At UCLA Medical Center, which prides itself on caring for critically ill patients, a recent study showed room for improvement in the way doctors manage dying patients -- and the findings likely apply to other hospitals as well, the researchers say. While doctors excelled at pain control, they did less well at talking to patients and families about prognosis and goals of care. They were good about ordering comfort care, but not about follow-up to make sure the care was effective. Lead author Dr. Anne Walling, of the University of California, Los Angeles, and colleagues analyzed the charts of 496 adults who were hospitalized at least three days before dying. The researchers assessed the patients' end-of-life care based on 13 quality indicators in three domains: eliciting goals of care, pain assessment and management, and assessment and management of dyspnea (difficulty breathing). More than half of the patients were admitted to the hospital with end-stage disease, one-third required removal from mechanical ventilation before death and 15 percent died while receiving CPR. Records showed that 85 percent of the patients were likely to die during the hospitalization, and 47 percent had "expected death" documented in their charts. One-third had mechanical ventilation discontinued before death, and 15 percent died during cardiopulmonary resuscitation. Eighty-four percent had do-not-resuscitate orders, which were written on the day of death in 28 percent of cases and two days before in half of cases. Only 18 percent had advance directives prepared. For 70 percent of the quality indicators studied, patients received recommended care.