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Public debate begins in Scotland on future of NHS

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4266 (Published 07 August 2015) Cite this as: BMJ 2015;351:h4266

Hospital care in the last year of life

We welcome the new ‘conversation’ on the future of health and social care in Scotland (BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4266 Published 07 August 2015) and see it as a huge opportunity to address issues of ageing and end of life care, especially relating to hospital services. This autumn, as the Scottish government prepares its Strategic Framework for Action on Palliative and End of Life Care and the Scottish Parliament holds an inquiry into palliative care, the timing could not be better.

In March 2014 we published a paper detailing the likelihood of death within 12 months of a cohort of all hospital inpatients in Scotland on a fixed ‘census’ date of 31 March 2010.1 It attracted a huge amount of media interest.2 In the study, 10,743 inpatients were identified in 25 Scottish teaching and general hospitals on the census date (cottage and community hospitals and long-stay facilities were excluded). 3,098 (28.8%) patients died during the one-year follow-up period. Mortality 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 as were those with a ‘medical’ rather than a ‘surgical’ diagnosis. A striking finding was that almost one in 10 patients (9.3%) died during the index admission.

It has now been possible to repeat this analysis for a cohort of patients in hospital in Scotland on 10 April 2013. Our purpose in doing this is primarily one of verification, as well as to look for trends over time. Was the original finding a ‘one off’, unrepresentative of the usual situation in Scottish hospitals on any given day? It would appear not. 10,595 patients were in hospital on 10 April 2013. The population characteristics of the 2010 and 2013 cohorts were similar overall. There was a slightly higher proportion of younger patients ( >60 years) in the 2010 cohort compared to the 2013 cohort (z test: p< 0.05) and a slightly higher proportion of older patients (’80-84’ and ‘85 and over’) in the 2013 cohort compared to 2010 (z test: p< 0.05). 29.5% of the 2013 cohort had died one year later (Table 1) and 852 (8.0%) died on the index admission. Our study is also being extended to Denmark and New Zealand.

Atul Gawande’s Reith lecture, delivered in Edinburgh last December, urged clinicians to engage actively in another kind of conversation: with patients about end of life issues. He highlighted the key questions that might be asked: What is your understanding of your situation? What are your fears and hopes if time is short? What are the trade-offs you are willing to make and not make? And what is the course of action that best serves this understanding? We know that, in England at least, these conversations do not happen.3 In Scotland, around 45% of all people in hospital are over 75 and over one third of these are entering the last year of their lives. We contend that the hospital setting can be an important place for such conversations to begin.

1 Clark, D Armstrong, M Allan, A Graham, F Carnon, A Isles, C Imminence of death among a national cohort of hospital inpatients. Palliative Medicine, 2014, 28 (6). 474-479. ISSN 0269-2163 (doi:10.1177/0269216314526443)

2 http://endoflifestudies.academicblogs.co.uk/hospitals-and-end-of-life-care-reactions-to-a-paper/

3 Gott, M Ingleton, C Bennett, M Gardiner, C Transitions to palliative care in acute hospitals in England: qualitative study. British Medical Journal 2011, 342:d1773.

The first pdf link goes to Table 1; Number and percentage of inpatients in teaching and general hospitals in Scotland on
census date.

The second pdf link goes to Table 2: Number and percentage of inpatients in teaching and general hospitals in Scotland on
census date who died within 12 months. There was a slightly higher proportion of younger patients ( >60 years) in the 2010 cohort compared to the 2013 cohort (z test: p< 0.05) and a slightly higher proportion of older patients (’80-84’ and ‘85 and over’) in the 2013 cohort compared to 2010 (z test: p< 0.05). 29.5% of the 2013 cohort had died one year later (Tables 1, 2)

Competing interests: No competing interests

12 August 2015
David Clark
Professor
Lauren Schofield, Fiona Graham, Lene Jarlbaek, Merryn Gott, Christopher Isles
University of Glasgow
Glasgow
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