What does it take to improve care review activities in hospital for older people nearing end of life?

An article written by Christine Brown

Jean, 78, presents to the Emergency Department with a urinary tract infection and is admitted to hospital for antibiotics. Jean lives alone, however has lots of support from her daughter and home help services for personal care and meals. When getting up to the toilet in hospital, Jean slips and hits her head. The medical emergency team is called, and Jean is found to have a small intracerebral haemorrhage and is sent to the Intensive Care Unit, where Neurosurgery are discussing whether to operate or not. Intensive care and surgery may not be the best option for Jean, as these may not benefit the remainder of Jean’s life or be in line with what Jean wants. This could be an example of non-beneficial care.

Hospitalisations for older people are becoming more common, with end-of-life care involving more interventions and often care that is non-beneficial to the patient. Addressing non-beneficial care is challenging, especially in large, complex hospitals and, despite many attempts, there have been few successful models of care focussed on providing appropriate care to older people.

Our study, the Intervention for Appropriate Care and Treatment (InterACT) was an NHMRC-funded project partnering with three large tertiary hospitals in South-East Queensland. The aim was to improve appropriate care and treatment decisions for older people at the end of life. We used two tools to identify older patients nearing the end of life, at risk of receiving non-beneficial care, then notified their doctors. The intent was that the doctors would initiate a conversation about the care that was appropriate and in line with the patient’s wishes and update the patient’s advance care planning documents accordingly, or complete a palliative care referral.

Screening of patients 75 years and older occurred twice a week for the duration of the trial. Over 7,000 patients were screened with nearly 60% identified as nearing the end of life and potentially at risk of receiving non-beneficial care.

Our study team has just published the outcomes that measured doctors’ response to the at-risk notification. These were care review activities and palliative care referrals. We had hoped to see an increase in these activities or an improvement in the time to review and document care directive measures. However, we did not find any increase in completion or reduction in time to completion of these care review activities. While some pandemic related challenges potentially affected our results, the failure to change these important aspects of care in this older population has highlighted some of the complexity involved in changing clinicians’ behaviour and attitudes toward end-of-life care and death and dying.

Other study limitations that may have influenced our outcomes can provide insights to improve future efforts. For example, our notification sent to doctors to notify them that their patient may be nearing the end of their life and at-risk of non-beneficial treatment was sent late in the day following screening. This timing meant that treatment decisions may have already been made. A real-time, or earlier notification could have been more effectively responded to, however this would require major changes to some current hospital notification systems.

Senior registered nurses screened patients to calculate risk status, however this was performed separately from the patient’s clinical care team. Integrating such screening into the role of the multi-disciplinary team caring for the patient may have had greater acceptance and response from doctors.

Our notification was also passive, designed to increase awareness, not undermine doctor autonomy or be prescriptive. This made it easy to ignore. A notification that required a documented response or action from doctors, may have been more effective.

With an ageing population and increasing demand for hospital-based care, failure to review care preferences with frail older people, including referral for palliative care when appropriate, is a reason for concern. Increasing awareness of care directives and care options, including palliative care, near the end of life and providing evidence through studies like InterACT to support health professional decision-making will be essential.

Read more:

The Australian Centre for Health Services Innovation (AusHSI)

The InterACT (Intervention for Appropriate Care & Treatment) study

The initial outcomes of InterACT in BMC geriatrics: ‘Impact of a prospective feedback loop on care review activities in older patients at the end of life. A stepped-wedge randomised trial’
 

Christine Brown
Research Project Coordinator
Australian Centre for Health Services Innovation (AusHSI)
School of Public Health and Social Work
Centre of Healthcare Transformation, Faculty of Health
Queensland University of Technology