Acute-Care Hospital Use Patterns Near End-of-Life for Cancer Patients Who Die in Hospital in Canada

Abstract

Background: Acute-care hospitals have a role in managing the needs of people with cancer when they are at the end-of-life; however, overutilization of hospital care at the end-of-life results in poorer quality of life and can worsen the patient's experience. Early integration of comprehensive palliative care can greatly reduce unplanned visits to the emergency department, reduce avoidable admissions to hospital, shorten hospital stays, and increase the number of home deaths as well as improve the quality of life of patients with advanced cancer. Aim: To describe the current landscape of acute-care hospital utilization near the end-of-life across Canada and indirectly examine access to palliative care in cancer patients who die in hospital. Methods: Data were obtained from the Canadian Institute for Health Information. The analysis was restricted to adults aged 18+ who died in an acute care hospital in 2014/15 and 2015/16 for nine provinces and three territories. The Discharge Abstract Database was used to extract acute-care cancer death abstracts. Data on intensive care unit (ICU) admissions includes only facilities that report ICU data. Results: Acute care utilization at end-of-life remains commonplace. In Canada (excluding Québec), 43% (48,987) of deaths from cancer occurred in acute-care hospitals, with 70% admitted through the emergency department (ED). In the last six months of life, cancer patients dying in hospital had a median cumulative length of stay ranging from 17 to 25 days, depending on the province. Between 18.1% and 32.8% of patients experienced two or more admissions to the hospital in the last month of life. The proportion of cancer patients admitted to the ICU in the last 14 days of life ranged from 6.4% to 15.1%. Patient demographics (age, sex, place of residence) and clinical factors (cancer type) were often predictors of hospital utilization at end-of-life and likely point to inequities in access to palliative and end-of-life care. Conclusion: Despite previous patient surveys indicating that patients would prefer to receive care and spend their finals days at home or in a hospice, there appears to be overuse of and overreliance on acute care hospital services near the end-of-life in Canada. The high rates of hospital deaths and admissions through the ED at the end-of-life for cancer patients may signal a lack of planning for impeding death and inadequate availability of or access to community- and home-based palliative and end-of-life care services. Acute care hospitals may have a role in managing the health care needs of people affected by cancer; however, end-of-life care should be an option in other settings that align with patient preferences. Standards or practice guidelines to identify, assess and refer patients to palliative care services earlier in their cancer journey should be developed and implemented to ensure optimal quality of life.