Hospitalisation in the last month of life and in-hospital death of nursing home residents: a cross-sectional analysis of six European countries

Abstract

ObjectivesTo examine the rate and characteristics of hospitalisation in the last month of life and place of death among nursing home residents and to identify related care processes, facility factors and residents’ characteristics.SettingA cross-sectional study (2015) of deceased residents in 322 nursing homes in six European countries.ParticipantsThe nursing home manager (N=1634), physician (N=1132) and primary nurse (N=1384) completed questionnaires.Outcome measuresHospitalisation and place of death were analysed using generalised linear and logistic mixed models. Multivariate analyses were conducted to determine associated factors.ResultsTwelve to 26% of residents were hospitalised in the last month of life, up to 19% died in-hospital (p<0.001). Belgian residents were more likely to be hospitalised than those in Italy, the Netherlands and Poland. For those dying in-hospital, the main reason for admission was acute change in health status. Residents with a better functional status were more likely to be hospitalised or to die in-hospital. The likelihood of hospitalisation and in-hospital death increased if no conversation on preferred care with a relative was held. Not having an advance directive regarding hospitalisations increased the likelihood of hospitalisation.ConclusionsAlthough participating countries vary in hospitalisation and in-hospital death rates, between 12% (Italy) and 26% (Belgium) of nursing home residents were hospitalised in the last month of life. Close monitoring of acute changes in health status and adequate equipment seem critical to avoiding unnecessary hospitalisations. Strategies to increase discussion of preferences need to be developed. Our findings can be used by policy-makers at governmental and nursing home level.

National trends in the proportion of in-hospital deaths by cause of death among older adults with long-term care: a nationwide observational study in Japan from 2007 to 2017

“…Finally, by care need levels, we observed a steeper decreasing trend in in-hospital deaths among those with higher care need levels. This is consistent with findings of previous studies which indicated that a higher care need level or a poorer functional status was negatively associated with in-hospital deaths [ 12 , 20 ]. As the level of care needs deteriorated, the five-year survival rates showed a decline, from 72.3% for people with the least disability support level, to 22.2% for those with care need level 5 (most disabled) [ 21 ].…”

A Situation-Specific Theory of End-of-Life Communication in Nursing Homes

“…Although knowledge of users' care preferences is essential for goal-concordant care, which is a quality indicator of palliative care, the preferences of our residents were poorly known, and their FCs' preferences were often explored too late. These findings confirm the data of a large cross-sectional analysis involving 322 NHs in six European countries, which found that only one-third of residents in Belgium had a 'do not transfer to hospital' advance directive, while barely anyone had similar documentation in Italy [14]. Similarly, our findings are close to those of previous focus group interviews with the FCs of Norwegian NH residents who often did not know their relative's wishes when decisions had to be made and experienced decision-making burden [48].…”

“…Similarly, our findings are close to those of previous focus group interviews with the FCs of Norwegian NH residents who often did not know their relative's wishes when decisions had to be made and experienced decision-making burden [48]. Poor knowledge of the residents' preferences is recognized to increase the likelihood of intensive care [14]. Instead, when the preferences were known, they were generally comfort-oriented and directed the HCPs towards palliative-oriented care [49].…”

“…One in six Italian residents visit the emergency department in the last month of life and over 80% of them die in the hospital [4]. End-of-life conversations between the HCPs and a relative of the resident about the preferred medical treatments and the course of care in the last phase of life were found to limit life-sustaining treatments and hospitalization [11,14]. When the discussion occurred, the FCs generally preferred to avoid burdensome hospitalizations and leave their relative to die quietly in the NH [9].…”

“…Less than 40% of the FCs of NH residents with advanced dementia remembered any communication about the possible treatment options for their relative at the end of life [16], only one in five joined care plan meetings [17], and no discussion occurred in over one-third of cases [18]. Similarly, less than 60% of Italian FCs remembered conversations with the NH staff about the preferred care in the last month of their relative's life [14].…”