Many people approaching death express the wish to remain at home. However, hospitalisation and emergency department attendance is common and rises exponentially in the last months of life.
Reducing unplanned hospitalisations could improve care for patients, as well as the efficiency of the system, but is an ongoing challenge that the NHS is struggling to meet.
Our recent Knowledge Exchange Seminar brought together academics, researchers, commissioners and clinicians to shine a spotlight on the issue of unplanned hospital admissions at the end of life and discuss potential solutions.
By focusing on one of the challenges facing palliative care service providers across the UK, this event was conceived as a forum for discussion about causes, challenges and possible solutions, as well as for sharing insights about effective models of care which are currently in place.
In a series of short talks, we heard about the factors that contribute to emergency department attendance for people approaching death.
Dr Katherine Sleeman (NIHR Clinician Scientist and Honorary Consultant in Palliative Care) presented data from a study of 5,000 people with dementia which found that ED attendance was more common among people who lived in deprived areas, and less likely for care home residents.
Most worrying, ED attendance has increased over time for people dying with dementia. This suggests that policy makers need to turn their attention towards other indicators of quality of care in addition to the place of death.
Anna Bone (Cicely Saunders International PhD Training Fellow) described findings from a new Systematic Review showing that palliative care is associated with fewer ED attendances among older people.
This reflects work published by Dr Lesley Henson (Registrar in Palliative Medicine,) which found receiving palliative care leads to fewer ED attendances among people with cancer.
Lesley presented some of her recent work which showed that patterns of health seeking behaviour, patient anxiety and feelings of security are also a major driver of ED attendance.
If a relationship between the palliative care team and the patient has already been developed, they are less likely to default to a more familiar, but less equipped, service during an emergency.
When should this relationship with palliative care teams be established? There is increasing evidence that palliative care can make the biggest difference for patients when it is provided early in the course of their disease.
Charles Normand (Professor of the Economics of Palliative Care and Rehabilitation) presented data showing that timely palliative care is effective, especially for people who are older, and for those with cancer or multi-morbidities.
The evidence implies that active management of cases and supporting better choices works to reduce hospital admissions, length of stay and overall costs of care.
So how can the gap between palliative care provision, with its clear benefits to costs, quality and care, and unplanned, sometimes unwanted, hospital admissions at the end of life be breached?
Dr Nick Gough (Consultant in Palliative Medicine) described some of the local initiatives that are making a difference.
For example, clinical services such as Bromley Care Coordination, Pal@Home and Coordinate My Care, as well as services such as Macmillan Specialist Care at Home and Marie Curie’s Nursing Service, can reduce hospital admissions by enabling early integration between hospitals and community palliative care teams.
If people, as well as the demographic or symptomatic triggers that may result in unplanned hospitalisation, are familiar to community palliative care teams, it is possible to lower the probability of patients and carers resorting to emergency departments during periods of anxiety or crisis.
Better clinical decision making can have a dramatic effect, both from a cost and care perspective. The voluntary sector is also important; the End of Life Care Coalition, six leading charities campaigning together to call for better quality care and support for those approaching the end of their lives, is lobbying the government to invest in community palliative care services.
Perhaps an effective strategy to reduce unplanned hospital admissions at the end of life, and shift the national and political focus to successful community based services rather than inpatient beds, can be summarised by the three C’s: Communication, Collaboration and Coordination.
We know through the work done by local hospices, clinical teams and researchers that there are clear and achievable strategies for preventing unplanned hospital admissions towards the end of life. We must continue working together to ensure the necessary funding and resources are provided.
The Knowledge Exchange Seminar demonstrated that there is an existing network of policy and advocacy experts, researchers, clinicians, and commissioners with a collective desire to tackle this problem. If we do not, emergency hospital attendance near the end of life will continue to rise.
The next Knowledge Exchange Seminar will be on the subject of palliative care rehabilitation and will be taking place at the Cicely Saunders Institute in early 2018. Please sign up to our events mailing list by following this link for details of future seminars.
To view our policy briefs detailing relevant research in this area, check out our website, and to view a briefing document created by the End of Life Care Coalition about the current bed crisis please click on the following link.