Moving From Place-to-Place for End-of-Life Care: A Mixed-Methods Investigation

Tuesday, 31 October 2017: 8:00 AM

Donna M. Wilson, PhD
Faculty of Nursing, Edmonton, AB, Canada
Stephen Birch, PhD
McMaster University, Hamilton, ON, Canada

As few deaths now are sudden and unexpected, most people approaching the end of life develop care needs (Thurston et al., 2011). These end-of-life (EoL) care needs typically change over time (Chochinov et al., 2016; Wodchis et al., 2016; Wilson, 2002). Increasing dependency on others for assistance with instrumental activities of daily living (such as banking, housework, and shopping) and then other activities of daily living (such as bathing and dressing) is common as terminal illnesses and other life-limiting conditions progress (Wilson, 2002). Moves from one care setting to another and moves within care settings may be required as care needs and circumstances change (Wilson et al., 2011; Wilson et al., 2012). However, many concerns over EoL care setting transitions exist; including low quality moves as mistakes and other mishaps can occur, frequent moves from one care setting to another are through to be common, and delayed or denied moves such as a transfer out of hospital for people who want to spend their last hours or days of life at home are likely. A mixed method study was undertaken in 2016 out of concern for effective and appropriate end-of-life care (EoL) setting transitions or moves from place to place in the last year of life. The qualitative study component purpose was to gain insights and advice from key informants (healthcare providers, healthcare managers, government representatives, lawyers, healthcare recipients, and their family/friends) on EoL care setting transition issues and solutions. Three themes emerged through in-depth interviewing of 39 key informants in the Canadian province of Ontario by telephone or in person and using constant-comparative grounded theory data analysis: (a) communication complexities and related solutions, (b) care planning and coordination gaps and related solutions, and (c) health system reform needs and related solutions. The quantitative study component purpose was to gain evidence about moves associated with hospitals in the last year of life. Complete individual-anonymous hospital data for Canada were analyzed using descriptive-comparative and logistic regression tests. This study found 49.1% of hospital decedents were only admitted once to hospital and another 46.1% were only admitted twice to hospital in the last year of life. Before dying in hospital, 3.6% had been living at a home while receiving publicly-funded home care services and another 67.0% had been living at home without this support. Most (79.0%) deaths in hospital followed an unplanned admission through the emergency room, as did most (78.7%) admissions over the last year of life. The hospital care provided during the last stay and over the last year of life was largely supportive nursing care, as <1% of deaths occurring during an intervention. Among other conclusions, these findings reveal the need for more palliative home care services to better support dying people in place to prevent the health and family caregiver crises that lead to hospital-based EOL care and death in hospital. Other actions were identified to eliminate the possibility of low quality transitions, frequent or repeated moves from one care setting to another, and delayed or denied necessary care setting desirable transitions.