Offering older hospitalised patients the choice to die in their preferred place.

BACKGROUND

A significant proportion of older people state a preference to die at home. However, the vast majority of people in hospital recognised as dying subsequently die there.

OBJECTIVES

To identify the proportion of older people dying in hospital where the possibility of ending life elsewhere was explored. To identify factors that could support hospital staff to enable patients' wishes to be met.

METHODS

Retrospective case-note review of 100 older patients (>75 years) who died during 2009 in an English Hospital.

RESULTS

Age range 75-97 years. Time from admission to death ranged from 0-118 days (median 8.5). 16% died within the first 48 h, rising to 30% for those from care homes. In only 8 patients was a potential alternative place of death discussed. Although subjective, in 10 patients it was considered admission could have been avoided through Advance Care Planning (ACP) to allow patients with poor prognosis to die in their normal place of residence or a hospice. 55% of Do-Not-Attempt-Resuscitation orders were made within 48 h of admission. 38% were commenced on the Liverpool Care Pathway (LCP), 1-504 h before death (median 16).

CONCLUSIONS

In few cases are the preferred places of death discussed in older people who die in our hospital. Although hospital admission was largely appropriate, in a minority judicious ACP could have avoided death in hospital. We recommend (1) increased use of ACP, with appropriate practicalities planned in advance (2) wide-scale introduction of the 'Rapid Discharge Home of the Dying Patient pathway' (3) routinely discussing preferred place of death in appropriate key situations (eg, discussion of resuscitation status or commencing the LCP).