Why are care home patients admitted to hospital at end of life? A qualitative study

Problem Statement
In Wales, over 50% of deaths occur in hospital. With health planners and Governments promoting end of life care at home, why is it that care home patients are sent into hospital to die?

Approach
This is a retrospective, qualitative, thematic analysis of all care home deaths in 6 residential homes, 6 nursing homes and 6 GP surgeries in the South Wales Valleys between 1st September 2016 and 31st August 2017. Interviews were carried out in each organisation and the resulting 18 interview transcripts were analysed and coded to provide main themes (such as arranged hospital admission) and subsidiary themes (such as lack of reflection by participants).

Results
Patients dying in their care homes usually died expected deaths.

Across all organisations there were 57 hospital deaths. Six trauma related deaths (following fractured neck of femur) were not discussed.

Admissions to hospital were mainly by care home staff calling emergency ambulances (39%) and arranged admissions by the patients’ own GPs (21%). Each main theme could be divided into several subthemes and it is apparent that patients were admitted to hospital for a wide variety of reasons. Within each organisational group there was significant variation in how organisations managed their patients/clients. Community hospices were utilised where available. Two patients were admitted to hospital as the patients did not have family and the GPs did not want to make an end of life decision in the home.

Subsidiary themes indicated poor communication between homes and GP surgeries, and lack of continuity of care.

Conclusions

Significant changes need to be made to the way care home patients are managed at end of life; 
– Care homes need to be of greater importance to politicians and NHS planners,
– Care homes should be registered to provide end of life care, and should be inspected and regulated accordingly.
– Locality groups should be established (e.g. with Ambulance personnel, GPs, care home staff, intermediate care, GP out of hours service etc) to facilitate improvements, and
– GPs should work closely with intermediate care teams to provide community centred care with physician-led governance.

Such changes would provide improvements in patient care in the community at minimal extra cost.

The author found no similar studies, and this work appears to fill a gap in our knowledge. The author was surprised to find that statistics around hospital admissions from care homes are not collated routinely.

Jones I ¹, Harris D ²

¹ Glyn Ebwy Surgery, Ebbw Vale, Blaenau Gwent, United Kingdom

²Consultant in Palliative Medicine