Abstract
BackgroundHospitalisation rates for the older population have been increasing with end-of-life care becoming a more medicalised and costly experience. There is evidence that some of these patients received non-beneficial treatment during their final hospitalisation with a third of the non-beneficial treatment duration spent in intensive care units. This study aims to increase appropriate care and treatment decisions and pathways for older patients at the end of life in Australia. This study will implement and evaluate a prospective feedback loop and tailored clinical response intervention at three hospitals in Queensland, Australia.MethodsA stepped-wedge cluster randomised trial will be conducted with up to 21 clinical teams in three acute hospitals over 70 weeks. The study involves clinical teams providing care to patients aged 75 years or older, who are prospectively identified to be at risk of non-beneficial treatment using two validated tools for detecting death and deterioration risks. The intervention’s feedback loop will provide the teams with a summary of these patients’ risk profiles as a stimulus for a tailored clinical response in the intervention phase. The Consolidated Framework for Implementation Research will be used to inform the intervention’s implementation and process evaluation. The study will determine the impact of the intervention on patient outcomes related to appropriate care and treatment at the end of life in hospitals, as well as the associated healthcare resource use and costs. The primary outcome is the proportion of patients who are admitted to intensive care units. A process evaluation will be carried out to assess the implementation, mechanisms of impact, and contextual barriers and enablers of the intervention.DiscussionThis intervention is expected to have a positive impact on the care of older patients near the end of life, specifically to improve clinical decision-making about treatment pathways and what constitutes appropriate care for these patients. These will reduce the incidence of non-beneficial treatment, and improve the efficiency of hospital resources and quality of care. The process evaluation results will be useful to inform subsequent intervention implementation at other hospitals.Trial registrationAustralia New Zealand Clinical Trial Registry (ANZCTR), ACTRN12619000675123p (approved 6 May 2019),
Highlights
Hospitalisation rates for the older population have been increasing with end-of-life care becoming a more medicalised and costly experience
The primary outcome is the proportion of patients who are admitted to intensive care units
A process evaluation will be carried out to assess the implementation, mechanisms of impact, and contextual barriers and enablers of the intervention. This intervention is expected to have a positive impact on the care of older patients near the end of life, to improve clinical decision-making about treatment pathways and what constitutes appropriate care for these patients
Summary
Hospitalisation rates for the older population have been increasing with end-of-life care becoming a more medicalised and costly experience. This study aims to increase appropriate care and treatment decisions and pathways for older patients at the end of life in Australia. Clinicians providing end-of-life care, who are often tasked with preparing patients and families for a transition to palliative and supportive care pathway [6], frequently experience barriers to these discussions [7, 8]. This leads to an increase in non-beneficial treatment, causes moral distress to clinicians, and prolongs or increases patient suffering [9]. A systematic review of 38 international studies found 33 to 38% of patients received non-beneficial treatment at the end of life [10]
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