A case study approach to investigating end-of-life decision making in an acute health service

Abstract

Aim. To identify end-of-life (EOL) decision making processes for patients with non-cancer illnesses in a major metropolitan hospital. Methods. A retrospective review using a case study framework of 47 randomly selected patient records over a 6-month period explored issues in EOL care planning. Results. Reviewed charts represented 53% of total deaths in the study period. All patients (aged 66–99) had co-morbid conditions. In 64%, the first record of EOL discussions occurred in the last 24 h of life. Four case groups were identified, ranging from a clear plan developed with patient/family involvement and fully implemented, to no plan with minimal patient/family involvement in decision making. Factors related to clearer EOL care planning according to expressed patient wishes included multiple previous admissions, shorter hospitalisations at EOL, living with a relative and involvement of family in decisions about care. Conclusion. This study has shown that the development and effective implementation of EOL plans is associated with the active involvement of both family members and health professionals. It also draws attention to the risks of delaying EOL discussions until late in the illness trajectory or later in life as well as pointing to challenges in acting on EOL developed outside the hospital environment. What is known about the topic? End of life (EOL) care planning has been widely discussed in some countries but research into outcomes of such programs has produced variable results both in real outcomes for patients and in satisfaction and ease of application for health professionals. Programs of advance care planning have been introduced in some Australian health services but are yet to produce definitive results. What does this paper add? This paper identifies some of the factors that appear to impact on EOL decision making processes in a major Australian metropolitan hospital for patients suffering non-cancer life-limiting illnesses. These data will facilitate the development of more effective EOL care processes in this and other similar healthcare services. What are the implications for practitioners? Clear effective processes for making EOL decisions are likely to result in better outcomes for patients, family members and practitioners. A distinctive cluster of patient circumstances may identify risk for poor advance care planning.