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Ethical considerations for classifying patients as ‘palliative’ when calculating Hospital Standardised Mortality Ratios
  1. James Downar1,2,
  2. Robert Sibbald3,4,
  3. Neil M Lazar1,2
  1. 1Department of Medicine, University Health Network, Toronto, Canada
  2. 2University of Toronto, Toronto, Canada
  3. 3London Health Sciences Centre, London, Canada
  4. 4University of Western Ontario, London, Canada
  1. Correspondence to Dr James Downar, 200 Elizabeth St 9N-926, Toronto M5G 2C4, Canada; james.downar{at}


The Hospital Standardised Mortality Ratio (HSMR) is a commonly used measure of hospital mortality that is standardised for age, comorbidities and other factors. By tradition, this statistic has always excluded patients classified as ‘palliative’. The HSMR has never been validated as a reliable measure of quality of care, and it can be very hard to interpret, partly due to difficulties with defining and applying the term ‘palliative’. In this paper, we review the Canadian experience with the palliative status flag, and explain why it is so difficult to define and apply consistently. We also highlight some potential concerns about clinicians labelling inpatients as ‘palliative’ during their admission. Finally, we propose an organisational ethics framework, and six specific suggestions for hospitals to use when publishing statistics such as the HSMR.

  • Policy Guidelines/Inst. Review Boards/Review Cttes
  • care of the dying patient

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  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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