What Continues To Be The Number One Cause Of Hospital Admissions And Service Member Deaths?

Research

Home care and end-of-life hospital admissions: a retrospective interview written report in English master and secondary intendance

British Journal of General Do 2019; 69 (685): e561-e569. DOI: https://doi.org/10.3399/bjgp19X704561

Abstract

Groundwork Enabling death at home remains an important priority in cease-of-life care policy. Nevertheless, hospital continues to be a more prevalent place of death than domicile in the United kingdom, with admissions at the stop-of-life oft negatively labelled. Admissions are ofttimes attributed to an unsuitable home environment, associated with inadequate family care provision and insufficient professional care commitment.

Aim To understand problems in professional person and lay intendance provision that discourage decease at habitation and lead to hospital admissions at the end of life.

Blueprint and setting A qualitative study of admission to a large English hospital of patients close to the end of their life.

Method Retrospective in-depth semi-structured interviews with healthcare professionals (n = xxx) and next-of-kin (northward = 3) involved in an admission. Interviews addressed why older patients (>65 years) close to the end of life are admitted to hospital. Interviews were transcribed and analysed thematically.

Results Abode-based end-of-life care appeared precarious. Hospital access was considered by healthcare staff when there was insufficient nursing provision, or where family support, which was ofttimes extensive but under supported, was challenged. In these circumstances, dwelling house was not recognised to exist a suitable place of care or death, justifying seeking intendance provision elsewhere.

Conclusion Challenges in dwelling house intendance provision led to infirmary admissions. Home end-of-life care depended on substantial input from family unit and professional person carers, both of which were under-resourced. Where either intendance was insufficient to see the needs of patients, home was no longer deemed to be desirable by healthcare staff and infirmary care was sought.

end of life care
domicile palliative care
hospitalisation
chief care

INTRODUCTION

Supporting patients at the end of life to die at domicile and preventing their access to hospital is a significant task for GPs and community nursing teams. Place of decease is a key policy marker of stop-of-life care success in both the United kingdom¹ ^, ² and internationally,³ though recent literature challenges the priority given to location in end-of-life intendance.⁴ Research has demonstrated that patient preferences for identify of death are complex,⁵ that notions of home are malleable and include other settings which may feel 'home like',^half-dozen ^– ⁸ and that the hospital is important in end-of-life care provision.^ix ^– ¹¹ However, death at dwelling house remains a policy concern. Reflecting this, stop-of-life infirmary admissions are frequently defined every bit 'avoidable', 'preventable' or 'inappropriate',^v ^, ¹² ^, ¹³ especially compared to community-based care.

It is not articulate why patients at the end of their lives are admitted to, and die, in infirmary¹⁴ ^, ¹⁵ though many reasons have been suggested. It seems likely that the provision of end-of-life intendance in the community from both professional and lay carers is an important factor, recognised in both the limited literature exploring stop-of-life hospital admissions¹¹ ^, ¹⁴ ^, ^sixteen ^– ¹⁸ and in related research on community-based terminate-of-life intendance. For example, the availability of professional abode-based stop-of-life care is associated with the likelihood of patients with cancer dying at home rather than in infirmary.^nineteen Notably nevertheless, the human relationship between professional cease-of-life care in the community and hospital admissions has yet to be explored robustly.²⁰ The challenge for family carers in providing intendance at home and the association between problems in this care and end-of-life hospital admissions is frequently identified in policy, and recognised by GPs.¹¹ ^, ¹⁸ ^, ²¹ Bug are ofttimes attributed to family members beingness 'panicked' by changes to a patient'southward symptoms in the dying phase,²² or because family members felt unable to cope with incessant care provision, and their ain distress in watching a relative die.²³ ^, ²⁴ Similar to professional intendance however, the circumstances that lead families to seek hospital intendance have not been considered in detail.

Hospital continues to be a more prevalent place of death than abode in England.²⁵ Understanding why these admissions occur will help GPs and customs nurses to support patients in their finish-of-life care, whether at home or elsewhere. This commodity explores empirically the relationship between the care requirements of dwelling house-based cease-of-life provision and infirmary admissions using healthcare staff, and family carer perspectives of why patients previously cared for in the community are admitted to, and die, in the acute hospital setting.

METHOD

Design and participants

The data presented are from a larger study exploring end-of-life hospital admissions.²⁶ ^, ²⁷ The focus of this article is on why patients shut to the end of life who are cared for at home practice non die there but are instead admitted to hospital. Interviews (n = 33) were conducted with healthcare staff and side by side of kin involved in the admission to a large English hospital of a patient who afterward died there within 3 days of admission (a 'case-patient').

How this fits in

It is known that dying at habitation is an end-of-life care policy priority, with reducing end-of-life hospital admissions targeted in finish-of-life intendance improvement measures. Many people currently die in hospital. Agreement why deaths occur in hospital rather than at dwelling is underexplored but is often assumed to be associated with issues in care provision. This written report shows that dwelling house-based end-of-life care can be precarious and an absence of nursing intendance or family unit support may facilitate hospital access; deaths in hospitals can occur where home is not considered a suitable place of care and death, and offers benefits to patients, family carers, and staff.

Interviewees included community healthcare staff (GPs, a customs specialist nurse, and ambulance staff) hospital staff, and the example-patients' next of kin. This report centres on the accounts of interviewees involved in the care of a example-patient who had been admitted to hospital from home. Additionally, the accounts of interviewees involved in the admission of instance-patients from other community settings have been included as they usefully reflected on other patients admitted from domicile. These quotations are indicated by (a).

Information collection

All interviews were semi-structured, in depth, and were conducted between 2012 and 2013. Healthcare staff interviews addressed the participants' involvement in the case-patients' access, their views on the reasons for the admission, and finish-of-life admissions more often than not. These interviews were conducted inside a month of the interviewee's involvement in the instance-patient's care, lasted approximately 30 minutes, and occurred at the participants' place of work or nearby. Next-of-kin interviews considered the example-patient's care in the last months before death, including their involvement in care provision. These interviews took place 4–7 months afterward the instance-patient's expiry, lasted approximately one hour, and occurred at their home.

Analysis

Interviews with staff and next of kin provided highly detailed accounts of the circumstances that led to the hospital admission of case-patients and for staff interviewees, like patients they had cared for previously. Interviews were audiorecorded and professionally transcribed verbatim. The transcripts were analysed thematically to empathise the reasons that facilitated admission to hospital. Transcripts were coded by hand and then using the software NVivo (version x), with sections of the text tagged using both a priori and emergent information categories. Codes were then sorted and charted to assess both the breadth and depth of data. Information were synthesised to sympathize both the private instance-patients' admission, and the admissions collectively, with synthesis aided by reference to both end-of-life care and sociological literature. Extended details nearly the report methodology²⁶ ^, ²⁷ and related findings^ten can exist found elsewhere.

Quotations in the text are followed by the participants' role, report number, and interview page number. Identifying details accept been omitted to protect the anonymity of the interviewees and the deceased case-patients.

RESULTS

Appendix 1 shows the characteristics of the case-patients and Table 1 provides a summary of all participant roles. Hospital admissions were instigated past patients, family carers, GPs, and ambulance staff, often working in collaboration. Dying at dwelling house was desirable for patients according to healthcare staff and next of kin. Notwithstanding, healthcare staff did not always feel that patients' place of care was necessarily a suitable environment to either receive end-of-life intendance or die. Important factors in this evaluation were the availability of professional person and family care provision, and bug in either were pertinent to the determination to facilitate patients to hospital.

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Table 1.

Report participant roles, Northward = 33

Facilitating death at dwelling house was desirable

Dying at home was advocated by healthcare staff from all occupational roles. The desirability of death at habitation was conceptualised using ideas of familiarity, comfort, and the presence of loved ones, as well as the fulfilment of perceived patient preferences about place of expiry. Even where staff articulated practical difficulties in supporting a patient's death to occur at home, it was typical to concurrently recognise the desirability of patients dying at home: 'Virtually people want to die at habitation right? Surrounded by, you know, their friends, family and everything else.' (GP, four, 5) 'I think people should be able to die at dwelling house. Almost elderly and concluding patients practise not want to die outside their habitation but I recollect there is a general fear and lack of conviction by relatives etc, and I don't retrieve necessarily at that place would exist resource to manage that. So I think if the resources were in place to assistance back up the family then I do think that would be a good choice.' (GP, 10, nine)

Importance of formal intendance provision

Despite the aspiration for dwelling house-based end-of-life care, the community was non ever a viable or a desirable place of treat patients co-ordinate to interviewees. A significant cistron in this negative assessment of domicile was the absence of sufficient domiciliary care to accost a patient's needs. For patients accounted to be in that state of affairs, the utility of infirmary as a care provider was recognised by interviewees. Community staff described facilitating admissions to ensure patients received appropriate care: 'I remember the affair that we struggle with in the community is the resources to manage a death, sometimes it tin exist quite difficult for the district nurses with short notice depending on what else is on their caseload. Things like hospice, information technology depends on bed availability and and so it can exist quite frustrating, you know what you want to do or yous know how you lot want to manage information technology and sometimes people do take, y'all know difficult symptoms that we have to refer to hospice, if they don't have a bed and so sometimes it becomes difficult considering what do you practise? You're kind of caught betwixt a rock and a hard place really.' (GP, 15, 7)

Availability and timeliness of nursing provision

Customs nursing was well regarded past interviewees, particularly GPs. However, the limited availability of this care, particularly at short notice, was a significant problem. Staff described the claiming of maintaining patients at dwelling where the patients' care needs had escalated and boosted intendance was required sooner than intendance could be organised or was available. This was peculiarly applicative when a patient's condition had deteriorated rapidly or they were experiencing unanticipated symptoms. In these circumstances, infirmary intendance was sought: 'I wondered about perhaps keeping [the example-patient] at domicile with some district nurse support [...], unfortunately when I rang the district nurses they were very busy with [a] cancer patient and there wasn't a district nurse bachelor to come and assistance, so I had a conversation to the patient and [their spouse] and said, "what do y'all feel near being admitted?", and [the case-patient] wasn't that peachy to get up [to the infirmary], [their spouse] was quite keen for [them] to be looked after, [the spouse] was struggling.' (GP, 1, 2)

Community care was supplemented by family care

Problems in domiciliary finish-of-life care were also associated with family care provision, specially for patients resident at habitation. These patients often received personal care from spouses and adult children who supported their day-to-day living and healthcare needs. Where patients required more intendance than family members could provide, hospital admission was oft sought both by community staff and family members. Staff descriptions of these admissions typically involved negative portrayals of family members as being unwilling to provide terminal care, or more than charitably, equally being unprepared for the patient's death: 'I felt that the main problem was that the family weren't able to manage [the case-patient's] condition at domicile. I felt it would have been more advisable for [them] to have stayed at dwelling house but to take had obviously a lot, the nursing support if it had been available at domicile. [...] [but arranging additional care] wouldn't have necessarily changed anything because I don't, every bit far every bit I sympathize I don't recall in that location is that service bachelor where, y'all know, they would have somebody at abode nursing [them] and I but call up the family did not desire to nurse [them] to [their] death.' (Locum GP, 10, 5)

To sympathise why infirmary admissions may have been sought considering family members did non 'want' to continue to provide care it is useful to explore the family unit caring role. In the adjacent section, the demands on family unit carers' time, physicality, and feel are examined in relation to stop-of-life hospital admissions.

Experience to provide care

Family care provision at domicile could be compromised by the limited feel some family unit carers had of death and terminate-of-life care. For healthcare staff, naïve family carer expectations of the dying procedure were idea to hinder the likelihood of decease at dwelling house, every bit unfamiliar but typical finish-of-life care symptoms were reported to lead family unit carers to seek reassurance and intendance. Consequently, hospital admissions were thought to occur, either directly, as carers sought help from ambulance or out-of-hours services, or indirectly, if they requested additional aid that could realistically but be fulfilled in hospital: ' [...] And then it does seem that nosotros had talked about finish-of-life care but we probably didn't talk nearly preferred identify of care or maybe the family weren't prepared well enough for the final stages of [the example-patient'south] dying to manage with the support that we have.' (Ward medico, 14, one)

For family carers, inexperience was often expressed as business organisation almost the quality of their care provision, particularly compared to professional person carers. While this was not cited past family unit carers as a reason for admission — family unit carers who had facilitated case-patient admissions said they did so to access necessary medical support — they acknowledged the hospital to exist a place for professional person attention and a place where their relative would receive appropriate care: 'I was pleased [they] died in infirmary, because I always used to think "If you lot're ill, infirmary is the best place to be, because there yous tin take all the correct attending and everything that you want". At domicile, I mean, I don't know all that much about the medical service really, [...] I couldn't be a nurse, I would do what I could for [my spouse] just I don't know, y'all know, how well I would be doing information technology compared with a qualified nurse.' (Next of kin, 6, 13)

All-encompassing intendance

Supporting a dying relative often involved significant investment of time and resource past family carers. The consequences of this to the family unit carer was infrequently recognised by the family carer themselves, who typically dismissed their ain care provision as just function of their family unit role. Yet, providing care could have negative effects on the family carer'southward wellbeing, and healthcare staff described how a patient's care demand could exceed the family carer's capacity to provide care. In these instances, boosted care was often recognised to be necessary, whether sought from infirmary providers or elsewhere: 'I don't retrieve [the family] understood how much work information technology would be [caring for the instance-patient]. [...] They merely looked drained. I think, peradventure, I don't know why they never had any intendance. [...] They were doing [the care] all themselves. The daughter was living there and she was doing, getting upwardly in the night and [...] I remember [the example-patient's] partner [likewise]. [...] [A]nd the daughter just looked so, so tired. [...] And I, I hateful, perchance with a bit more ... they was saying to me about [the instance-patient] going into, maybe a home. They understood that [the case-patient] had probably got to that point because [the example-patient] was getting very hard for them to manage. [...] Considering [the instance-patient] didn't sleep much at night, the family was all up all nighttime and then they were finding it difficult during the day.' (Specialist nurse, 11, 3–4).

Concrete care

The family unit caring role was recognised by professional staff to be physically demanding. This could make family unit care provision difficult, particularly if a carer was a frail older individual and the patients' health had deteriorated such that they required substantial hands-on back up. In these instances, both customs and infirmary interviewees recognised that the continued maintenance of patients at dwelling was impractical without additional support. Where this was not thought possible, staff recognised the helpfulness of care elsewhere, including hospital: 'And there is, you know, this applied side of nursing people, you know, mobilising, fifty-fifty moving them safely when they can no longer movement themselves. [...] I went to visit an elderly couple and found both of them on the flooring where they had been, God assist them, all that night, because she had been trying to go him out of bed to the loo and he had fallen on top of her, and there they had lain all night long.' (aGP, 28, 10) '[...] the factors that contributed [to the case-patient's admission] were an inability to at that time ensure [they were] comfortable at home, uncertainty about how best to meet [their] needs, lack of nursing support at home because [they] were there with [only their partner]. It's a lilliputian fleck difficult to see how annihilation else could take happened unless a nursing team could take been on site or a doc and then mayhap with a nurse could have been on site to support [their] last hours. Function of that is my ignorance, I don't think I know enough almost how you support a death to happen while at habitation when you merely have, say, an elderly spouse there.' (Ward physician v, 3–4)

Caring for patients at dwelling house

Ensuring a patient could die at abode in a way that met staff expectations of an appropriate death was not easy. The factors identified in a higher place were ofttimes considered to be interdependent issues, which could exist challenging for GPs to encounter and therefore could precipitate hospital admissions: 'And nursing someone who is ... is ... you lot know, completely physically dependent, information technology'due south very strenuous, and you need a lot of kit. And [...] fifty-fifty the changes that y'all have to ... you know, information technology's ... [...] We [GPs] like people to dice at home, and we do try very hard to organise it as much as we can. But it'southward ... it'southward difficult. I hateful, the [community care team] are amazing. I wish at that place was about eight times more than of them.' (aGP, 28, x)

DISCUSSION

Summary

The present research identifies that hospital admissions at the end of life can be a result of the challenges in delivering cease-of-life care at home. Insufficient available nursing provision and family unit carers who had exceeded their chapters to care countered the desirability of dwelling equally a place to evangelize end-of-life care. These circumstances oft caused GPs, together with family carers and other healthcare staff to seek intendance for patients through hospital admissions.

Strengths and limitations

This article has explored the consequences of insufficient community-based care as a forerunner to finish-of-life hospital admissions. This research usefully contributes to the limited show base of operations on terminate-of-life hospital admissions. In a policy and clinical context where the desirability of dying at dwelling is presumed, the present findings also add together insight to the practicalities of home-based cease-of-life care.

The findings of this study are from an in-depth qualitative report of 33 healthcare professionals and side by side of kin involved in the admission to one English hospital of ix patients close to the finish of life. The extent to which interviewee accounts of the case-patients', and similar patients', community-based care, and the reasons for their hospital access, can be extrapolated to cease-of-life care in general is therefore limited. For instance, it is probable that some other patients with bug in the provision of professional or family care would proceed to remain at home and not seek hospital care. However, the challenges faced past healthcare staff and family carers in providing end-of-life care accords with existing research, as outlined later on, and contributes to an understanding of why admissions occur.

Formal care provision that occurs at the interface of health and social care, such as supporting personal hygiene, or eating and drinking, has not been addressed in this article. This care is pertinent to understanding how stop-of-life care can be facilitated at dwelling,²⁸ and paid carers were known to accept supported some of the case-patients. Interviewing these carers was outside the study scope, and their function was not sufficiently elaborated by other interviewees to be considered.

Comparing with existing literature

The limited availability and capacity of domiciliary nursing care was cited as a reason why interviewees instigated infirmary admissions for patients close to the terminate of life. The challenge for GPs in arranging customs nursing finish-of-life care is too reported in a UK-wide survey,²⁹ and seems likely to be due to the restricted capacity of community nursing, where ascent demand for services coincides with staff shortages.³⁰ Internationally, the importance of community-based finish-of-life care provision for facilitating decease at habitation accords with review evidence, which identifies receipt of community-based nursing, home palliative intendance, and GP abode visits equally key factors.³¹ ^, ³²

The importance of family care provision in facilitating death at home is well-established.³¹ ^, ³³ The present research shows that where lay care is recognised to be no longer tenable, healthcare providers may seek infirmary intendance for patients, supporting GP accounts about the reasons for end-of-life admissions¹⁸ and debasing rhetoric about family carers.^{half dozen} ^, ^eighteen However, it would be inaccurate to assert on the basis of this that issues in lay intendance provision instigate these admissions,²³ ^, ³⁴ without acknowledging simultaneously the contribution of family unit care provision in maintaining patients at home. Interviewees demonstrated that family unit members delivering easily-on intendance provided vital support, supplementing professional intendance provision.³⁵ ^, ³⁶ Therefore, information technology is plausible that hands-on intendance from family members tin defer admission to hospital for some patients while resident at dwelling house. This is pertinent given the context of lay care provision: family carers were understood to be oftentimes ill-prepared for their function^one ^, ¹⁸ ^, ³⁴ ^, ³⁷ with often substantial, if typical, psychological²³ ^, ³⁴ and physical⁶ ^, ³⁶ ^, ³⁸ demands made of them, particularly for those with limited mobility such equally fragile older people. Information technology seems likely therefore that family carers' ability to sustain their intendance provision, and prevent hospital admissions, is compromised without supplementary back up.³⁹

Facilitating end-of-life care at home was important for professional person carers, who echoed prevalent notions about the desirability of death at home.⁸ ^, ³⁷ Yet, interviewees besides recognised that the safety of end-of-life intendance at home could exist compromised.⁸ ^, ¹⁰ ^, ⁴⁰ Where the cause of this could non be addressed fairly, healthcare staff and family carers sought care for the patients elsewhere. While hospice and residential nursing homes were considered, challenges in accessing these institutions at curt find meant hospital care was prioritised⁴¹ highlighting the importance of infirmary as a provider for terminate-of-life care.^x

Implications for inquiry and do

The present analysis was informed by a sociological interest in dying at home, focusing on the physical and technical infrastructure of domicile and hospital, the skills of lay carers and professionals, and the way dying is understood by those involved.⁴² This perspective exposed the vulnerability of dwelling house intendance for some patients, which can be dependent on stretched professional and lay provision, and builds on over a decade of sociological scholarship on the role of dwelling house as a place of care.⁶

The case-patients' hospital admissions demonstrate the difficulty of providing and maintaining care at dwelling house. The authors' findings challenge the prevalent discourse that home is an inherently better place to receive end-of-life care than hospital and highlight the dissonance between policy rhetoric and the everyday reality of caring for patients shut to the end of life. The present research suggests that if policy and practice maintain an accent on facilitating deaths at abode, there must besides be a concurrent focus on ensuring that patients tin can dice at that place safely. Identifying how all-time to accomplish this will crave further enquiry, and is likely to require investment to ensure that customs nursing provision is fairly staffed, responsive, and available throughout the mean solar day and nighttime.⁴³ Supplementing this essential provision with rapid and reliable specialist clinical services that offer support for patients at home for extended periods of time, such as hospice at domicile and Marie Curie nursing services, would too be pertinent.⁴⁴ ^– ⁴⁶ To facilitate care commitment, primary care clinicians must be supported by acceptable information-sharing practices,⁴⁷ and be confident in delivering palliative and finish-of-life care.⁴⁸ Family carers must also be supported, including greater recognition of their needs.⁴⁹ Pejorative assessments of the association between family intendance and stop-of-life hospital admissions obscures the meaning undertaking of lay carers to support patients at home. Future research could productively address how families persist in providing intendance, and how GPs and others can all-time support them.

Acknowledgments

The authors would like to thank the participants and those involved in the ready-upwards and running of the study.

Appendix 1. Instance-patient characteristics, N = 9

Characteristics	n
Sex
Female	7
Male	ii
Historic period, years
65–69	1
70–79	2
80–89	five
>89	1
Status
Cancer	two
COPD	2
Dementia	v
Previous place of care
Dwelling house	6
Residential home^a	3
Fourth dimension of admission
Weekday (nine.00 am to five.00 pm)	3
Weekday (5.00 pm to ix.00 am)	2
Weekend	four

Notes

Funding

This written report presents independent research part funded by the National Institute for Health Inquiry Collaborations for Leadership in Applied Health Research and Care (NIHR CLAHRC) Cambridge and Peterborough (grant number: RG55908), and NIHR CLAHRC East of England (grant number: RG74481). The writing of the article was funded past the NIHR Schoolhouse for Chief Care Research (NIHR SPCR) (grant number: RG85520 [NIHR SPCR-2016-S67]). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Section of Health. The Marie Curie Blueprint to Care programme is a service improvement programme. This enquiry forms part of the design stage of this programme (grant number: RG87570), which is funded past Marie Curie, the U.k.'southward leading charity caring for people living with any terminal illness and their families.

Ethical approval

The written report was approved by the Hertfordshire Inquiry Ideals Committee (England) (ethical blessing number: 11/EE/0491. Approval to view the patients' medical records to identify potential interviewees was granted by the and so National Data Governance Board (ethical approving number: ECC i-v (Grand)/2012). All interviewees gave consent to have part in the written report.

Provenance

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.

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Received Oct 22, 2018.
Revision requested December 7, 2018.
Accustomed Dec 24, 2019.

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