Imminent Death in Internal Medicine: From Best Diagnostic Practices to a Comprehensive Care Plan

Death is, today, primarily a hospital event. The professionalism of the specialty of Internal Medicine, the most cross-cutting hospital specialty, is invariably linked to the holistic care of the patient, including end-of-life care. However, the approach to patients in their final hours or days of life often resembles, in practice and according to scientific evidence, that of acute care, resulting in intense and unnecessary suffering. There is no validated model in Portugal tailored to the needs of Internal Medicine and the population it serves concerning comprehensive end-of-life care. The MiMI Project (Morte Iminente em Medicina Interna/ Imminent Death in Internal Medicine) is a joint effort by a national scientific society, in partnership with a prestigious Portuguese academy, in collaboration with a reputable international scientific entity in the field of Palliative Care. Its aim is to fill a significant knowledge gap about the care of people in their final hours or days of life and provide a foundation for a methodology to improve the quality of care at a national level in this area. The research planning behind the project allows for a comprehensive evaluation of the phenomenon of caring for this type of patient from both a clinical (audit) and human perspective. It also includes an assessment of the healthcare professional's experience and the identification of opportunities for performance improvement, based on the opinions of internists. These data, combined with the national validation of a care organisation tool, based on the best global scientific evidence, will enable the creation of an educational curriculum, equipping internists with the necessary skills to appropriately manage the last hours/days of life. Thus, the MiMI Project can have a broad societal impact, promoting peaceful deaths and healthy mourning.

Objectives and Phases of the Project

The MiMI Project (Morte Iminente em Medicina Interna / Imminent Death in Internal Medicine) is being developed in five steps, with the aim of capturing the full scope of caring for people in their final hours or days of life from clinical, technical, and humanistic perspectives. The information gathered will allow the planning of a training curriculum that meets the needs of citizens and medical professionals in the specialty of Internal Medicine, equipping them with the necessary skills to appropriately manage the last hours or days of life. The five phases of the MiMI Project (Morte Iminente em Medicina Interna / Imminent Death in Internal Medicine) are as follows:

(I) National validation of a best practice model for patients in imminent death under the care of Internal Medicine: A qualitative methodology will be employed, using a semi-structured Delphi-type questionnaire, applied to a convenience panel of doctors specialising in Internal Medicine and Palliative Medicine, recruited through direct invitation, evaluating the level of agreement or disagreement with the elements of a care organisation tool based on the best practices of the International Collaborative for the Best for the Dying Person. This will involve: i) A characterisation form for the professionals: professional profile (length of professional experience) and training (year of certification in Palliative Medicine); ii) An assessment form evaluating the degree of agreement with the elements of the tool in question and providing an opportunity for free comments. The results are expected to be published in 2024, in a prestigious scientific journal with high visibility in national and international Internal Medicine, with the approved care structure being made available for use by Internal Medicine teams.

(II) Prospective identification of the type of care for the patient in imminent death under the care of Internal Medicine (One Day Survey): This phase aims to: (1) Characterise the care process for patients in their final hours or days of life in Internal Medicine wards in Portugal, following validated best practice principles; (2) Characterise the population in imminent death situations admitted to Portuguese Internal Medicine services. A cross-sectional, multicentre, non-interventional assessment methodology will be used to evaluate the quality of care for patients in imminent death situations, based on the care organisation tool derived from the best practices of the International Collaborative for the Best for the Dying Person and validated by a group of internists and national experts in Palliative Medicine. The target population is adult patients in imminent death situations admitted to Portuguese Internal Medicine services who agree to participate on the assessment day. Local coordinators will assist in identifying the target population (clinical diagnosis of imminent death), following approval from the ethics committees of the participating services/hospitals and obtaining informed consent. Data will be collected by local research coordinators, including: i) A service characterisation form: number of beds; annual overall mortality rate of the service (latest available data); number of patients who died in the service over one year (latest available data); number of patients who died in the hospital over one year (latest available data); availability of a Palliative Medicine team in the service; presence of individual rooms; flexible visitation hours upon imminent death diagnosis; flexibility in the number of visitors allowed in the event of imminent death diagnosis; availability of a private room for family conversations; possibility for family members to stay overnight in the event of imminent death; number of patients admitted to the service on the data collection day; ii) A patient characterisation form: age; gender; primary diagnosis of the underlying illness (according to provided descriptors); Charlson comorbidity index; time in imminent death situation; status of clinical co-management with the hospital’s palliative care team; iii) Best practice audit form for the final hours or days of life. iv) Data collection is scheduled for 5 June 2024 (with an additional date, if necessary, on 3 July 2024). The results are intended for publication in 2024, in a highly visible scientific journal for national and international Internal Medicine. Each participating service will receive an individualised report, enabling the identification of clinical strengths, areas for improvement, and benchmarking with other participating teams.

(III) Characterisation of the internist’s experience in caring for patients in imminent death situations: A qualitative methodology will be applied using a questionnaire disseminated by the Portuguese Society of Internal Medicine, with a semi-structured model based on a narrative medicine tool – parallel clinical record – involving a convenience panel of doctors specialising in Internal Medicine, available for collaboration with the project, following an email invitation sent to the universe of internists, members of the Portuguese Society of Internal Medicine. Data collection will focus on the completion of a Professional Characterisation Form: demographic, professional, and training details, and a Parallel Clinical Record Completion Form. The results are expected to be published in 2024 in a prestigious scientific journal with high visibility for national and international Internal Medicine.

(IV) Identification of training needs in the area of imminent death: The objectives are to (1) identify the main challenges and opportunities for improving the quality of care for patients in imminent death situations and their families under the care of Internal Medicine, from the perspective of healthcare professionals (doctors and nurses working in Internal Medicine); (2) identify training needs in various aspects of caring for patients in imminent death situations (diagnosis, adjusting individual and integrated care plans, death, and post-death care). A qualitative methodology will be used, with a Focus Group meeting. The sample will be a convenience sample of healthcare professionals working in Internal Medicine, providing care to patients in imminent death situations, specifically 10 (ten) healthcare professionals: internists with service management roles, doctors specialising in Internal Medicine, residents in Internal Medicine, nurses working in Internal Medicine, and 2 behavioural science professionals (psychiatrists and/or psychologists) with experience supporting Internal Medicine wards. The professional characterisation form will include: professional profile (length of professional experience) and training (previous training in Palliative Care). The focused discussion guide will cover the following topics: diagnosis of imminent death, approach/construction of an individualised and integrated care plan, care at the time of death, and post-death care. The session will be recorded, and verbal information will be transcribed. The results are expected to be published in 2024, in a prestigious scientific journal with high visibility in national and international Internal Medicine. These results will naturally be incorporated into the construction of the training curriculum that will underpin the care organisation tool.

(V) Development of Educational Curriculum, Pedagogical Model, and Training in the Relevant Area: Building on the data collected in the previous phases of the MiMI Project, the goal is to create a pedagogical training model that integrates the values and desired outcomes for caring for patients at this stage of life. The training model will adopt the Competency-Based Medical Education strategy defined by the World Health Organization. Using Kolb’s Learning Cycle principles, the curriculum will be developed (desired outcomes, values to be integrated, training programme, resources, and infrastructure).