Policy Brief: Blog post - What influences older people's transition to hospital at the end of life?

POLICY BRIEF – OCTOBER 2016

What influences older people’s transition to hospital at the end of life?

New research carried out at the Cicely Saunders Institute at King’s College London and Sussex Community NHS Foundation Trust published by the Journal of the American Geriatrics Society shows:   

There is a reliance on hospital care at the end of life for older people, despite the majority preferring to die in their usual place of care.

Older people who experience severe breathlessness in the last week of life, or have a primary diagnosis of respiratory disease are more likely to transition to hospital as their place of death.

Older people who have discussed end of life care preferences, or who identify a key health professional who they can rely on, are less likely to transition to hospital

Summary of policy recommendations:   

Invest in evidence-based community breathlessness services for older people to reduce end of life transition to hospital.

Assign a key healthcare professional, skilled in coordinating care, facilitating complex discussions and in future care planning with older people and their family.

Increase training for community health care professionals in communication of difficult conversations and anticipatory care planning for older people with uncertain illness trajectories.

Please reference the study as: Bone AE, Gao W, Gomes B, Sleeman KE, Maddocks M, Wright J, Yi D, Higginson IJ, Evans CJ. Factors Associated with Transition from Community Settings to Hospital as Place of Death for Adults Aged 75 Years or Older: A Population-Based Mortality Follow-back Survey. Journal of the American Geriatrics Society 2016 doi. 10.1111/jgs.14442

Contact us:

anna.bone@kcl.ac.uk

@AnnaEBone

What we know The number of people aged 75 and older is growing and this group currently account for two thirds of deaths(1). Most older people die in hospital(2), despite most preferring to die in their usual place of care (3). A major cost driver in the provision of end of life care is hospital inpatient care(4). Reducing the proportion of older people, particularly those with noncancer conditions, transitioning to and dying in hospital is critical to align end of life care to older peoples’ preferences and to contain costs.

What we did A survey (QUALYCARE survey) was sent to bereaved relatives of people aged 75 and over, identified from death registrations. The survey included questions about the older person’s experiences in the last months and weeks of life, including symptoms and service use.

What we found 443 bereaved relatives responded (response rate of 50%).

The older people who died were mostly female (58%) and died from noncancer causes (76%) at average age of 87 years. A third of our sample transitioned to hospital at the end of life and died there, even though only 2% wished to die in hospital.

End of life transition to hospital as place of death was approximately twice as likely for older people with:  respiratory disease as cause of death compared to cancer  severe breathlessness in their last week of life End of life transition to hospital was less likely for older people who:  had discussed end of life preferences with a healthcare professional  identified a key healthcare professional upon which they could rely

References 1.

National End of Life Care Intelligence Network. Deaths in Older Adults in England.

Bristol: South West Public Health Observatory, 2010.

2.

National End of Life Care Intelligence Network. Variations in Place of Death in England. Inequalities or appropriate consequences of age, gender and cause of death? Bristol: National End of Life Care Intelligence Network, 2010.

3.

Gomes B, Calanzani N, Gysels M, Hall S, Higginson IJ. Heterogeneity and changes in preferences for dying at home: a systematic review. BMC Palliat Care. 2013;12:7.

4.

Georghiou T, Bardsley M. Exploring the cost of care at the end of life Research report.

Nuffield Trust: Nuffield Trust, 2014.

BGS BLOG – SEPTEMBER 2016 Palliative care for frail older people: what, when, how?

British Geriatrics Society Blog: https://britishgeriatricssociety.wordpress.co m/2016/09/05/palliative-care-for-frail-older-people-what-when-and-how/ Anna Bone is a Cicely Saunders International PhD Training Fellow in the Department of Palliative Care, Policy, and Rehabilitation at King’s College London. In this blog Anna discusses her recent Age and Ageing paper on developing a model of palliative care for frail older people. This is part of the OPTCare Elderly Study, a joint project between King’s College London and Sussex Community NHS Foundation Trust, led by Dr Catherine Evans. @AnnaBone In the minds of many, palliative care is synonymous with cancer and end of life.

This is unsurprising, as it is within this context that palliative care has developed.

The goal of palliative care is to relieve suffering and improve the quality of life of people with life threatening illness. It is increasingly believed that palliative care has much to offer to other patient groups whose health is deteriorating, and not just at the end of their life.

People are now living longer, with multiple chronic illnesses and frailty, and dying at older ages. We need to consider the needs of this growing group. Specialist palliative care services for frail older people with deteriorating health may provide an extra layer of support to help them and their families live as well as possible.

However, applying the standard model of palliative care to frail older people is problematic. For older people with non-cancer illnesses the end of life phase is difficult to predict and so, unlike for cancer, we cannot rely on a diagnosis to trigger a referral to palliative care. When, therefore, is the best time for a referral to palliative care? What are its possible benefits? How can palliative care be integrated into existing health services to support older people and their carers?

We aimed to develop a model of palliative care for frail older people living at home or in a care home. Informed by previous work, we proposed a short-term

intermittent service delivered by a specialist palliative care team working in an integrated way with GPs and community nurses. To shape the elements of this model of care we sought the views of key stakeholders. Using a combination of focus groups, consultations and a follow-up consensus survey we engaged a broad range of people including older people, carers, health professionals and researchers. We asked for their views on the possible benefits, timing of referral, and ways to integrate this model into existing services.

We found that stakeholders considered specialist palliative care acceptable for older people with non-cancer conditions. Stakeholders agreed that it could benefit patients and families in a number of ways, including management of complex symptoms, planning future care, and providing reassurance to carers. It was suggested that referrals should start early when the person is vulnerable to decline to establish a relationship with the team, but also when the person’s health is deteriorating. Timing of referral must balance the possible benefits of early intervention with the reality of finite specialist resource. An important feature of integrated working was a skilled key worker identified from the team with most involvement with the older person and family, to coordinate care. A single point of access to palliative care services for older people and carers and also for referring health services was considered important.

Key stakeholders agree that a model of short-term integrated palliative and supportive care for frail older people with non-cancer conditions has potential benefits for older people and carers within community settings, but differ in opinion on the optimal timing and indications for this service. The model now needs testing to firstly assess the feasibility of delivering it in the existing health system, and secondly to evaluate its effectiveness in improving outcomes for older people and carers. We need robust evidence to inform a much needed shift in provision of care for frail older people.

Please reference the study as: Bone AE, Morgan M, Maddocks M, Sleeman KE, Wright J, Taherzadeh S, Ellis-Smith C, Higginson IJ, and Evans CJ. Developing a model of short-term integrated palliative and supportive care for frail older people in community settings: perspectives of older people, carers and other key stakeholders. Age and Ageing 2016 doi. 10.1093/ageing/afw124

Contact us:

anna.bone@kcl.ac.uk

@AnnaEBone