Understanding end-of-life care in Australian hospitals

Abstract

ObjectiveTo explore end-of-life care in the ward and intensive care unit (ICU) environment in nine Australian hospitals in a retrospective observational study. MethodsIn total, 1693 in-hospital deaths, 356 in ICU, were reviewed, including patient demographics, advance care plans, life-sustaining treatments, recognition of dying by clinicians and evidence of the palliative approach to patient care. ResultsMost patients (n = 1430, 84%) were aged ≥60 years, with a low percentage (n = 208, 12%) having an end-of-life care plan on admission. Following admission, 82% (n = 1391) of patients were recognised as dying, but the time between recognition of dying to death was short (ICU (staying 4–48 h) median 0.34 days (first quartile (Q1), third quartile (Q3): 0.16, 0.72); Ward (staying more than 48 h) median 2.1 days (Q1, Q3: 0.96, 4.3)). Although 41% (n = 621) patients were referred for specialist palliative care, most referrals were within the last few days of life (2.3 days (0.88, 5.9)) and 62% of patients (n = 1047) experienced active intervention in their final 48 h. ConclusionsLate recognition of dying can expose patients to active interventions and minimises timely palliative care. To attain alignment to the National Consensus Statement to improve experiences of end-of-life care, a nationally coordinated approach is needed. What is known about the topic?The majority of Australian patient deaths occur in hospitals whose care needs to align to the Australian Commission on Safety and Quality in Health Care’s National Consensus Statement, essential elements of safe and high-quality end-of-life care. What does this paper add?The largest Australian study of hospital deaths reveals only 12% of patients have existing advance care plans, recognition of death is predominantly within the last 48 h of life, with 60% receiving investigations and interventions during this time with late symptom relief. What are the implications for practitioners?Given the poor alignment with the National Consensus Statement, a nationally coordinated approach would improve the patient experience of end-of-life care.

Australian health service organisation assessment outcome data for the first 2 years of implementing the Comprehensive Care Standard

“…This was the result of an update to the advisory 14 where some actions that did not previously apply to day procedure services were reconsidered. The end-of-life care actions were included in the CCS to support implementation of the National Consensus 21 End-of-life care is a recognised area for improvement in Australia, 22 which is demonstrated in the assessment outcome data. Although it is unlikely that day procedure services frequently provide care to patients in their last days, some procedures may be appropriate for people who are at the end of life.…”

Bundle of care to drive improvements in palliative and end-of-life care (PEOLC) in an acute tertiary hospital

“…Two audits were performed as part of our participation in a national audit of quality end-of-life care in hospitals 13 ; measures were chosen based on the ACSQHC standards and were standardised nationally. The audit randomly sampled cases from all deaths across a public tertiary hospital in two separate 12-month periods; the first was from June 2015 to June 2016 and the second from June 2018 to June 2019.…”

“…The John Hunter Hospital, a ~750 bed tertiary level teaching hospital in Newcastle, Australia implemented of a bundle of care aimed at improving palliative and end-of-life care (PEOLC) which included three dedicated, on-site nurses providing clinical care and education that incorporated the NSW Resuscitation Plan 11 and roll-out of a Last-Days-of-life Toolkit. 12 These interventions took place in between two national audits of deaths (including our hospital), 13 providing an opportunity to evaluate if the new service model improved quality PEOLC.…”

The goals of care framework and the perioperative period: A practical approach

“…Over 60% of patients who die in an acute hospital setting receive active interventions in the last 48 h of life, demonstrating the importance of distinguishing between the palliative and terminal phases. 31 This distinction is crucial as it is inappropriate to offer surgery to patients in the terminal phase when comfort, dignity and preparation for a peaceful death are the only priorities. 1,5,6 Assignment of the GOC category, to communicate discussed GOC and LOMT consistent with the illness phase, completes the GOC framework.…”