Advance care planning in older hospitalised patients following an emergency admission: A mixed methods study

Abstract

Introduction Although advance care planning may be beneficial for older adults in the last year of life, its relevance following an emergency hospitalisation requires further investigation. This study quantifies the one-year mortality outcomes of all emergency admissions for patients aged 70+ years and explores patient views on the value of advance care planning following acute hospitalisation. Method This mixed methods study used a two-stage approach: firstly, a quantitative longitudinal cohort study exploring the one-year mortality of patients aged 70+ admitted as an emergency to a large multi-centre hospital cohort; secondly, a qualitative semi-structured interview study gathering information on patient views of advance care planning. Results There were 14,260 emergency admissions for 70+-year olds over a 12-month period. One-year mortality for admissions across all conditions was 22.6%. The majority of these deaths (59.3%) were within 3 months of admission. Binary logistic regression analysis indicated higher one-year mortality with increasing age and male sex. Interviews with 20 patients resulted in one superordinate theme, “Planning for health and wellbeing in the spectrum of illness”. Sub-themes entitled (1) Advance care planning benefitting healthcare for physical and psycho-social health, (2) Contemplation of physical deterioration death and dying and 3) Collaborating with healthcare professionals to undertake advance care planning, suggest that views of advance care planning are shaped by experiences of acute hospitalisation. Conclusion Since approximately 1 in 5 patients aged 70+ admitted to hospital as an emergency are in the last year of life, acute hospitalisation can act as a trigger for tailored ACP. Older hospitalised patients believe that advance care planning can benefit physical and psychosocial health and that discussions should consider a spectrum of possibilities, from future health to the potential of chronic illness, disability and death. In this context, patients may look for expertise from healthcare professionals for planning their future care.

Views of advance care planning in older hospitalized patients following an emergency admission: A qualitative study

“…The coding hierarchy outlining themes and subthemes is accompanied in the supplementary material. Findings generated from the same interview series regarding the spectrum of ACP is reported in depth elsewhere [ 3 ].…”

“…(1) Bespoke planning to holistically support a sense of self, (2) ACP as a socio-cultural phenomenon advocating for older persons rights, (3) The role of personal relationships, (4) Navigating unfamiliar territory and (5) Harnessing resources.…”

“…Our previous paper explained how an emergency hospitalisation in later life can act as a catalyst for ACP [ 3 ]. As the quantitative element of the mixed methods paper had revealed that one in five patients aged 70 and over were likely to be in the last year of life, the qualitative element explored how an emergency hospitalisation in later life can be used as an opportunity to initiate advance care planning [ 3 ].…”

“…Our previous paper explained how an emergency hospitalisation in later life can act as a catalyst for ACP [ 3 ]. As the quantitative element of the mixed methods paper had revealed that one in five patients aged 70 and over were likely to be in the last year of life, the qualitative element explored how an emergency hospitalisation in later life can be used as an opportunity to initiate advance care planning [ 3 ]. The novel results presented in the current paper have a different focus and explore how ACP impacts the lives of older persons, including consideration for how ACP can be enacted for older persons within society, including from a health systems perspective.…”

“…ACP is a spectrum of possible discussions, including future care planning, urgent care planning and end-of-life care planning [ 5 ]. Future care planning considers person-centred care for those with several years prognosis, including health, well-being, and disease management [ 3 , 6 ]. Urgent care planning is mostly targeted to people with a 1–2-year life expectancy, considering medical care, prognosis, treatment limitations, and may include cardio-pulmonary resuscitation decisions [ 7 ].…”