four-country study (Belgium, the Netherlands, Italy and Spain) examines prevalence and types of final transitions between care settings of cancer patients and the extent to which patient/family wishes are cited as a reason for the transition. Data were collected from the EUROSENTI-MELC study over a 2-year period. General practitioners within existing Sentinel Networks registered weekly all deaths of patients within practices using a standardized questionnaire. This registration included place of care in the final 3 months and wishes for the final transition to place of death. All non-sudden deaths due to cancer (+18 years) were included in the analyses. We included 2048 non-sudden cancer deaths; 63% of patients had at least one transition between care settings in the final 3 months of life. 'Hospital death from home' (25-55%) and 'home death from hospital' (16-30%) were the most frequent types of final transitions in all countries. Patients' or families' wishes were mentioned as a reason for a final transition in 5-27% (P<0.001) and 10-22% (P=0.002) across countries. 'Hospital deaths from home' is the most prevalent final transition in three of four countries studied, in a significant minority of cases because of patient/family wishes.

Clinical Inferences of Cardiovascular Implantable Electronic Device Analysis at Autopsy

BackgroundCardiovascular implantable electronic device (CIED) removal and interrogation are recommended at autopsy in suspected cases of sudden cardiac death, but data on the role of nonselective post-mortem CIED (pacemaker or defibrillator) analysis in this setting are lacking. ObjectivesThis study undertook an institutional registry analysis to determine the utility of systematic routine CIED removal, interrogation, and analysis at autopsy. MethodsFrom May 19, 2009, to May 18, 2015, autopsy subjects with a CIED at a Johns Hopkins University medical institution (Baltimore, Maryland) underwent CIED removal and interrogation by an electrophysiologist for clinical alerts. The CIED was then submitted for technical analysis by the manufacturer. The CIED interrogation, the manufacturer’s technical analysis, and the final autopsy report were all cataloged in the Johns Hopkins Post-mortem CIED Registry. ResultsA total of 2,025 autopsies were performed; 84 subjects had CIEDs removed and analyzed. These devices included 37 pacemakers and 47 defibrillators. Overall, 43 subjects had died suddenly, and 41 had not died suddenly. Significant clinical alerts (sustained tachyarrhythmias or an elevated fluid index value) were seen in 62.8% cases of sudden deaths. In the nonsudden death cohort, 19.5% displayed a significant clinical alert. Significant association of CIED alerts were noted when comparing sudden deaths versus nonsudden deaths (p < 0.001), defibrillators versus pacemakers (p < 0.005), and cardiac versus noncardiac causes of death (p < 0.001). Manufacturer analyses revealed a case of premature pacemaker battery depletion, as well as a hard reset in a defibrillator as a result of cold exposure. ConclusionsPost-mortem CIED analysis was clinically useful in assisting with determination of the timing, mechanism, and cause of death in the majority of sudden deaths and in almost 20% of nonsudden deaths. The authors advocate CIED removal with analysis as an important diagnostic tool in all autopsies and to assist manufacturers in identifying potentially fatal device failures.

Elevated fibroblast growth factor-23 and risk of cardiovascular disease or mortality in the general population: A meta-analysis

Elevated fibroblast growth factor-23 and risk of cardiovascular disease or mortality in the general population: A meta-analysis

Sudden cardiac death in non-dialysis chronic kidney disease patients

BackgroundA relatively high proportion of deaths in dialysis patients occur suddenly and unexpectedly. The incidence of sudden cardiac death (SCD) in non-dialysis advanced chronic kidney disease (CKD) stages has been less well investigated. ObjectiveThis study aims to determine the incidence and predictors of SCD in a cohort of 1078 patients with CKD not yet on dialysis. MethodsProspective observational cohort study, which included patients with advanced CKD not yet on dialysis (stage 4–5). The association between baseline variables and SCD was assessed using Cox and competing-risk (Fine and Gray) regression models. Demographic, clinical information, medication use, and baseline biochemical parameters of potential interest were included as covariates. ResultsDuring the study period (median follow-up time 12 months), 210 patients died (19%), and SCD occurred in 34 cases (16% of total deaths). All-cause mortality and SCD incidence rates were 113 (95% CI: 99–128), and 18 (95% CI: 13–26) events per 1000patient-years respectively. By Cox regression analysis, covariates significantly associated with SCD were: Age, comorbidity index, and treatment with antiplatelet drugs. This latter covariate showed a beneficial effect over the development of SCD. By competing-risk regression, in which the competing event was non-sudden death from any cause, only age and comorbidity index remained significantly associated with SCD. ConclusionsSCD is relatively common in non-dialysis advanced CKD patients. SCD was closely related to age and comorbidity, and some indirect data from this study suggest that unrecognized or undertreated cardiovascular disease may predispose to a higher risk of SCD.

Muerte súbita en pacientes con enfermedad renal crónica avanzada

BackgroundA relatively high proportion of deaths in dialysis patients occur suddenly and unexpectedly. The incidence of sudden cardiac death (SCD) in non-dialysis advanced chronic kidney disease (CKD) stages has been less well investigated. ObjectiveThis study aims to determine the incidence and predictors of SCD in a cohort of 1078 patients with CKD not yet on dialysis. MethodsProspective observational cohort study, which included patients with advanced CKD not yet on dialysis (stage 4–5). The association between baseline variables and SCD was assessed using Cox and competing-risk (Fine and Grey) regression models. Demographic, clinical information, medication use, and baseline biochemical parameters of potential interest were included as covariates. ResultsDuring the study period (median follow-up time 12 months), 210 patients died (19%), and SCD occurred in 34 cases (16% of total deaths). All-cause mortality and SCD incidence rates were 113 (95% CI: 99–128), and 18 (95% CI: 13–26) events per 1000 patients/year, respectively. By Cox regression analysis, covariates significantly associated with SCD were: Age, comorbidity index, and treatment with antiplatelet drugs. This latter covariate showed a beneficial effect over the development of SCD. By competing-risk regression, in which the competing event was non-sudden death from any cause, only age and comorbidity index remained significantly associated with SCD. ConclusionsSCD is relatively common in non-dialysis advanced CKD patients. SCD was closely related to age and comorbidity, and some indirect data from this study suggest that unrecognised or undertreated cardiovascular disease may predispose to a higher risk of SCD.

Diabetes, glucose tolerance, and the risk of sudden cardiac death.

BackgroundDiabetes predisposes to sudden cardiac death (SCD). However, it is uncertain whether greater proportion of cardiac deaths are sudden among diabetes patients than other subjects. It is also unclear whether the risk of SCD is pronounced already early in the course of the disease. The relationship of impaired glucose tolerance (IGT) and SCD is scarcely documented.MethodsA general population cohort of 10594 middle-aged subjects (mean age 44 years, 52.6 % male, follow-up duration 35–41 years) was divided into diabetes patients (n = 82), subjects with IGT (n = 3806, plasma glucose ≥9.58 mmol/l in one-hour glucose tolerance test), and controls (n = 6706).ResultsDiabetes patients had an increased risk of SCD after adjustment confounders (hazard ratio 2.62, 95 % confidence interval 1.46–4.70, p = 0.001) but risk for non-sudden cardiac death was similarly increased and the proportion of SCD of cardiac deaths was not increased. The SCD risk persisted after exclusion of subjects with baseline cardiac disease or non-fatal cardiac events during the follow-up. Subjects with IGT were at increased risk for SCD (univariate hazard ratio 1.51; 95 % confidence interval 1.31–1.74; p < 0.001) and also for non-sudden cardiac deaths and non-fatal cardiac events but adjustments for other risk factors attenuated these effects.ConclusionsDiabetes was associated with increased risk of SCD but also the risk of non-sudden cardiac death was similarly increased. The proportion of cardiac deaths being sudden in subjects with diabetes was not increased. The higher SCD risk in diabetes patients was independent of known cardiac disease at baseline or occurrence of non-fatal cardiac event during the follow-up.

No Negative Impact of Palliative Sedation on Relatives' Experience of the Dying Phase and Their Wellbeing after the Patient's Death: An Observational Study.

BackgroundPalliative sedation is the widely-used intervention of administering sedating agents to induce a state of unconsciousness to take away a dying patient’s perception of otherwise irrelievable symptoms. However, it remains questionable whether this ethically complex intervention is beneficial for patients and whether the associated lack of communication in the last phase of life has a negative impact on relatives’ wellbeing.MethodsAn observational questionnaire study was conducted among relatives of a consecutive sample of patients who died a non-sudden death in the Erasmus MC Cancer Institute or in the hospice ‘Laurens Cadenza’ (both in Rotterdam) between 2010 and 2013.ResultsRelatives filled in questionnaires regarding 151 patients who had been sedated and 90 patients who had not been sedated. The median time since all patients had passed away was 21 (IQR 14–32) months. No significant differences were found in relatives´ assessments of the quality of end-of-life care, patients´ quality of life in the last week before death and their quality of dying, between patients who did and did not receive sedation, or in relatives’ satisfaction with their own life, their general health and their mental wellbeing after the patient’s death.ConclusionsThe use of sedation in these patients appears to have no negative effect on bereaved relatives’ evaluation of the patient’s dying phase, or on their own wellbeing after the patient’s death.

Hospice care in the Netherlands: who applies and who is admitted to inpatient care?

BackgroundTen percent of non-sudden deaths in the Netherlands occur in inpatient hospice facilities. To investigate differences between patients who are admitted to inpatient hospice care or not following application, how diagnoses compare to the national population, characteristics of application, and associations with being admitted to inpatient hospice care or not.MethodsData from a database representing over 25 % of inpatient hospice facilities in the Netherlands were analysed. The study period spanned the years 2007–2012. Multivariate regression analyses were performed to study associations between demographic and application characteristics, and admittance.ResultsTen thousand two hundred fifty-four patients were included. 84.1 % of patients applying for inpatient hospice care had cancer compared to 37.0 % of deaths nationally. 52.4 % of applicants resided in hospital at the time of admission. Most frequent reasons for application were the wish to die in an inpatient hospice facility (70.5 %), needing intensive care or support (52.2 %), relieving caregivers (41.4 %) and needing pain/symptom control (39.9 %). Living alone (OR 1.68, 95 % CI 1.46–1.94), having cancer (OR 1.40, 95 % CI 1.11–1.76), relieving caregivers (OR 1.18, 95 % CI 1.01–1.38), needing pain/symptom control (OR1.72, 95 % CI 1.46–2.03) wanting inpatient hospice care until death (vs respite care) (OR 3.59, 95 % CI 2.11–6.10), wanting to be admitted as soon as possible (OR 1.64, 95 % CI 1.42–1.88), and being referred by a primary care professional (OR 1.36, 95 % CI 1.17–1.59) were positively associated with being admitted. Wishing to die in an inpatient hospice facility was negatively associated with being admitted (OR 0.85, 95 % CI 0.72–1.00).ConclusionsThis study suggests that when applying for inpatient hospice care, patients who seem most urgently in need of inpatient hospice care are more frequently admitted. However, non-cancer patients seem to be an under-represented population. Staff should consider application based on need for palliation, irrespective of diagnosis.

Abstract 13695: Global Electrical Heterogeneity Risk Score Predicts Sudden Cardiac Death in the General Population

Background: The majority of sudden cardiac deaths (SCDs) in the general population occur in asymptomatic individuals. Our goal was to develop and validate a SCD risk score for use in the general population. Methods: The prospective Atherosclerosis Risk in Communities (ARIC) study [n=15,366; age 45-64 yr; 45% male; 73% white; 5% prevalent coronary heart disease (CHD), median 14 yrs of follow-up] was used for risk score development. ECG markers of global electrical heterogeneity (GEH) [sum absolute QRST integral (SAI QRST), spatial ventricular gradient (SVG), and spatial QRS-T angle] were measured on standard 12-lead ECGs and abnormal values were derived using the Youden index. Competing risk models were evaluated using C-statistics, integrated discrimination improvement, net reclassification improvement (NRI), and Akaike Information Criterion. Internal cross-validation was performed in 5 partitions. Adjudicated SCD was the primary outcome. Results: Overall SCD incidence was 1.51 (95% CI 1.35-1.69) per 1,000 person-yrs. The most accurate risk model included gender-, race-, and CHD-specific GEH ECG parameters [SAI QRST, spatial QRS-T angle, and SVG direction (azimuth and elevation)], demographics (sex, race, age≥55 y), clinical characteristics (CHD, diabetes, hypertension, stroke), QTc interval, and 1 interaction term (abnormal SVG azimuth in age≥55 yrs). C-statistic was 0.842 (95% CI 0.814-0.859) in the whole cohort and ranged 0.782-0.866 in 5 cross-validation partitions. The risk score classified 10-yr SCD risk as low (0 to &lt;1%), intermediate (1-10%), and high (&gt;10%) in 65.5%, 32.3%, and 2.2% of participants, respectively. With addition of GEH ECG markers to clinical/demographic factors C-statistic increased from 0.813 to 0.837 (p=0.004), 28/311 (9%) of participants were appropriately reclassified from intermediate to high risk, and only 4/311 (1.3%) were inappropriately reclassified from high to intermediate risk. NRI was 13.3% (P&lt;0.001). The score was highly specific (98.2%) for SCD, and predicted SCD better than non-sudden cardiac death. Negative predictive value for SCD was up to 99.5%. Conclusion A risk score using basic clinical characteristics and novel GEH ECG parameters accurately predicted SCD in the general population.

Abstract 15631: The Hemodynamic Determinants and Physiologic Correlates of QTc Interval Using Impedance Cardiography in Heart Failure

Background: Prolonged QTc interval is a known risk factor for adverse cardiac events, including sudden and non-sudden cardiac death. Understanding the determinants and physiologic correlates of QTc can guide the proper strategy for the primary prevention of sudden death in high risk patients. Methods &amp; Results: This was an observational study that recruited ambulatory heart failure patients (NYHA I-III) from an outpatient clinic in NL, Canada. In supine resting position, consented participants underwent non-invasive 12-lead ECG and hemodynamic monitoring using BioZ Dx Impedance Cardiography (Sonosite Inc., WA, USA). ECGs were evaluated by a reviewer blinded to clinical data. Participants with pacing (n=12) or left bundle branch block (n=9) were excluded. Three measures of interest were automatically computed: (1) QTc interval (i.e., from QRS onset to T offset), (2) QRS duration (i.e., from QRS onset to QRS offset), and (3) JTc (i.e., QTc interval minus QRS duration). Effect sizes were computed using Pearson’s r coefficients. The final sample (n=23) was 62±13 years of age and 70% male with LVEF of 34±10%. The mean QTc was 441±39 milliseconds, and 10 patients (43%) had prolonged QTc (≥450 milliseconds). QTc interval negatively correlated with cardiac output (r= -0.57), and positively correlated with systemic vascular resistance (r= +0.57), as well as thoracic fluid content (r= +0.43). QRS duration alone was not specifically associated with any hemodynamic parameter, but JTc interval positively correlated with total arterial compliance (r=+0.42). Conclusions: In heart failure patients, we interestingly found that increased systemic vascular resistance results in QTc interval prolongation, where repolarization time is specifically influenced by arterial compliance. This suggests potential benefit from antihypertensive therapy targeted at lowering systemic vascular resistance in those with prolonged QTc/JTc. Nevertheless, these intervals need to be interpreted with caution in patients with thoracic fluid overload (e.g., pulmonary edema).

End-of-life decisions for children under 1 year of age in the Netherlands: decreased frequency of administration of drugs to deliberately hasten death

ObjectiveTo assess whether the frequency of end-of-life decisions for children under 1 year of age in the Netherlands has changed since ultrasound examination around 20 weeks of gestation became routine...

Common Variants in TRDN and CALM1 Are Associated with Risk of Sudden Cardiac Death in Chronic Heart Failure Patients in Chinese Han Population.

BackgroundRecent studies suggest that variants in two calcium handling genes (RyR2 and CASQ2) associated with sudden cardiac death (SCD) and non-sudden cardiac death (NSCD) in subjects with heart failure and coronary artery disease, respectively. The purpose of this study was to identify other calcium handling genes associated with SCD in the long-term of chronic heart failure (CHF) in Chinese Han population.Methods and ResultsWe investigated 20 SNPs representing 10 genes that regulated calcium handling in 1429 patients with CHF, and the genetic association with SCD and all-cause death was analysed. During a median follow-up period of 63 months, 538 patients (37.65%) died from CHF, of whom 185 (34.38%) had SCD and the others were NSCD. SNPs that pass a P value cut-off of 0.0025 were considered as significant. We found that patients carrying the CC genotype of rs3814843 on CALM1 gene had greater risks of SCD (HR 5.542, 95% CI 2.054–14.948, P = .001) and all cause death (HR 3.484, 95% CI 1.651–7.350, P = .001). After adjusting for other risk factors, significant associations remained. Moreover, patients carrying G allele of rs361508 on TRDN gene also had increased risk of SCD.ConclusionsCommon variants in TRDN and CALM1 are associated with increased risk of SCD in patients with CHF. These findings provide further evidence for association of variants in calcium handling regulating proteins and SCD in chronic heart failure.

Cardiac innervation imaging: implications for risk stratification and therapeutic decision-making

Neurocardiology, the specialty that deals with the interaction between brain, heart, and autonomic nervous system, is a vivid area of research. It is well known that a lifethreatening stressor may induce a generalized autonomic storm, with both sympathetic and parasympathetic effects and the apparent predominance of one over the other depends on the variables considered, the timing of the observations and, probably, the type of the stressor. Moreover, remodeling of the cardiac nervous system influences the course of several cardiac diseases. As an example, cholinergic transdifferentiation of cardiac adrenergic neurons into cholinergic neurons, induced by leukemia inhibitory factor via a gp130 signaling pathway, supports the existence of potential plasticity of sympathetic neurons in heart failure (HF). The translational relevance of cardiac and extracardiac neural remodeling is under investigation and at this time many studies have demonstrated the value of autonomic indices to identify patients at risk for sudden death [1]. Relevant aspects of cardiac innervations, including preand postsynaptic receptors of the autonomic nervous system, are now investigated either by single-photon emission computed tomography (SPECT) and positron emission tomography (PET). In the setting of HF, the prognostic relevance of cardiac neuronal imaging is under active evaluation. Several studies have indicated worse prognosis and higher risk of sudden death in patients with HF and reduced I-metaiodobenzylguanidine (MIBG) myocardial uptake or higher washout rate. Although dichotomizing the late H/M ratio may be useful for stratifying patients into high-and low-risk categories, the patient survival rate decreases linearly accordingly to the impairment in cardiac MIBG activity. Moreover, the endpoint selection may influence the results observed in the setting of HF prognostication [2]. These challenges have slowed the wider clinical use of cardiac MIBG imaging, and the great potential of adrenergic system imaging still needs to be investigated in larger prospective studies before this technique can be implemented in clinical guidelines [3]. As an example, the importance of non-sudden cardiac death risk in predicting benefit from implantable cardioverter defibrillators (ICD) therapy must be considered. Due to the high cost of widespread ICD use, it is mandatory to identify a high-risk population who will benefit most from these devices. A number of non-left ventricular ejection fraction risk stratification tests for predicting a variety of outcomes (overall mortality, arrhythmic events/mortality, ICD shocks, and mortality benefit from ICD) are under evaluation. These tests include signal-averaged electrocardiogram, microvolt T wave alternans, electrophysiological testing, serum markers (including brain natriuretic peptide), and autonomic function evaluation (including heart rate variability, baroreflex sensitivity, heart rate turbulence, and deceleration capacity of heart rate). However, these tests have not demonstrated sufficiently high predictive value for arrhythmic death or arrhythmic events. Thus, it has been hypothesized that cardiac radionuclide imaging may be useful for identifying patients at risk for sudden cardiac death, therefore potentially offering a way to better select patients for ICD therapy. In patients with previous myocardial infarction, assessing the presence of an innervation/perfusion mismatch, i.e., a peri-infarction zone of sympathetic denervation that extends beyond the area of myocardial scar, as well as the presence of regional & M. Petretta petretta@unina.it

A novel method to predict the proportional risk of sudden cardiac death in heart failure: Derivation of the Seattle Proportional Risk Model

Patients with heart failure are at increased risk of both sudden death and pump failure death. Strategies to better identify those who have greatest net benefit from implantable cardioverter-defibrillator (ICD) implantation could reduce morbidity and maximize cost-effectiveness of ICDs. We aimed to identify baseline variables in patients with cardiomyopathy that are independently associated with a disproportionate fraction of mortality risk attributable to sudden death vs nonsudden death. We used data from 9885 patients with heart failure without ICDs, of whom 2552 died during an average follow-up of 2.3 years. Using commonly available baseline clinical and demographic variables, we developed a multivariate regression model to identify variables associated with a disproportionate risk of sudden death. We confirmed that lower ejection fraction and better functional class were associated with a greater proportion of mortality due to sudden death. Younger age, male sex, and higher body mass index were independently associated with a greater proportional risk of sudden death, while diabetes mellitus, hyper/hypotension, higher creatinine level, and hyponatremia were associated with a disproportionately lower risk of sudden death. The use of several heart failure medications, left ventricular end-diastolic dimension, or NT-pro brain natriuretic peptide concentrations were not associated with a disproportionate risk of sudden death. Several easily obtained baseline demographic and clinical variables, beyond ejection fraction and New York Heart Association functional class, are independently associated with a disproportionately increased risk of sudden death. Further investigation is needed to assess whether this novel predictive method can be used to target the use of lifesaving therapies to populations who will derive greatest mortality benefit .

71 Identifying Patients with Less Potential to Benefit from Implantable Cardiac Defibrillator Therapy

Background Implantable cardiac defibrillator (ICD) therapy reduces mortality in selected patients at high risk of sudden cardiac death. However, patients at high risk of non-sudden cardiac death, whose risk of short-term mortality following device implantation is high, may gain no significant benefit from an ICD. A number of approaches have been proposed to identify these high-risk patients, including single clinical markers and more complex scoring systems. The aims of this study were to use the proposed scoring systems to: (1) establish how many current ICD recipients may be too high risk to derive significant benefit from ICD therapy and (2) evaluate how well the proposed scoring systems predict short-term mortality in an unselected cohort of ICD recipients. Methods We performed asingle-centre retrospective observational study of all new ICD implants over 5years (2009–2013). We used 3 published scoring systems (Kramer et al 1 ; Barsheshet et al 2 ; Parkash et al 3 ) to identify new ICDrecipients whose short-term risk of death following ICD implantation waspredicted to be high. We then evaluated how well the scoring systems predicteddeath during follow-up. Results Over 5 years there were 406 new implants (79% male, age 67 ± 13 years). The majority (58%) were primary prevention implants and 45% were cardiac resynchronisation therapy-defibrillator devices. During a mean follow-up of 936 ± 560 days, 77 patients died. Using the published scoring systems, the proportion of ICD recipients predicted to be at high risk of short-term mortality were 4% (Kramer), 36% (Barsheshet) and 23% (Parkash). Three-year mortality rates in these high-risk groups were 76%, 32% and 36% respectively; in the overall study population 3-year mortality was 20%. In univariate Cox regression analyses, all 3 scoring systems predicted death (p Conclusions Using published scoring systems, a significant proportion of current ICD recipients are at high risk of short-term mortality following device implantation. Although all 3 scoring systems predicted mortality during follow-up, only the Kramer model added predictive accuracy compared to renal function alone. RENCES Kramer DB, Friedman PA, Kallinen LM, Morrison TB, Crusan DJ, Hodge DO, Reynolds MR, Hauser RG. Development and validation of a risk score to predict early mortality in recipients of implantable cardioverter-defibrillators. Heart Rhythm 2012; 9 :42–6 Barsheshet A, Moss AJ, Huang DT, McNitt S, Zareba W, Goldenberg I. Applicability of a risk score for prediction of the long-term (8-year) benefit of the implantable cardioverter-defibrillator. J Am Coll Cardiol 2012; 59 :2075–9 Parkash R, Stevenson WG, Epstein LM, Maisel WH. Predicting early mortality after implantable defibrillator implantation: a clinical risk score for optimal patient selection. Am Heart J 2006; 151 :397–403

The effect of duration of follow-up and presence of competing risk on lifespan-gain from implantable cardioverter defibrillator therapy: who benefits the most?

In at-risk patients with left ventricular dysfunction, implantable cardioverter defibrillators (ICDs) prolong life. Implantable cardioverter defibrillators are increasingly implanted for primary prevention and therefore into lower risk patients. Trial data have demonstrated the benefit of these devices but does not provide an estimate of potential lifespan-gain over longer time periods, e.g. a patient's lifespan. Using data from landmark ICD trials, lifespan-gain was plotted against baseline annual mortality in the individual trials. Lifespan-gain was then extrapolated to a time-horizon of >20 years while adjusting for increasing 'competing' risk from ageing and non-sudden cardiac death (pump failure). At 3 years, directly observed lifespan-gain was strongly dependent on baseline event rate (r = 0.94, P < 0.001). However, projecting beyond the duration of the trial, lifespan-gain increases rapidly and non-linearly with time. At 3 years, it averages 1.7 months, but by 10 years up to 9-fold more. Lifespan-gain over time horizons >20 years were greatest in lower risk patients (∼5 life-years for 5% baseline mortality, ∼2 life-years for 15% baseline mortality). Increased competing risks significantly reduce lifespan-gain from ICD implantation. While high-risk patients may show the greatest short-term gain, the dramatic growth of lifespan-gain over time means that it is the lower risk patients, e.g. primary prevention ICD implantation, who gain the most life-years over their lifetime. Benefit is underestimated when only trial data are assessed as trials can only maintain randomization over limited periods. Lifespan-gain may be further increased through advances in ICD device programming.

Transitions between health care settings in the final three months of life in four EU countries.

Transitions between care settings may be related to poor quality in end-of-life care. Yet there is a lack of cross-national population-based data on transitions at the end of life. International mortality follow-back study with data collection in Belgium, Netherlands, Italy and Spain (2009-11) via existing representative epidemiological surveillance networks of general practitioners (GPs). All general practitioners reported weekly, on a standardized registration form, every deceased patient (≥18 years) in their practice and identified those who died 'non-suddenly'. Among 4791 non-sudden deaths in Belgium, Netherlands, Italy and Spain, 59%, 55%, 60% and 58%, respectively, were transferred between care settings at least once in the final 3 months of life (10%, 8%, 10% and 13% in final 3 days of life); 10%, 5%, 8% and 12% were transferred three times or more (P < 0.001 in multivariate analyses adjusting for country differences in age, sex, cause of death, presence of dementia). In all countries, transitions were more frequent among patients residing at home (61-73%) than among patients residing in a care home (33-40%). Three months before death 5-7% of patients were in hospital, and this rose to 27-39% on the day of death. Patient wishes were cited as the reason for the last transition before death in 27%, 39%, 9% and 6% of cases in Belgium, Netherlands, Italy and Spain, respectively (P < 0.001). End-of-life transitions between health care settings are common across EU countries, in particular late hospitalizations for people residing at home. Frequency, type and reasons for terminal hospitalizations vary between countries.

Depressive symptoms in the last days of life of patients with cancer: a nationwide retrospective mortality study

ObjectivesDepressive symptoms are common in patients with cancer and tend to increase as death approaches. The study aims were to examine the prevalence of depressive symptoms in patients with cancer...

Care provided and care setting transitions in the last three months of life of cancer patients: a nationwide monitoring study in four European countries.

BackgroundThis is an international study across four European countries (Belgium[BE], the Netherlands[NL], Italy[IT] and Spain[ES]) between 2009 and 2011, describing and comparing care and care setting transitions provided in the last three months of life of cancer patients, using representative GP networks.MethodsGeneral practitioners (GPs) of representative networks in each country reported weekly all non-sudden cancer deaths (+18y) within their practice. GPs reported medical end-of-life care, communication and circumstances of dying on a standardised questionnaire. Multivariate logistic regressions (BE as a reference category) were conducted to compare countries.ResultsOf 2,037 identified patients from four countries, four out of five lived at home or with family in their last year of life. Over 50% of patients had at least one transition in care settings in the last three months of life; one third of patients in BE, IT and ES had a last week hospital admission and died there. In the last week of life, a treatment goal was adopted for 80-95% of those having palliation/comfort as their treatment goal. Cross-country differences in end-of-life care provision included GPs in NL being more involved in palliative care (67%) than in other countries (35%-49%) (OR 1.9) and end-of-life topics less often discussed in IT or ES. Preference for place of death was less often expressed in IT and ES (32-34%) than in BE and NL (49-74%). Of all patients, 88-98% were estimated to have distress from at least one physical symptom in the final week of life.ConclusionAlthough palliative care was the main treatment goal for most cancer patients at the end of life in all four countries, frequent late hospital admissions and the symptom burden experienced in the last week of life indicates that further integration of palliative care into oncology care is required in many countries.

P087: An Audit of Death Certification at a Geriatric Rehabilitation Hospital in Malta

The effective study sample included 3,623 deaths (response rate: 58.4%). Non-sudden deaths of patients aged 75 years and older were selected (N=1681). Main outcome was the main goal of treatment in the last week of life. Results: In patients older than 75, the main goal of treatment in the last week was in the majority of cases palliative care (77.9%). Patients between 75 and 85 more often received lifeprolonging/curative treatment than older patients (26.6% vs. 15.8%). The patient’s age was independently related to having comfort care as the main goal of treatment. Conclusions: Age is independently related to the main goal of treatment in the last week of life with people over 85 being more likely to receive palliative care and less likely to receive curative/life-prolonging treatment compared with those aged 75–85. This difference could be due to the patient’s wishes but could also be the result of the attitudes of care givers towards the treatment of older people.