w. PNQ. GAugust 1992
journalofAin and &mpom Manypent
Robin L. Fainsinger, MD, Tara Palhztbe CareF~ogram(R.LX, TM., E.B.), EdmontonGeneralHospital,andDepartment OfEpidemiology
O.H.), CrossCancerInstitnte, &bnonton,Atierta,Canado
Recentrqhn-ts have commentedon the need to improveour hnowlec&eand managementof urinal problems in termmal&ill patients. We conducteda prospectivestu& in 61 consecutive patients admittedto our palliativecare unit (PCU), who were assessedfm urinal problems, use of urinary catheters,and managementofproblemsassociatedwith thecathekrs.A totalOf74% (45 of 61) of the patientsrequireda catheterbeforedeath, with 23 (38%) being admittedto the PCU with a catheter, and 22 patients (36O/4)requin*;ns a catheterduring admissionto PCU. Mre presentourfindings [email protected]
thedurationof catheteruse, ina5cationsforcathekrs,typeof cathetersused, and complicatwns of catheters.Yhe da& collectedsuggestthat, althoughurinag problems and catheteruse are common in terminalillness, $stit gu~dehnesarefollowed thereis ROdemonstrablemortality,and morb&y associatedwith catheteruse is outwe+$edby patient ben$t. J Pain Symptom Manage 1992;7:333-338.
By Words Cancer, cat&errs, terminate ill, complications,indications
There has been veq Me published on the management of urinary incontinence and the use of urinary catheters in terminally ill patients.‘~* Enck’ reports that urinary incontinence is a common finding in hospice patients, and there is a need to study this problem. We have previously reported on the absence of studies on catheters in palliative care, and the need to determine appropriate indications for catheter use, as well
Address reprintrequests to: Robin Fainsinger, MD, Palliative Care Program, Edmonton General Hospital, 11111 Jasper Avenue, Edmonton, Alberta, Canada T5K OL4. Accepudfwpubticatio~ February 13,1992. 0 U.S. Cancer Pain Relied Committee, 1992 Published by Elsevier, New York, New York
as to increase our knowledge of potential complications and appropriate management.* In the absence of studies in a palliative care setting, decisions have been based on reports in other patient groups, including the geriatric population,3 those with spinal cord injury,4 and the general hospital population5 The unique needs and problems of the terminally ill, however, require that data gained in other popdation groups be used with caution. Ln view of this identified need, we conducte prospective study on our 14bed palliative care unit to determine the prevalence of minary problems, indications for the use of utilary catheters, as well as the complications and management of problems associated with urinary catheters.
Fainsi&r et al.
?-a 1 Patient Chairacteristics
25/36 (:ll%,59%) 66f 12
Sex: female/male Average age (yr) Diagnosis Gastrointestinal Genitourinary Lung Breast Head and neck Unknown Hematological Lymphoma
Patients were assessed daily for the presence of urinary symptoms or the need for the use of a urinary collecting device. If the patient arrived on the unit with a urinary catheter in place, they were reassessed upon admission. The date the catheter was started and stopped, as well as the indication for the catheter and the reason for catheter cessation, were recorded. In some patients admitted to the unit with the catheter in place, we were not able to determine the date the catheter use started or the indication. The type and size of catheter, as well as the size of the catheter bulb in indwelling urinary catheters, were recorded. Note was also made of any change in the catheter, as well as catheter-related complications, such as bladder spasms, bacteriuria, catheter encrustation, fever, or sepsis. Treatment of these complications was recorded. A urine culture and sensitivity was performed weekly in an attempt to determine the incidence and prevalence of bacteriuria, the most common infecting organisms, and any change in bactcriuria that might occur. Experiences from other clinical setting&+9 were used to determine our indications for catheter use. If behavioral changes, nursing care, use of diapers, and medication changes
were unsuccessful in managing urinary difficulties, a device to collect urine was considered. In men, the use of an external device, i.e., the condom catheter, was used first unless it was determined that the problem related to urinary retention. Indications for a long-term catheter were (a) patient comfort, where the physical discomfort related to frequent changes of clothes and bed linen, or the psychological distress associated with incontinence, led the patient and/or family to decide that dryness and comfort outweighed the risks of catheterization; (b) management and/or prevention of decubiti and other skin wounds; (c) overflow incontinence associated with retention; and (S) urinary retention. When an indwelling urinary catheter was started on our unit, preference was given to latex catheters, which cost less than those made of silicone. Although the latter have been reported as being better tolerated with long-term use,8 the relatively short duration of admission on our unit (Table 2) should not allow any benefit to the more expensive silicone catheters. A balloon size
Information was collected prospectively in 61 consecutive patients admitted to, and dying on, our palliative care unit between December 1990 and June 199 1. Patients who were transferred or discharged from the unit were excluded. Patient characteristics are summarized in Table 1.
18 (29.5%) 17 (27.9%) 15 (24.6%) 4 (6.6%) 4 (6.60/o 1 (l.SO/o) 1 (I.S”/o) 1 (1.6Vo)
l-able2 Admission Chaxacteristics Catheter on admission Catheterized on unit No catheter
23 patients (38%), 95% CI: 16-30 22 patients (36%), 95% CI: 15-29 16 patients (26%), 95% CI: 10-22
Average duration (days) of admission (ADA) ADA when catheterized on unit ADA when catheterized prior to admission ADA when not catheterized
37f41 40f32 38f51 32f36
Average duration (days) of catheter (ADC) ADC when inserted on unit ADC on unit when inserted prior to admission
22f39 lo* 14 32f52
Utimg Cathetersin Tminal dllncss
Catheters insertedprior to admission(IV= 23) Foley Silicone Condom
16 6 1
UnspeciEed 14 G 16 G 18 G 22 G
3 4 13 1 1
5 cc 1occ 30 cc Unspecified
6 4 9 3
Unspecified 14 G 18 G
1 10 12
5 cc 1occ Unspecified
14 5 4
Catheters inserted after admission(IV= 29) Foley Siicone Condom
23 0 6
of 5-l 0 mL was selected, as it has been reported to provide effective drainage and cause the least discomfort in the majority of patients.g When using the condom catheter, routine care to avoid constriction and catheter g was used,7 without routine removal to wash and dry the penis unless indicated by local complications. In the care of an indwelling urethral catheter, standard guidelines were followed,s including sterile technique to insert the device, closed drainage system, no routine catheter change, careful attention to catheter position, and catbeter irrigation only for repeated plugging. Complications of catheters were only treated. when symptomatic.8
Of the 61 patients studied, 23 patients had a catheter on admission, 22 patients were catheterized during their admission on the unit, and 16 patients died without the use of any urinary collecting device. There was very little variation among the average duration of admission, the duration of admission when the catheter was inserted prior to admission, and the duration of
admission when the catheter was inserted during the stay in the unit (Table 2). Patients who were not catheterized had an average duration of admission shorter than the catheterized patients. Table 3 contains a summary of the type of catheters used, allowing comparison between the catheters used prior to admission and the type of catheters used on our unit. Of the 23 patients, 6 had a silicone catheter on admission, and 9 patients had a 30-cc bulb. None of the patients catheterized on the unit received a silicone catheter or a 30-cc bulb. Table 4 lists the complications and treatment of complications in 52 catheters, i.e., the 23 catheters on admission, the 22 catheters inserted for the first time on the unit, plus an additional 7 patients who had their first catheter stopped and a second catheter reinserted for a second indication. As expected, the most common complication was bacteriuria in 54% (28 of 52) of tbe catheters. The timing of bacteriuria relative to the start of catheter use could not be established in 17 catheters. Of the 35 catheters evahtable, 24 had no bacteriuria. Two of the latter group, who had catheter durations of 17 and 49 days, respec-
Table4 Complications of Catheters and Treatment Treaanent of complications
Complicationsof 52 catheters Bacteriuria Encrustation Bladder spasms Fever Urethritis Total
28 8 4 2 2 44
Antibioticfor symptomaticinkction Antispasmodics Catheter change due to encrustation Illi~tiOll
5 4 6 4
Ku! 7No. GAggist 1992
Fainsi*nger et td
comfortwas, again, the main indication; Only two patients had the catheter stopped later due to increased mobility. Of the 16 patients dying without a catheter, 13 (No/o) had a rapid deterioration (defined as a change from alert and stable to deterioration and death within 48-72 hr), and 1 died suddenly. Tabk 8 lists the symptoms that resulted in the indication of patient comfort; asthenia and pain were the most common causes.
la? 5 Bacteria Cultured (some Cultures Grew Two Bacteria) 16 11
7 6 : : 1
As we have previously pointed out,* it is possible that the cachexia, metabolic changes, and poor immune defenses could accelerate the development of catheter complications. In all cases, there is a need to weigh the benefits of catheter use against the risks. The average duration of admission when the patient did not receive a catheter compared with the average duration of admission when a catheter was used suggests that there was no significant increased mortality from catheter use. In addition, during this prospective study, no patient was noted to have died from any apparent catheter complication; however, these findings should be interpreted cautiously in view of the small number of patients and the variable stage of disease upon admission. The fact that most patients who did not require catheters had rapid deterioration or sudden death, and that asthenia was one of the main indicators for catheterization, both suggest that the need for a catheter may be higher among patients with longer and slower deterioration. Catheter use was associated with significant morbidity. There was a high prevalence of asymptomatic bacteriuria, even though a significant number of patients did not have the catheter for a sufficient duration to develop this complication. As expected, the majority of complications
tively, were receiving antibiotics for respiratory tract infections; in the remaining 22 catheters, the median catheter duration was 4 days, with a range of 1-31 days. Ofthe 16 catheters evahrable after 7 days, 7 (44a/o) were positive for bacteriuria; 9 of 12 catheters (75Oo)evaluable at 14 and 21 days, and 11 of 12 catheters (92’10) evahrable at 28 days, demonstrated bacteriuria. Of the 7 patients treated with a condom catheter, 4 were documented to have bacteriuria. A change in the nature of the bacteriuria was often noted, with 7 patients having one change, 3 patients having two changes, and 2 patients showing a change in the type of bacteria on four occasions. The median days to change of bacteria was 9.5 days (range, 7-163 days). Table 5 lists the bacteria cultured. EMerk~iu coli and Ent.mcoccus faealis were the most frequently isolated organisms. Table 6 shows the indications for starting ana stopping the catheter in the patients catheterized prior to admission, and during admission. The main indication for catheterization prior to admission was patient comfort; 5 patients had their ca,theter stopped due to increased mobility or unnecessary indication. The main indication for restarting the catheter at a later date in tbis group Was urinary retention. Of the 22 patients catheterized on the unit (Table 7), patient Tiblc 6
Catheter on Admission (23 Reason for discontinuation
Patient comfort unknowll Urinary retention Urine incontinence
10 8 4 1
Patient died Increase mobility Regained urinary limction Change from condom to indwelling catheter
‘One patientdied suddenlywithoutcatheter.
Patients) Reason for restarting catheter
17 3 2 1
Urinary retention Patient comfort
Reason for discontinuation 4 1
Patient comfort Urine retention Retention with overflow incontinence Decubitus ulcers Urine incontinence (condom catheter)
10 5 3 3 1
Patient died Increase mobility Change from condom to indwelling catheter Pulling catheter off
restarting catheter 18 2 1
Two patientshad incontinencemanagedwith diapersuntil death. 38 patients-16 died without catheter: Rapid deterioration
Suddendeath Incontinencemanagedby othermeans
and treatment of complications related to problems surrounding short-term catheter use. The problems associated with long-term catheter use (such as periurethral ctions, cystitis, urinary stones, and bladder perforation) were not noted in our patienta Previous studies have indicated that the incidence of bacteriuria is about 5%0-10% per day7 with the majority of cases occurring within 30 days of catheterization. Due to our use of urine cultures weekly and the short duration of the catheter use in many patients, it was not possible to accurately determine the incidence of bacterimia in our patient population; however, 92% of catheters evaluable at 28 days did demonstrate bacteriuria. As many of our patients have their catheter started in their last days of life, they will Rave minimal exposure to catheter complications related to bacteriuria. It has also been noted that bacteriuria is dynamic and can change rapidly,7JoJ I and this was observed on our unit, where patients who did have long-term catheterization were noted to have dynamic bacteriuria, with the median tune to change being 9.5 days. Our data suggest that it might be
l-abk8 for Indication of Patient Codort (iv= 21)
hhenia Fain unknown Dyspnca Nausea Delirium
8 5 3 3 1 1
;: 14 14 5 5
to do a urinalysis on starting a catheter, and about every 14 days thereafter to allow for more accurate use of antibiotics should symptomatic infection develop. Alternatively, the cmphic use of antibiotics after sen a urine for culture has also been recommended for symptomatic infkction.8 The bacteriologic findings in our patients and the occurrence ofpolymicrobial infections are similar to the findings of other sm&es_4Q-l5 help
The pattern of catheter use, as demonstrated in Tables 6 and 7, suggests that patients who do not have a rapid deterioratisn will likely develop an indication for use of a urine-collecting device. Patient comfort was the indication for starting a catheter in 2 1 patients and was the major reason for catheter commencement both on and off our unit. It is significant that, although the major symptoms of physical distress in terminally ill patients (e.g., pain, dyspnea, nausea, and delirium)ts were all symptom indications for patient comfort, the major reason for this indication was asthenia. This is perhaps not that surprismg in view of the high prevalence of asthenia in patients with advanced cancer.17 Urinary retention was also a common indication for catheter use in our patients, occurring in 15 (250/o) of 61 patients. This compares with the report by Lichter and Hunt18 who noted urinary retention in 2 l% of patients and incontinence in 32% during the last 48 hr of life. We used a condom catheter in 7 (19%) of 36 male patients and an indwelling urinary catheter in 45 (74’10) of 61 patients, whereas Richter and Hunt18 used an indwelling catheter in 44% and a male external catheter in 4”/0. The difference in catheter use between these two studies might be related to the
difference in patient groups; 40% of the patients treated by Richter and Hunt died in their own homes, in contrast to our patients, all of whom died in a palliative care unit that admits predominantly highly symptomatic, terminally ill patients. I6The other possible explanation is that Lichter and Hunt’* never used parenteral hydration, whereas we often use hypodermoclysis for dehvdration.‘g
Con&.m*on This prospective study of 6 1 patients who died in a palliative care unit shows that even with strictly controlled guidelines for catheter use, 74% of patients still required a urinary collecting device. Despite this high prevalence, there was no demonstrable mortality in any of the patients treated, and morbidity was mostly due to the predictable bacterituia. 3 the complications were treated relatively easily. With good indications for catheter use, routine catheter care, and close supervision for complications, the morbidity associated with catheter use is far outweighed by the benefit to the patient.
Ref~ences 1. Enck RE. The management of urinary incontinence. Am J Hosp Care 1989;6(6):9-10. 2. Fainsinger R, Bruera E. Palliative care round: urinary catheters in palliative care. J Pain Symptom Manage 1991;6:449451.
m 7No. GAqust 1992
5. Mulhall AB, Chapman
RG, Crow RA. Bacteriuria during indwelling urethral catheterization.J Hosp Infect 1988;11:253-262. 6. Warren JW. Catheter associated urinary tract ir&ections. Infect Dis Clin North Am 1987;1:823-853. 7. WarrenJW. Catheters and catheter care. Clin Getiatr Med 1986;2:857-871. 8. Woods DR, Bender BS. Long term urinary tract catheterization. Med Clin North Am 1989;23:1441-1454. 9. Crow RC, Mulhall A, Chapman R. Indwelling catheterization and related nursing practice. J Adv Med 1988; 13:489-495. 10. WarrenJw, Platt R, Thomas RJ, et al. Antibiotic irrigation and catheter associated urinary tract infections. N Engl J Med 1978;299:570-573. 11. Breitenbacher RB. Bacterial changes in urine samples of patients with long term indwelling catheters. Arch Intern Med 1984;14+1585-1588. 12. Warren Jw, Tenney JH, Hoopes JM, et al. A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters. J Infect Dis 1982;6:719-723. 13. Jaff MR, Paganini EP. Meeting the challenge geriatric UTI’s. Geriatrics 1989;44:60-69.
14. Nicolle LE. Urinary tract infections--a common geriatric problem. Can J Geriatrics 1990;6(6):21-29. 15. Harding GK, Nicolle LE, Ronald AR, et al. How long should catheter-acquired urinai~ tract infections in women be treated? Ann Intern Med 1991;114:713-719. 16. Fainsinger R, Bruera E, Miller MJ, Hanson J, MacEachem T Symptom control during the last week of life on a palliative care unit. J Palliat Care 1991;7:5-11. 17. Bruera E, MacDonald RN. Asthenia in patients with advanced cancer. J Pain Symptom Manage 1988;3:9-14.
3. Zilkowsld NW, Smucker BR. Urinary tract infections in the elderly. Am Fam Phys 1989;39:125-134.
18. Lichter I, Hunt E. The last 48 hours of life. J Palliat Care 1990;6:7-15.
4. PetersonJR, Roth EJ. Fever, bacteriuxia, and pyuria in spinal cord injured patients with indwelling urethral catheters. Arch Phys Med Rehabil 1989;70:839-841.
19. Fainsinger RL, Bruera E. Hypodermoclysis (HDC) for symptom control vs the Edmonton Injector (EQ. J Palliat Care 199 1;7(4):5-8.