Issue 18 / 23 May 2011

OUR health system supports a model of care that is strongly reliant on provision of services in hospital.

Two studies reported as rapid online publications by the MJA illustrate the dominance of this model, the increasing demands on the system, and the way that the quality of care provided may be inappropriate for two major groups in our community — the very old and those with terminal disease. An accompanying editorial calls for a patient-focused “learning” health system to facilitate care for these groups.

It has long been accepted that the majority of an individual’s health care costs are expended during the last few months of life. However, acknowledging the futility of this has not led to the development of effective alternatives.

Little work has previously been done in Australia to examine the delivery of care for seriously ill Australians in their last months of life. The findings of one study in this regard are bleak, but perhaps not surprising.

Of patients in this study who were suitable for palliative care, 70% had at least one visit to the emergency department and 96% were admitted to hospital during their last year of life, with an average of eight admissions and a mean length of stay of 6 days. Most of the admissions and time spent in hospital occurred within the last 3 months of life, and 62% of patients died in hospital.

These are all markers of a poor standard of palliative care, which we accept too readily.

In the other study researchers analysed the use of emergency ambulance transport in Melbourne, showing an increasing demand for this service and, by implication, the hospital system, particularly by patients aged 85 years or older. Since 1994–95, the annual rate of emergency ambulance transfers increased by almost 5% beyond what could be explained by population changes.

The authors project a further increase in usage to 2014–15 of up to nearly 70%.

Although people aged 85 years or older comprised 1.6% of the population in 2007–08, they accounted for 13.6% of emergency transportations. As the authors point out, ambulance transportation most often results in emergency department attendance, with a high rate of subsequent hospital admission.

Older patients are more likely to be admitted, and typically for longer, than other age groups. As our population ages, demand for both ambulance and hospital services will rise, and this will need to be factored into health planning.

At heart, both these studies identify a need for an alternative model of care. An aggressive-treatment, event-determined and hospital-centred model fails to give appropriate care to the terminally ill and older people who have complex chronic comorbidities.

These articles canvass some alternative models, but neither suggests assessing whether good primary care can reduce demand on ambulance and hospital service use.

Palliative care and aged care should not primarily be the province of the hospital and the acute health care system, and our continued acceptance of this and of the concentration of health care spending in the last months of life is no longer tenable.

It represents both bad care and a waste of money.

Dr Annette Katelaris is the editor of the MJA.

This article is reproduced from the MJA with permission.

Posted 23 May 2011

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One thought on “Annette Katelaris: Futility in end-of-life care

  1. George Burkitt says:

    The way that we manage care at the end of life must become a subject of intense scrutiny not least because the current system of sending such dying people into hospital without any coherent management plan and often against the terms of advance directives represents a systematic abuse of human rights as well an immense drain on scarce financial resources.
    The fundamental problem is that we as a scientific community have failed to recognise that death at the end of a long life is a normal healthy phenomenon and not a pathological event. Because of this, we have never studied the processes of dying at a great age from a the standpoint of normality and thus we do not have any real understanding of the natural history of dying. This must include describing the physiology, psychology, spirituality and various possible preterminal events involved in the process.
    Without understanding the normal processes of dying at a great age we are thus unable to define when the process is underway and manage it as a normal process. An analogy might be trying to manage childbirth without understanding the normal psysiology of childbirth.
    What do others think?

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