Older Hospitalized Patients and Their Preferred Place to Die
Older Hospitalized Patients and Their Preferred Place to Die
Background A significant proportion of older people state a preference to die at home. However, the vast majority of people in hospital recognised as dying subsequently die there.
Objectives To identify the proportion of older people dying in hospital where the possibility of ending life elsewhere was explored. To identify factors that could support hospital staff to enable patients' wishes to be met.
Methods Retrospective case-note review of 100 older patients (>75 years) who died during 2009 in an English Hospital.
Results Age range 75–97 years. Time from admission to death ranged from 0–118 days (median 8.5). 16% died within the first 48 h, rising to 30% for those from care homes. In only 8 patients was a potential alternative place of death discussed. Although subjective, in 10 patients it was considered admission could have been avoided through Advance Care Planning (ACP) to allow patients with poor prognosis to die in their normal place of residence or a hospice. 55% of Do-Not-Attempt-Resuscitation orders were made within 48 h of admission. 38% were commenced on the Liverpool Care Pathway (LCP), 1–504 h before death (median 16).
Conclusions In few cases are the preferred places of death discussed in older people who die in our hospital. Although hospital admission was largely appropriate, in a minority judicious ACP could have avoided death in hospital. We recommend (1) increased use of ACP, with appropriate practicalities planned in advance (2) wide-scale introduction of the 'Rapid Discharge Home of the Dying Patient pathway' (3) routinely discussing preferred place of death in appropriate key situations (eg, discussion of resuscitation status or commencing the LCP).
It has been shown that the proportion of older people dying in hospital is rising. Not all older people wish to die at home due to concerns such as being a burden, the availability of adequate symptom relief, or a dislike of the need for carers in the home. However, it has been reported in a community based sample that nearly four-fifths of those aged 65–85 years and just under half of those 85 years or older would choose to die at home. In a study of those 65 years or older recently hospitalised with cardiac or respiratory problems, 47% of those expressed a preference to die at home; however, it is recognised that nearer the time of death views of place of death can change.
This issue is recognised at a national level. The UK National End of Life Care Strategy recognises that a significant proportion of people do not die in their preferred place and makes key recommendations which include identifying people approaching the end of life, care planning, co-ordinating care and providing rapid access to services.
Depending on the needs of the individual in question a rapid supported discharge may be appropriate to the patient's home (typically with the care of a partner or children), a hospice, or a care home accredited by the Gold Standards Framework.
There are many problems inherent in discharging a dying patient from hospital. Evidence suggests older people are less likely to be known to Specialist Palliative Care teams and there may be inequitable access to hospice services. Practicalities are key and delays in providing equipment such as mattresses or setting up new or increased care packages have been shown to be contributory factors to patients dying in hospital rather than elsewhere.
Emerging strategies such as the 'Liverpool Integrated Care Pathway for the Rapid Discharge Home of the Dying Patient' attempt to address these issues. However, such measures require prompt co-ordination of social services, palliative care teams, general practitioners, district nurses and relatives' families or significant others. This document aims to facilitate medical and nursing palliative care from hospital to community in a seamless and timely manner, and can act as a continuation of in-hospital end of life care. A criterion for use is that family are aware that social/supportive care and equipment may not fully be in place (due to the urgency of the plan).
It is recognised that some patients admitted to hospital have little to gain from such an admission, and indeed it may be distressing or against the wishes of the patient. Advance Care Planning (ACP) including Preferred Priorities of Care forms allow decisions to be made that reflect the views of patients and relatives, and aim to avoid certain courses of action that may be of little benefit. For example, terminally ill care home residents often fall unwell at night when the patient's general practitioner and notes are unavailable, family may not be contactable, and care home staff may be junior and unsupported. Without documented ACP, it is almost inevitable that such individuals will be transferred to an acute care facility, even if care in the existing place of residence is preferred and more appropriate. Doctors have a key role to play in instituting ACP as they come in frequent contact with many of those who have most to gain from it for example, at diagnosis, when facilitating discharge from hospital (often with a new diagnosis, or to a new place of care), or as part of a community service.
The aim of our study was to perform a retrospective analysis of those who have died in hospital to identify the proportion where the possibility of dying at home was explored. A further objective was to identify factors that could support hospital staff to enable patients' wishes, by collecting data on key time points during the hospital stay that could help aid future planning in this area. These included the usage and timing of Do Not Attempt Resuscitation (DNAR) orders, and observing the duration before death the Liverpool Care Pathway (LCP) was initiated (where used). In addition, an assessment was made about whether the use of ACP prior to acute decline could have led to a more appropriate alternative to acute hospital admission being considered.
Abstract and Introduction
Abstract
Background A significant proportion of older people state a preference to die at home. However, the vast majority of people in hospital recognised as dying subsequently die there.
Objectives To identify the proportion of older people dying in hospital where the possibility of ending life elsewhere was explored. To identify factors that could support hospital staff to enable patients' wishes to be met.
Methods Retrospective case-note review of 100 older patients (>75 years) who died during 2009 in an English Hospital.
Results Age range 75–97 years. Time from admission to death ranged from 0–118 days (median 8.5). 16% died within the first 48 h, rising to 30% for those from care homes. In only 8 patients was a potential alternative place of death discussed. Although subjective, in 10 patients it was considered admission could have been avoided through Advance Care Planning (ACP) to allow patients with poor prognosis to die in their normal place of residence or a hospice. 55% of Do-Not-Attempt-Resuscitation orders were made within 48 h of admission. 38% were commenced on the Liverpool Care Pathway (LCP), 1–504 h before death (median 16).
Conclusions In few cases are the preferred places of death discussed in older people who die in our hospital. Although hospital admission was largely appropriate, in a minority judicious ACP could have avoided death in hospital. We recommend (1) increased use of ACP, with appropriate practicalities planned in advance (2) wide-scale introduction of the 'Rapid Discharge Home of the Dying Patient pathway' (3) routinely discussing preferred place of death in appropriate key situations (eg, discussion of resuscitation status or commencing the LCP).
Introduction
It has been shown that the proportion of older people dying in hospital is rising. Not all older people wish to die at home due to concerns such as being a burden, the availability of adequate symptom relief, or a dislike of the need for carers in the home. However, it has been reported in a community based sample that nearly four-fifths of those aged 65–85 years and just under half of those 85 years or older would choose to die at home. In a study of those 65 years or older recently hospitalised with cardiac or respiratory problems, 47% of those expressed a preference to die at home; however, it is recognised that nearer the time of death views of place of death can change.
This issue is recognised at a national level. The UK National End of Life Care Strategy recognises that a significant proportion of people do not die in their preferred place and makes key recommendations which include identifying people approaching the end of life, care planning, co-ordinating care and providing rapid access to services.
Depending on the needs of the individual in question a rapid supported discharge may be appropriate to the patient's home (typically with the care of a partner or children), a hospice, or a care home accredited by the Gold Standards Framework.
There are many problems inherent in discharging a dying patient from hospital. Evidence suggests older people are less likely to be known to Specialist Palliative Care teams and there may be inequitable access to hospice services. Practicalities are key and delays in providing equipment such as mattresses or setting up new or increased care packages have been shown to be contributory factors to patients dying in hospital rather than elsewhere.
Emerging strategies such as the 'Liverpool Integrated Care Pathway for the Rapid Discharge Home of the Dying Patient' attempt to address these issues. However, such measures require prompt co-ordination of social services, palliative care teams, general practitioners, district nurses and relatives' families or significant others. This document aims to facilitate medical and nursing palliative care from hospital to community in a seamless and timely manner, and can act as a continuation of in-hospital end of life care. A criterion for use is that family are aware that social/supportive care and equipment may not fully be in place (due to the urgency of the plan).
It is recognised that some patients admitted to hospital have little to gain from such an admission, and indeed it may be distressing or against the wishes of the patient. Advance Care Planning (ACP) including Preferred Priorities of Care forms allow decisions to be made that reflect the views of patients and relatives, and aim to avoid certain courses of action that may be of little benefit. For example, terminally ill care home residents often fall unwell at night when the patient's general practitioner and notes are unavailable, family may not be contactable, and care home staff may be junior and unsupported. Without documented ACP, it is almost inevitable that such individuals will be transferred to an acute care facility, even if care in the existing place of residence is preferred and more appropriate. Doctors have a key role to play in instituting ACP as they come in frequent contact with many of those who have most to gain from it for example, at diagnosis, when facilitating discharge from hospital (often with a new diagnosis, or to a new place of care), or as part of a community service.
The aim of our study was to perform a retrospective analysis of those who have died in hospital to identify the proportion where the possibility of dying at home was explored. A further objective was to identify factors that could support hospital staff to enable patients' wishes, by collecting data on key time points during the hospital stay that could help aid future planning in this area. These included the usage and timing of Do Not Attempt Resuscitation (DNAR) orders, and observing the duration before death the Liverpool Care Pathway (LCP) was initiated (where used). In addition, an assessment was made about whether the use of ACP prior to acute decline could have led to a more appropriate alternative to acute hospital admission being considered.
