End of life care trajectories – hospital inpatient care in last two years of life

Abstract

Introduction : End of life (EOL) care trajectories have been found to differ by cause of death categories representing different trajectories of functional decline (Fassbender et al. 2009). The aim of our study is to use the same categorisation of causes of death (terminal illness, organ failure, frailty, sudden deaths, other) to investigate hospital inpatient care utilisation patterns in the last two years of life in Norway. Methods : Data on cause of death, place of death, age and gender for all decedents in 2011 from the Norwegian cause of deaths registry were linked by unique person identifier with data from Norwegian Patient register on inpatient hospital utilisation in the last 730 days before death. Statistical analysis of differences in care utilisation in different time periods before death, as well as graphical analysis of time pattern in service use were performed. Results : The highest median number of inpatient days over the last two years before death was found for terminal illness, more than double compared to organ failure, which in turn was the double of frailty and sudden death. For all trajectory groups the proportion being in hospital on a particular day before death increases steeply in the last months of life, starting earlier for terminal illness than for organ failure, which in turn started earlier than for frailty and sudden death. Nearly 70 percent of decedents dying of terminal illness had hospital stay within the last 30 days of life. The corresponding proportions was 50% for organ failure, and about 1/3 for frailty and sudden death. Differences in utilisation as well as time pattern within trajectory groups varied with age as well as place of death. Typically, the highest number of hospital days was found for hospital deaths and lowest for home deaths, and the number of days in hospital decreased with higher age among the elderly decedents. Discussions : The overall results are in line with the findings in Fassbender et al. (2009) which found the same ranking of cost for inpatient care between terminal illness, organ failure and frailty. Conclusions : Cause of death trajectories categories help to differentiate patterns of hospital utilisation before death. Lessons learned : Care trajectories differ by place of death already several month or even years before death, which could reflect that place of death is an indication of differences in functional decline of decedents within the cause of death trajectory categories. Care trajectories should also be studied separately for different age groups. Limitations : The study only looks at inpatient hospital use, other health and care services could serve as alternatives to hospital admission. Suggestions for future research : In our future research, we will include other health and care services. References : 1- Fassbender K, Fainsinger RL, Carson M and Finegan BA. Cost trajectories at the end of life: the Canadian experience. J Pain Symptom Manag. 2009; 38: 75-80.