It is a rare experience in an academic career to carry out a project with a simple research question, to publish the findings and then to find there is unprecedented interest from many quarters. That was how things worked out with our study of the imminence of death among a national cohort of hospital inpatients, which we presented in the journal Palliative Medicine in March 2014.
Fiona Graham, Christopher Isles, Ananda Allan, Matthew Armstong, Andrew Carnon and I set out to determine on any given day, how many people are in hospital who are in the last year of the lives. Our reasoning was that knowing this is key to organising a ‘systems level’ response to the delivery of palliative care and advanced care planning in the hospital.
The focus of this work is not on dying in hospital, though we do have some data on that. Rather we are trying to explore what potential exists in hospital for the identification of people who are in the last year of life – and who may go on to die in a variety of settings.
This work has found a wide audience. It is frequently cited in policy documents and discussions, slides reporting our data often pop up in conference presentations, and it has a growing number of citations in the scientific literature. We are also extending the study in a collaboration with colleagues in Denmark and New Zealand, using the same method.
To recap, the original study demonstrated that in Scotland on a fixed ‘census’ date of 31 March 2010, 10,743 patients were hospitalised in 25 teaching and general hospitals (cottage and community hospitals and long-stay facilities were excluded). Of these, 3,098 (28.8%) patients had died one year later. The likelihood of death rose steeply with age and was three times higher at one year for patients aged 85+, compared to those under 60. Men were more likely to die than women. A striking finding was that almost one in 10 patients (9.3%) died during the admission we recorded.
You might like to watch this short video in which I give a quick explanation of the study:
Of course, we were asked could this be a fluke result – some quirk of the chosen date or circumstances at that particular time? On that basis we have now repeated the study, and found pretty much the same result, which we reported as a BMJ rapid response in August 2015. Using the same method, but a new ‘census’ date of 10 April 2013, with a one year follow up, we found that 29.5% (of 10,595 patients) had died one year later. And 8% died on the recorded admission.
We now know that almost one in ten patients in hospital in Scotland will die on their current admission. Almost one patient in three is in the last year of life. Our large, acute hospitals therefore have end of life care as part of their core business. This presents major opportunities for changing clinical priorities and for resource allocation. It is unlikely that each of these patients will have had an assessment for palliative and end of life care. More investment could be made in identifying these patients on a prospective basis in order to consider the potential for palliative and end of life care interventions.
In this short audio clip you can hear Dr Kirsty Boyd, Palliative Care Consultant at the Edinburgh Royal Infirmary, talk about the implications of the study findings for healthcare practitioners:
Seminar
It is this issue which will be explored at a seminar organised by Marie Curie Scotland and the University of Glasgow on 10 November 2015 with support from the Economic and Social Research Council under the ‘impact acceleration’ scheme. So far, more than 200 people have signed up to come along, and there is still time for you to book a place and join us at Glasgow Royal Concert Halls.
The seminar will explore some important questions including:
- How can patients in hospital who are nearing the end of life be identified?
- What tools and methods seem to have value?
- What role can hospitals play in thinking more ‘structurally’ about their approach to end of life care?
- What does this mean for specialist palliative care services and what can be done to support all staff to engage more effectively with the end of life care needs of those for whom they care?
The seminar is to be chaired by Richard Meade, Head of Policy and Public Affairs at Marie Curie Scotland, and the speakers will include myself as well as Professor Craig White, Divisional Clinical Lead at the Scottish Government and Anne Harkness, Director – South Sector, Acute Services, NHS Greater Glasgow & Clyde.
Here’s a short interview with Richard, where he talks about some of the challenges and questions raised by our study:
I am looking forward to the talks and the debate, and hope that you’ll participate, either in Glasgow in person or by joining the discussion online and via Twitter #hospitalEOLC. We plan to publish footage of the seminar and host some follow-up discussions in the coming weeks so keep an eye on this hashtag and follow us @EndofLifeStudy.
On the back of all this however, it has been a total surprise and a delight to learn that the work has been nominated for the award of Research Project of the Year by the Times Higher Education. The result will be announced on the night of 26 November, at the ‘University Oscars’ event in London – please keep your fingers crossed for us!
David Clark