The impact of advance care planning of place of death, a hospice retrospective cohort study

Abstract

ObjectivesThere is limited evidence of the impact of advance care planning (ACP) on outcomes. We conducted a retrospective cohort study on deaths of all patients known to a hospice in a 2.5-year period to see if use of ACP affected actual place of death, hospital use and cost of hospital care in the last year.Results969 patients were included. 550 (57%) people completed ACP. 414 (75%) achieved their choice of place of death. For those who chose home, 34 (11.3%) died in hospital; a care home 2 (1.7%) died in hospital; a hospice 14 (11.2%) died in hospital and 6 (86%) who chose to die in hospital did so. 112 (26.5%) of people without ACP died in hospital. Mean number of days in hospital in the last year of life was 18.1 in the ACP group and 26.5 in the non-ACP group(p<0.001). Mean cost of hospital treatment during the last year of life for those who died in hospital was £11,299, those dying outside of hospital £7,730 (p<0.001). Mean number of emergency admissions for those who died in hospital was 2.2 and who died elsewhere was 1.7 (p<0.001).ConclusionsACP can be used routinely in a hospice setting. Those who used ACP spent less time in hospital in their last year. ACP is associated with a reduction in the number of days in hospital in the last year of life with less hospital costs, supporting the assumptions made in the End of Life Care Strategy 2008.

The economic evidence for advance care planning: Systematic review of evidence

“…All but four of the 18 included studies are from the US, with two from the UK (Abel et al, 2013;Baker et al, 2012), one from Canada and one from Singapore .…”

Care and communication between health professionals and patients affected by severe or chronic illness in community care settings: a qualitative study of care at the end of life

“…4,137 Some studies have reported benefits. 128,[130][131][132]138,139 These tend to be based on surveys, and to focus on a comparative reduction in days and deaths in hospital and costs associated with care in the last year of life. Detering et al 128 report the results of a randomised controlled trial in Australia in which patients receiving a structured ACP intervention were more likely to die in their preferred place.…”

“…Carers expressed increased satisfaction with EOLC, and costs for health care were reduced. Abel et al 132 conducted a retrospective cohort study of deaths among known hospice users and concluded that those who had an ACP in place spent fewer days in hospital and had lower costs of care than those without. However, a growing body of qualitative evidence gives an indication of the great complexity, ambivalence and variability of patients' desire to engage in ACP, and their responses to professional invitations to do so.…”

“…ACP is reported to increase the chances of patients dying in their preferred place, assumed usually to be home, and experiencing less invasive (and less costly) treatment. 128,[130][131][132]138,139 Nevertheless, evidence regarding the effectiveness of ACP is limited and conflicting. 4 The policy is not based on evidence about patients' and the public's understanding and experience of ACP, their preferences for how and when this should be discussed, or their attitudes to death and dying.…”

Ten clinician-driven strategies for maximising value of Australian health care

“…65 In one study, such an approach reduced both days and costs of hospitalisation in the last year of life by almost one-third. 66 Inappropriate overinvestigation and over-treatment of older patients with multimorbidity can be minimised by management approaches that integrate care-specific benefit-harm trade-offs with life expectancy, care goals and patients' values and preferences. 67 …”