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

Abstract

BackgroundImproving the provision of palliative and end-of-life care is a priority for the NHS. Ensuring an appropriately managed ‘transition’ to a palliative approach for care when patients are likely to be entering the last year of life is central to current policy. Acute hospitals represent a significant site of palliative care delivery and specific guidance has been published regarding the management of palliative care transitions within this setting.Aims(1) to explore how transitions to a palliative care approach are managed and experienced in acute hospitals and to identify best practice from the perspective of clinicians and service users; (2) to examine the extent of potentially avoidable hospital admissions amongst hospital inpatients with palliative care needs.DesignA mixed-methods design was adopted in two hospitals in England, serving diverse patient populations. Methods included (1) two systematic reviews; (2) focus groups and interviews with 58 health-care professionals to explore barriers to, and facilitators of, palliative care transitions in hospital; (3) a hospital inpatient survey examining palliative care needs and aspects of management including a self-/proxy-completed questionnaire, a survey of medical and nursing staff and a case note review; (4) in-depth interviews with 15 patients with palliative care needs; (5) a retrospective case note review of all inpatients present in the hospital at the time of the survey who had died within the subsequent 12 months; and (6) focus groups with 83 key decision-makers to explore the implications of the findings for service delivery and policy.ResultsOf the 514 patients in the inpatient survey sample, just over one-third (n = 185, 36.0%) met one or more of the Gold Standards Framework (GSF) prognostic indicator criteria for palliative care needs. The most common GSF prognostic indicator was frailty, with almost one-third of patients (27%) meeting this criteria. Agreement between medical and nursing staff and the GSF with respect to identifying patients with palliative care needs was poor. In focus groups, health professionals reported difficulties in recognising that a patient had entered the last 12 months of life. In-depth interviews with patients found that many of those interviewed were unaware of their prognosis and showed little insight into what they could expect from the trajectory of their disease. The retrospective case note review found that 35 (7.2%) admissions were potentially avoidable. The potential annual cost saving across both hospitals of preventing these admissions was approximately £5.3M. However, a 2- or 3-day reduction in length of stay for these admissions would result in an annual cost saving of £21.6M or £32.4M respectively.ConclusionsPatients with palliative care needs represent a significant proportion of the hospital inpatient population. There is a significant gap between NHS policy regarding palliative and end-of-life care management in acute hospitals in England and current practice.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

End‐of‐life care decisions for haemodialysis patients – ‘We only tend to have that discussion with them when they start deteriorating’

“…There is growing evidence that advance care planning is valuable to patients with ESRD: it allows them to avoid unwanted medical interventions, help prepare themselves and those around them for death, achieve a sense of control and relieve burden placed on others . However, the results of this study support previous findings that in practice patients rarely discuss end‐of‐life treatment preferences with their health‐care team, often due to the discomfort of their health‐care professionals in discussing these issues .…”

Death and the Oldest Old: Attitudes and Preferences for End-of-Life Care - Qualitative Research within a Population-Based Cohort Study

“…[ 9 ; 11 ; 14 ; 23 ; 29 ; 36 – 40 ] Others have given thoughtful consideration to the need to recognise that more dying people are following longer frailty trajectories and the implications for care services. [ 6 ; 16 ; 26 ; 41 ; 42 ] Previous research has highlighted challenges of improving communication about preferences[ 7 ; 25 ; 26 ; 34 ; 40 ; 41 ; 43 – 46 ]; we noted with interest other researchers’ comments that participants welcomed interviews as an opportunity to express thoughts,[ 11 ] as did many of ours. We found questions on specific topics could open up dialogue with people hesitant to discuss dying in general.…”

“…[ 38 ; 42 ; 56 ] Half of UK deaths aged ≥85 are in hospitals and a third in care homes[ 53 ] so improving end-of-life care for very old people in all settings is a priority. [ 7 ; 30 ; 41 ; 42 ; 54 ; 57 – 60 ] Prospective population-based research with older old people, and their informal and formal carers, examining determinants of staying-in-place or transitions is needed to understand what would enable older people to die in the place and with the support they would choose.…”

Old age rational suicide

“…It is known that older people are increasingly likely to have unplanned hospital admissions as their health deteriorates in the last year of life. In the UK, research suggests that at any one time, nearly 30% of hospital inpatients are likely to die within the next year (Clark et al, 2014;Gott et al, 2013) and that for inpatients who are over 85 years old, this proportion increases to 45% (Clark et al, 2014). Research also shows that, despite being in the last year of life, older people tend not to be referred to specialist palliative care services (Burt & Raine, 2006) or to receive care at home that would enable them to die at home (Gomes & Higginson, 2008).…”