Improving regional care in the last year of life by setting up a pragmatic evidence-based Plan–Do–Study–Act cycle: results from a cross-sectional survey

Abstract

ObjectivesTo set up a pragmatic Plan–Do–Study–Act cycle by analysing patient experiences and determinants of satisfaction with care in the last year of life.DesignCross-sectional postbereavement survey.SettingRegional health services research and development structure representing all health and social care providers involved in the last year of life in Cologne, a city with 1 million inhabitants in Germany.Participants351 bereaved relatives of adult decedents, representative for age and gender, accidental and suspicious deaths excluded.ResultsFor the majority (89%) of patients, home was the main place of care during their last year of life. Nevertheless, 91% of patients had at least one hospital admission and 42% died in hospital. Only 60% of informants reported that the decedent had been told that the disease was leading to death. Hospital physicians broke the news most often (58%), with their communication style often (30%) being rated as ‘not sensitive’. Informants indicated highly positive experiences with care provided by hospices (89% ‘good’) and specialist palliative home care teams (87% ‘good’). This proportion dropped to 41% for acute care hospitals, this rating being determined by the feeling of not being treated with respect and dignity (OR=23.80, 95% CI 7.503 to 75.498) and the impression that hospitals did not work well together with other services (OR=8.37, 95% CI 2.141 to 32.71).ConclusionsFollowing those data, our regional priority for action now is improvement of care in acute hospitals, with two new projects starting, first, how to recognise and communicate a limited life span, and second, how to improve care during the dying phase. Results and further improvement projects will be discussed in a working group with the city of Cologne, and repeating this survey in 2 years will be able to measure regional achievements.Trial registration numberDRKS00011925.

What are the risk factors for avoidable transitions in the last year of life? A qualitative exploration of professionals’ perspectives for improving care in Germany

“…The situation is similar in a longer period of the last 12 months of life [ 5 , 6 , 8 , 11 , 12 ]. The proportion of people who had been admitted at least once to hospital, nursing home or hospice in the LYOL ranged from 54% (France) to 76% (Austria, Israel, Slovenia) [ 11 ] while in Cologne (Germany) the value reached 91% [ 9 ]. In an Australian study nearly all of the decedents spent time in hospital with a marked increase in hospitalizations in the last 108 days of life for people who died of cancer [ 8 ].…”

“…Several studies found transitions increase in the last months of life [1][2][3][4][5], with most of them concerning hospitalization [1,3,4,[6][7][8]. The frequent hospital attendance at this stage of life contradicts most patients' preference for home-based care [7,9,10]. The situation is similar in a longer period of the last 12 months of life [5,6,8,11,12].…”

“…According to a recent study of our group, the five most frequent transitions in the LYOL included hospital care. About half of them were from home to hospital, almost a quarter from hospital to home, and transitions between nursing home to hospital and hospital to hospital were less frequent [9]. Numerous transitions across healthcare settings in the last months of life are potentially avoidable [10,[13][14][15][16].…”

Last Year of Life Study-Cologne (LYOL-C) (Part II): study protocol of a prospective interventional mixed-methods study in acute hospitals to analyse the implementation of a trigger question and patient question prompt sheets to optimise patient-centred care

“…4 As shown in the Last Year of Life Study Cologne (LYOL-C) Part I Status Quo Report, 42.2% of the Cologne population died in hospitals. 5 Almost 30% of hospital patients are in their last year of life, 6 and 75% of deaths are from conditions other than cancer. 7 Other literature shows that 40%-50% of patients who died in hospitals could have died in the community with better support and training.…”

“…As reported by a representative sample of relatives, general hospital units are the most important checkpoints for transitions in the last year of life (eg, diagnosis of 'entering' the last year of life, hospitals as one of the five most frequent care transitions in the last year of life and place of death). 5 Yet, satisfaction in general hospital units is lowest among all health services, especially in comparison to care at home and in nursing homes. Therefore, LYOL-C II aims to test an intervention for general acute hospital units by using a two-sided (healthcare professionals (HCPs) and patients) trigger question-based intervention to 'shake' the system in a minimally invasive manner.…”