End-of-life care in hospital: a descriptive study of all inpatient deaths in 1 year

Abstract

The objectives of this study are to ascertain how many patients who died in a district general hospital in England might have been able to be cared for at home, to obtain the cost of each inpatient stay, to make an estimate of the maximum resource implications of care packages for these patients, and to calculate the savings in hospital admissions that could be used for the development of community services. These objectives are dependant on full implementation of the End of Life Strategy. A descriptive study of all inpatient deaths in one year in a district general hospital in the south west of England was conducted. Data collection - case notes of all patients who died at the hospital from the beginning of June 2006 to end of May 2007. A total of 599 case notes of 627 patients who died in the study period were reviewed. A total of 331 patients (56%) were not assessed as being in the last year of life. Of the remaining 44%, 152 (26%) were clearly in the last year of life and 110 (18%) had significant co-morbidities and could probably have been recognised as being in the last year of life. A total of 399 (67%) of patients were appropriately admitted to hospital for their final illness, 194 (33%) could have been looked after at home. At least 119 (20%) clearly and 75 (13%) probably could have stayed at home. The mean cost of admission was 3173 pound per patient. A total of 77 (13%) of patients were admitted from nursing homes and 53 (69%) of these could have stayed in the nursing home to die. A total of 44% of all patients who died within the district general hospital had chronic life threatening illnesses. A maximum of one third of all hospital deaths could have been looked after at home if excellent end of life services were in place. When commissioning end of life care services, it is possible to calculate how many extra patients may need community care packages and the cost that could be redistributed from hospital to community for these services.

Transitions to palliative care for older people in acute hospitals: a mixed-methods study

“…A third study 82 was a descriptive analysis of the change in usage and costs of health-care services following the introduction of two community-based services in Boston, Lincolnshire, as part of the Marie Curie Delivering Choice Programme to develop services that allow people to be looked after and die in the place of their choice. The final two studies 79,83 were retrospective analyses of patient records for patients who had died in hospital to estimate the proportion of final admissions that could be classified as avoidable.…”

“…The two retrospective studies reported a high level of potentially avoidable admissions. Abel and colleagues 79 concluded that up to one-third of final admissions were avoidable; at least 20% were defined as 'clearly avoidable' and 13% as 'probably avoidable'. These assessments were based on the assumption that the End of Life Care Strategy for England 5 was fully implemented and services always had capacity.…”

“…However, there is a lack of consensus regarding how these patients should be identified and this has significant implications for quality of patient care. 79,83,125,126 The challenge in agreeing a consensus of definition and identification of palliative care needs has additional implications for generalist palliative care providers. Recent policy and research have sought to engage more effectively with the generalist provider; 125,126 however, our survey results show that many generalists are struggling to identify patients who might benefit from palliative care input.…”

“…The proportion of admissions identified as potentially avoidable was low relative to the proportions reported in two recent UK studies. 79,83 This difference is most likely attributable to the fact that, in our study, not only were data relating to admission and patient characteristics such as comorbidities, age and living arrangements considered, we also took into account the availability of local services. If local services were known to be inadequate to support the patient in the community, then the admission was considered appropriate.…”

“…If local services were known to be inadequate to support the patient in the community, then the admission was considered appropriate. In contrast, Abel and colleagues 79 based their retrospective case note review on the assumption that the End of Life Care Strategy for England 5 had been fully implemented and that local services were always available and had capacity. Employing this method, these researchers classified one-third of all deaths in hospital as avoidable, suggesting that they could have occurred at home.…”