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Link between admission rate and disability at end of life

  • 3 Comments

A high number of hospital admissions in the last year of life is linked with increasing disability in older patients, which may influence palliative care discussions, according to a US study.

Researchers found a close association between acute admissions and the development and progression of disability among older adults at the end of life.

They said their findings may have “profound implications” for clinical decision-making for older people and those who care for them.

“The disabling process in the last year of life is strongly influenced by the occurrence of acute hospitalisations”

Thomas Gill

The researchers, from Yale School of Medicine, conducted a prospective study of more than 500 adults over age 70.

Through home-based assessments and monthly telephone interviews, they collected data on the health and functional status of participants over a 15-year period.

They asked about hospital stays and reasons for admission. They also asked about participants’ ability to perform basic tasks – bathing, dressing, walking, standing from a chair – without assistance.

The researchers, led by Dr Thomas Gill, said they uncovered a strong association between hospital admissions for acute conditions and disability progression.

“These results suggest that the disabling process in the last year of life is strongly influenced by the occurrence of acute hospitalisations,” he said.

Based on the resulting data, they identified six “distinct trajectories” or patterns of disability in the last year of life, ranging from no disability to persistently severe disability.

The six trajectories were: no disability, catastrophic disability, accelerated disability, progressively mild disability, progressively severe disability, and persistently severe disability

Most participants, 70%, had been hospitalised at least once, and 45% had multiple hospitalisations in the last year of life, said the study authors in the British Medical Journal.

However, the frequency distribution of hospital admissions differed considerably across the disability trajectories, with the largest number observed for accelerated disability and the smallest number observed for no disability.

“Our results may help inform decisions about the management of disability and the appropriate level of care at the end of life,” said Dr Gill.

For example, he suggested restorative interventions may be indicated for older patients with previously low levels of disability, while palliative care may be preferable for those hospitalised with severe disability.

“For older patients admitted to hospital with progressive or persistent levels of severe disability… clinicians might consider a palliative care approach to facilitate discussions about advance care planning and to better deal with personal care needs,” said the study authors.

  • 3 Comments

Readers' comments (3)

  • michael stone

    Clinicians might consider describing prognoses to the patient, with and without any possible/offered treatments, and then asking the patient what the patient wants - just a thought !

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  • michael stone | 21-May-2015 2:20 pm

    it's all very cut and dry for you isn't it.
    nursing and medicine would be perfect if we all thought like you and some lay-management and the government and disregarded any individual differences. welcome to the supermarket conveyor belt system of healthcare!

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  • michael stone

    Anonymous | 21-May-2015 6:47 pm

    No, it is all 'very complicated' - 'asking' is very problematic. Which is why I'm less than enthusiastic, about 'a heavy reliance on EPaCCS', which seems to be the current idea for EoL at home (it might work, if everyone did talk to each other, so that EPaCCS did reflect 'what is going on' - but at the moment, there is no way that 'EPaCCS can know enough, and be up-to-date often enough').

    My objection to the above piece - why I wrote my comment- comes from:

    “For older patients admitted to hospital with progressive or persistent levels of severe disability… clinicians might consider a palliative care approach to facilitate discussions about advance care planning and to better deal with personal care needs,” said the study authors.

    It isn't the clinicians who should be 'considering the approach' - the patient should, where possible, 'consider' the benefits or otherwise, of active v palliative.

    Saying that the clinicians have got to talk to their patients, and find out what the patients want, is exactly the opposite to 'the conveyor belt system of healthcare', by the way !

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