Care to the end: a retrospective observational study of aged care facility residents transferred to hospital in the last day of life

Abstract

Background While transfer of aged care facility (ACF) residents to an acute hospital is sometimes necessary, for those at end of life this can cause fragmented care and disruption. Aim To explore the characteristics of ACF residents transferred to hospital in the last 24 h of life and factors that might influence this decision, including access to medical review, advance care planning (ACP) and pre‐emptive symptom management prescribing, an area not previously researched. Methods A retrospective observational audit of ACF residents transferred to a metropolitan hospital between 2012 and 2017 who died within 24 h of transfer. Results A total of 149 patients met the criteria. The median age was 87 years, and 63 (42%) were male. Eighty‐three (56%) were transferred ‘out‐of‐hours’, the majority (71%) having no medical review in the 24 h prior, and 43 (29%) died within 4 h of arrival. The most common reasons for transfer were dyspnoea (46%) and altered conscious state (32%), and the most common cause of death was pneumonia (37%). Some form of ACP documentation was available in 48%. Of the 86 (58%) patients who required injectable opioid for symptom management in hospital, only 7 (8%) had this pre‐emptively prescribed on their ACF medication chart. Conclusions Appropriate decision‐making around hospital transfers and end‐of‐life care for ACF residents may be influenced by access to professionals able to diagnose dying and access to appropriate symptom management medications. ACP is important, but often requires the aforementioned to be enacted. Further research is needed to better inform how we can identify and meet the end‐of‐life care needs of this cohort.

Quality of information transferred to palliative care

“…Palliative care guidelines recommended that patient's preferences, medical decisions and treatment limitations should be included in the end‐of‐life care documents (Olsson et al, 2021). Earlier studies have shown, however, that ACP records were rare at the end‐of‐life stage (Brownstein et al, 2021; Izumi et al, 2020; Kuusisto et al, 2022; Sjöberg et al, 2021) and there was a lack of prognostication documentation, such as updating the patient's prognosis in the care plans (Gott et al, 2011).…”

“…In the study of Gott et al (2011), patients and family members were unaware of the care plan. In the case of palliative patients, it is especially important to take into account patients' own up‐to‐date wishes (Brownstein et al, 2021; Kuusisto et al, 2022).…”

“…From the perspective of informativeness of information, documents sent between palliative care settings have been nonspecific and general, not always providing important information such as patients' end‐of‐life (Brownstein et al, 2021; Kuusisto et al, 2022; Sjöberg et al, 2021) or spiritual care wishes (Baetz‐Dougan et al, 2021). In transitions from hospital to hospice, lack of information on end‐of‐life and everyday care and medication was found (Izumi et al, 2020).…”

“…From the viewpoint of usability of information, document analyses have provided information on the quality of the documentation in palliative care (e.g. Brownstein et al 2021; Sjöberg et al, 2021; Song et al, 2015). Care plans and discharge reports have been inconsistent, depending on the palliative care unit and the professional (Mertens et al, 2021).…”

Why is it so hard to organise healthcare for older people in residential aged care facilities in Australia?

“…In this issue of the Internal Medicine Journal , Brownstein and colleagues examine some of the characteristics of healthcare provision at the interface of RACF and State‐run healthcare facilities 8 . They examined the course of 149 older frail people who were transferred to hospitals and died there within 24 h. In general, most of the residents presented with an acute and distressing change in their condition and the transfer to acute care was mostly in keeping with their advance care plans, if available.…”