Understanding end-of-life care in Australian hospitals
Imogen Mitchell A , Jeanette Lacey B C , Matthew Anstey D E , Cathy Corbett F , Carol Douglas G , Christine Drummond H , Michel Hensley I J , Amber Mills K , Caroline Scott L , Jo-Anne Slee M , Jennifer Weil N O , Brett Scholz
A S , Brandon Burke P Q and Catherine D’Este R
A ANU Medical School, The Australian National University; Canberra Health Services, ACT, Australia. Email: imogen.mitchell@anu.edu.au
B John Hunter Hospital, Medicine and Interventional Services, Newcastle, NSW, Australia. Email: jeanette.lacey@hnehalth.nsw.gov.au
C University of Newcastle, NSW, Australia.
D Sir Charles Gairdner Hospital, Perth, WA, Australia. Email: matthew.anstey@health.wa.gov.au
E School of Public Health, Curtin University, Perth, WA, Australia.
F Alfred Hospital, Melbourne, Vic., Australia. Email: c.corbett@alfred.org.au
G Palliative and Supportive Care, Royal Brisbane and Women’s Hospital, Qld, Australia. Email: carol.douglas@health.qld.gov.au
H Central Adelaide Palliative Care Service. Email: christine.drummond@health.sa.gov.au
I Royal Prince Alfred Hospital, Sydney, NSW, Australia.
J University of Newcastle, NSW, Australia. Email: michael.hensley@newcastle.edu.au
K Central Clinical School, Faculty of Medicine, Nursing & Health Sciences, Monash University, Vic., Australia. Email: amber.mills@monash.edu.au
L Centre of Palliative Care, St Vincent’s Hospital, Melbourne, Vic., Australia. Email: caroline.scott@svha.org.au
M The Royal Melbourne Hospital, Vic., Australia. Email: jo-anne.slee@mh.org.au
N University of Melbourne, Department of Medicine, Vic., Australia. Email: jennifer.weil@unimelb.edu.au
O St Vincent’s Hospital, Melbourne, Vic., Australia.
P Christchurch Hospital, Christchurch, New Zealand.
Q University of Otago Christchurch School of Medicine, New Zealand. Email: brandon_j_burke@hotmail.com
R National Centre for Epidemiology and Population Health (NCEPH), The Australian National University, ACT, Australia. Email: catherine.deste@anu.edu.au
S Corresponding author. Email: brett.scholz@anu.edu.au
Australian Health Review 45(5) 540-547 https://doi.org/10.1071/AH20223
Submitted: 25 August 2020 Accepted: 16 February 2021 Published: 2 June 2021
Journal Compilation © AHHA 2021 Open Access CC BY-NC-ND
Abstract
Objective To explore end-of-life care in the ward and intensive care unit (ICU) environment in nine Australian hospitals in a retrospective observational study.
Methods In 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.
Results Most 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.
Conclusions Late 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.
References
[1] Virdun C, Luckett T, Davidson PM, Phillips J. Dying in the hospital setting: A systematic review of quantitative studies identifying the elements of end-of-life care that patients and their families rank as being most important. Palliat Med 2017; 31 587–601.| Dying in the hospital setting: A systematic review of quantitative studies identifying the elements of end-of-life care that patients and their families rank as being most important.Crossref | GoogleScholarGoogle Scholar | 27932631PubMed |
[2] Broad JB, Gott M, Kim H, Boyd M, Chen H, Connolly MJ. Where do people die? An international comparison of the percentage of deaths occurring in hospital and residential aged care settings in 45 populations, using published and available statistics. Int J Public Health 2013; 58 257–67.
| Where do people die? An international comparison of the percentage of deaths occurring in hospital and residential aged care settings in 45 populations, using published and available statistics.Crossref | GoogleScholarGoogle Scholar | 22892713PubMed |
[3] Swerissen H, Duckett SJ. What can we do to help Australians die the way they want to? Med J Aust 2015; 202 10–1.
| What can we do to help Australians die the way they want to?Crossref | GoogleScholarGoogle Scholar | 25588426PubMed |
[4] Australian Commission on Safety and Quality in Health Care. Safety and Quality of End-of-Life Care in Acute Hospitals: A Background Paper. Sydney: ACSQHC; 2013.
[5] Scholz B, Goncharov L, Emmerich N, Lu VN, Chapman M, Clark S, Wilson T, Slade D, Mitchell IA. Clinicians’ accounts of communication with patients in end-of-life care contexts: A systematic review. Patient Educ Couns 2020; 103 1913–21.
| Clinicians’ accounts of communication with patients in end-of-life care contexts: A systematic review.Crossref | GoogleScholarGoogle Scholar | 32650998PubMed |
[6] Yabroff KR, Mandelblatt JS, Ingham J. The quality of medical care at the end-of-life in the USA: existing barriers and examples of process and outcome measures. Palliat Med 2004; 18 202–16.
| The quality of medical care at the end-of-life in the USA: existing barriers and examples of process and outcome measures.Crossref | GoogleScholarGoogle Scholar | 15198133PubMed |
[7] Lynn J, Teno JM, Phillips RS, Wu AW, Desbiens N, Harrold J, et al. Perceptions by family members of the dying experience of older and seriously ill patients. Ann Intern Med 1997; 126 97–106.
| Perceptions by family members of the dying experience of older and seriously ill patients.Crossref | GoogleScholarGoogle Scholar | 9005760PubMed |
[8] Anstey MH, Adams JL, McGlynn EA. Perceptions of the appropriateness of care in California adult intensive care units. Crit Care 2015; 19 51
| Perceptions of the appropriateness of care in California adult intensive care units.Crossref | GoogleScholarGoogle Scholar | 25887104PubMed |
[9] Australian Commission on Safety and Quality in Health Care. Essential Elements of Safe and High Quality End-of-life Care. Sydney: Australian Government; 2015. Available at: http://www.safetyandquality.gov.au/wp-content/uploads/2015/05/National-Consensus-Statement-Essential-Elements-forsafe-high-quality-end-of-life-care.pdf. [verified 7 April 2016].
[10] Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. Engaging physicians in a shared quality agenda. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2007.
[11] Bloomer MJ, Hutchinson AM, Botti M. End-of-life care in hospital: An audit of care against Australian national guidelines. Aust Health Rev 2019; 43 578–84.
| End-of-life care in hospital: An audit of care against Australian national guidelines.Crossref | GoogleScholarGoogle Scholar | 30830856PubMed |
[12] Fins JJ, Miller FG, Acres CA, Bacchetta MD, Huzzard LL, Rapkin BD. End-of-life decision-making in the hospital: Current practice and future prospects. J Pain Symptom Manage 1999; 17 6–15.
| End-of-life decision-making in the hospital: Current practice and future prospects.Crossref | GoogleScholarGoogle Scholar | 9919861PubMed |
[13] Becker G, Sarhatlic R, Olschewski M, Xander C, Momm F, Blum HE. End-of-life care in hospital: Current practice and potentials for improvement. J Pain Symptom Manage 2007; 33 711–9.
| End-of-life care in hospital: Current practice and potentials for improvement.Crossref | GoogleScholarGoogle Scholar | 17531911PubMed |
[14] Maubach N, Batten M, Jones S, Chen J, Scholz B, Davis A, Bromley J, Burke B, Tan R, Hurwitz M, Rodgers H, Mitchell I. End‐of‐life care in an Australian acute hospital: a retrospective observational study. Intern Med J 2019; 49 1400–5.
| End‐of‐life care in an Australian acute hospital: a retrospective observational study.Crossref | GoogleScholarGoogle Scholar | 30908873PubMed |
[15] Cochrane W. Sampling Techniques, Third Edition. New York: John Wiley & Sons, Inc.; 1977.
[16] Royal College of Physicians. End-of-life Care Audit: Dying in Hospital: National report for England 2016. London: Royal College of Physicians; 2016.
[17] Cardona-Morrell M, Kim JCH, Turner RM, Anstey M, Mitchell IA, Hillman K. Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem. Int J Qual Health Care 2016; 28 456–69.
| Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem.Crossref | GoogleScholarGoogle Scholar | 27353273PubMed |
[18] Anstey M, Watts N, Orford N, Seppelt I, Mitchell I. Does anyone ever expect to die? Anaesth Intensive Care 2017; 45 466–8.
| Does anyone ever expect to die?Crossref | GoogleScholarGoogle Scholar | 28673216PubMed |
[19] Thurston AJ, Wilson DM, Hewitt JA. Current end-of-life care needs and care practices in acute care hospitals. Nurs Res Pract 2011; 2011 869302
| Current end-of-life care needs and care practices in acute care hospitals.Crossref | GoogleScholarGoogle Scholar | 22315678PubMed |
[20] Detering KM, Buck K, Ruseckaite R, et al. Prevalence and correlates of advance care directives among older Australians accessing health and residential aged care services: multicentre audit study. BMJ Open 2019; 9 e025255
| Prevalence and correlates of advance care directives among older Australians accessing health and residential aged care services: multicentre audit study.Crossref | GoogleScholarGoogle Scholar | 31676659PubMed |
[21] Moon F, McDermott F. Social Work End-of-Life Care Interventions for Patients and their Families in Hospital. Aust Soc Work 2020;
| Social Work End-of-Life Care Interventions for Patients and their Families in Hospital.Crossref | GoogleScholarGoogle Scholar |
[22] Block BL, Jeon SY, Sudore RL, Matthay MA, Boscardin WJ, Smith AK. Patterns and Trends in Advance Care Planning Among Older Adults Who Received Intensive Care at the End of Life. JAMA Intern Med 2020; 180 786–9.
| Patterns and Trends in Advance Care Planning Among Older Adults Who Received Intensive Care at the End of Life.Crossref | GoogleScholarGoogle Scholar | 32119031PubMed |
[23] Sudore RL, Fried TR. Redefining the “planning” in advance care planning: preparing for end-of-life decision making. Ann Intern Med 2010; 153 256–61.
| Redefining the “planning” in advance care planning: preparing for end-of-life decision making.Crossref | GoogleScholarGoogle Scholar | 20713793PubMed |
[24] Mudge AM, Douglas C, Sansome X, Tresillian M, Murray S, Finnigan S, et al. Risk of 12-month mortality among hospital inpatients using the surprise question and SPICT criteria: A prospective study. BMJ Supportive & Palliative care 2018; 8 213–20.
| Risk of 12-month mortality among hospital inpatients using the surprise question and SPICT criteria: A prospective study.Crossref | GoogleScholarGoogle Scholar |
