Hospital admissions, age, and death: retrospective cohort study
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.38072.481933.EE (Published 27 May 2004) Cite this as: BMJ 2004;328:1288
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Spin is, it seems, an affliction not restricted to political
machinations.
Staff working in the health service see the problem in front of them on a
daily basis as an inability to appropriately manage the old patient who
may also be in the process of dying, albeit slowly. Unfortunately it is
increasingly difficult to just die in hospital; one has to have a ‘cardiac
arrest’ instead with all the unpleasantness that follows on from that
before or after ticking the ‘admitted to ITU’ box.
As dying in hospital becomes almost the norm GPs are, understandably,
increasingly reluctant to leave the patient at home for fear of
accusation that they didn’t do all that was ‘possible’.
I have long been a supporter and advocate of the 'fair innings' argument
but without the ‘third way’ of patient care being available, well ......
We do know what patients want and it’s not time in ITU, tubed, cannulated
and festooned with wires and pipes. Euthanasia is not something to be
feared, indeed in the future it may be something to be welcomed. Patients
value good end-of-life care (1).
The mean of 29.9 days spent in hospital in the last year fits with
experience and it is quite simply the sheer numbers of elderly patients
which threatens to overwhelm the
system. 'Extremely elderly and terminally ill patient(s) consuming large
amounts of resources shortly before death' is, in fact, born out by the
authors' own figures as 77% of the 253779 deaths were aged 70 or above and
indicates the scale of the problem.
All patients, as they demonstrate, use significant resource in the final
year(s) often to uncertain purpose, most not directed towards
compassionate support and caring.
These costs of dying are, really, an integral and significant part of the
cost of aging until we as a caring society come to manage it better and we
only fool ourselves
if we don't admit it.
1. Bryce CL, Loewenstein G, Arnold RM, Schooler J, Wax RS, Angus DC.
Quality of Death: Assessing the importance placed on end-of-life treatment
in the intensive-care unit. Med Care 2004; 42: 423-31.
Competing interests:
None declared
Competing interests: No competing interests
In general, I heartily approve of the ELPS (electronic long, paper
short) format that the BMJ uses for many of its papers. However, this time
it seems to have been taken to extremes. It was very hard to follow the
abridged version of this paper when the table with the most important
results (number of days spent in hospital) had been banished to the web
version.
Please can we ensure that tables or graphs of primary results are
always included in the abridged version?
Competing interests:
None declared
Competing interests: No competing interests
The authors suggest that population ageing will not increase health
care costs. This may be true of those dying, who incur a similar cost of
death at any age. But this overlooks both the cost of elective care for
older people and the cost of long term non-NHS care. If many of those
dying in old age have elective procedures more than three years before
death, their cost will not be included in this study. The authors note
some data on low rates of surgical intervention in the dying group.
Surely, if more people survive to old age, we will need more resources for
hip replacements, eye and heart surgery and for long term care. Dying may
be the end of a period of clinical activity with a similar cost at many
ages but surely more older people means more surgery, treatment and care
for the non-dying than currently.
Competing interests:
YHEC Ltd is a contract research company and works for the pharmaceutical industry, DH and the NHS. No conflicts exist in relation to this paper or comment.
Competing interests: No competing interests
U.S. Rates of Hospitalization in the Last Years of Life
I thought that it might be helpful to know comparable data from the
US. In 1996-1999, in the 5% sample of Medicare fee-for-service
beneficiaries, 143,861 died outside of hospitals and 89,563 in hospitals,
for a rate of dying in the hospital of 38.4%. Of course,some die in
veteran's hospitals and other hospital settings that are not part of
Medicare, but that is probably a small percentage, and those in managed
care Medicare are lost from numerator and denominator. Even with these
caveats, our rate is much lower than the rate that Dixon et al cite, which
was 50-55%.
Among those who died in the hospital, the mean rate of
hospitalizations in the three years before dying is 3.82, with 34.2 days
of hospitalization. This compares with the British rate of 2.2
hospitalizations and around 38 days. So, the US seems to have a few more
hospitalizations, but much shorter hospitalizations. Among those who died
in hospitals, 71% had 4 or fewer hospitalizations in their last
three years.
Among those who did not die in the hospital, our rates are not
greatly different from those who did die in the hospital - 3.3
hospitalizations and 27.9 days in the hospital.
Competing interests:
None declared
Competing interests: No competing interests