The challenges of end of life care in acute hospitals

Abstract

Recently, the Australian Commission on Safety and Quality in Health Care (ACSQHC) released a national Consensus Statement titled ‘Essential Elements for Safe and High-Quality End-of-Life Care’ (2015). This document, targeted at acute health services including intensive care was written following consultation with health consumers, carers and experts in the field. The purpose was to describe the elements essential for delivering safe and high quality end of life care in Australia (ACSQHC, 2015Australian Commission on Safety and Quality in Health Care (ACSQHC) National consensus statement: Essential elements for safe and high-quality end-of-life care. ACSQHC, Sydney2015Google Scholar). The Consensus Statement makes recommendations about practice in acute care settings where end of life care is provided (2015). This publication is a positive and essential move forward but for the nursing workforce in particular, several significant problems remain, and lack due attention in the Consensus Report. The patterns of death and dying in Australia are changing (Aleksandric and Hanson, 2010Aleksandric V. Hanson S. Health system reform and care at the end of life: A guidance document. Palliative Care Australia, Deakin West, Australia2010Google Scholar). Recent statistics report that approximately 70% of all deaths occur in institutions (Trankle, 2014Trankle S.A. Is a good death possible in Australian critical and acute care settings?: Physician experiences with end-of-life care.BMC Palliative Care. 2014; 13: 14PubMed Google Scholar). As a result, the number of patients requiring end of life care in the acute hospital sector will continue to increase (Bloomer et al., 2011Bloomer M.J. Moss C. Cross W. Problems associated with Care at the End of Life in Acute Hospitals.End of Life Journal. 2011; 1Crossref Google Scholar). However, in health services that operate on a curative model of health care, where care of the dying is neither a focus nor a priority (Pincombe et al., 2003Pincombe J. Brown M. McHutcheon H. No time for dying: A study of the care of dying patients in two acute care Australian hospitals.Journal of Palliative Care. 2003; 19: 77-86PubMed Google Scholar), the Consensus Statement is inadequate. For nurses, there are many other challenges to contend with on a regular basis, which are not identified or detailed in the Consensus Statement and remain under-acknowledged in the literature. A recent Australian study highlighted that nurses in acute care settings find many aspects of end of life challenging (Bloomer et al., 2013Bloomer M.J. Endacott R. O’Connor M. Cross W. The ‘dis-ease’ of dying: Challenges in nursing care of the dying in the acute hospital setting. A qualitative observational study.Palliative Medicine. 2013; 27: 757-764Crossref PubMed Scopus (48) Google Scholar). Differentiating between an acutely ill patient and a dying patient can be extremely difficult for many clinicians. Thus achieving consensus amongst clinician teams about when to transition from curative care to end of life care is equally challenging (Bloomer et al., 2013Bloomer M.J. Endacott R. O’Connor M. Cross W. The ‘dis-ease’ of dying: Challenges in nursing care of the dying in the acute hospital setting. A qualitative observational study.Palliative Medicine. 2013; 27: 757-764Crossref PubMed Scopus (48) Google Scholar). Nurses can find themselves continuing to provide curative or resuscitative care even when they may have realised that a patient is dying (Bloomer et al., 2013Bloomer M.J. Endacott R. O’Connor M. Cross W. The ‘dis-ease’ of dying: Challenges in nursing care of the dying in the acute hospital setting. A qualitative observational study.Palliative Medicine. 2013; 27: 757-764Crossref PubMed Scopus (48) Google Scholar). This problem is not only limited to acute care wards however. This issue has also been noted in the intensive care settings, with identifying the transition from active treatment to end of life care reported by doctors and nurses as one of the most problematic and challenging issues in this setting (Coombs et al., 2012Coombs M.A. Addington-Hall J. Long-Sutehall T. Challenges in transition from intervention to end of life care in intensive care: A qualitative study.International Journal of Nursing Studies. 2012; 49: 519-527Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar). When managing acutely unwell patients in hospital wards whilst coping with the day-to-day workload issues can also make providing ‘gold standard’ care at the end of life a big ask. When faced with such pressures, some nurses default to a task focus to get the job done (Bloomer et al., 2013Bloomer M.J. Endacott R. O’Connor M. Cross W. The ‘dis-ease’ of dying: Challenges in nursing care of the dying in the acute hospital setting. A qualitative observational study.Palliative Medicine. 2013; 27: 757-764Crossref PubMed Scopus (48) Google Scholar). However focusing on the tasks at hand may not be just about meeting workload demands. There is evidence that, despite the frequency of deaths in acute care wards, not all nurses are comfortable in caring for the dying patient. Patient's death can be uncomfortable, ambiguous and difficult (Pincombe et al., 2003Pincombe J. Brown M. McHutcheon H. No time for dying: A study of the care of dying patients in two acute care Australian hospitals.Journal of Palliative Care. 2003; 19: 77-86PubMed Google Scholar), typifying the emotional impact that a dying patient can have on the nurse (Bloomer et al., 2013Bloomer M.J. Endacott R. O’Connor M. Cross W. The ‘dis-ease’ of dying: Challenges in nursing care of the dying in the acute hospital setting. A qualitative observational study.Palliative Medicine. 2013; 27: 757-764Crossref PubMed Scopus (48) Google Scholar). This finding suggests that as much as some emotion can be considered normal in response to a death, not all nurses inherently have the emotional preparation or particular skills and qualities necessary for providing high quality end of life care outlined by the Consensus Statement (2015). Acknowledging that some progress has been made towards improving end of life care in acute settings, many challenges remain. Health service organisational processes and practices can also impede ideal end of life care. Identified as a source of frustration and dissatisfaction by nurses, these issues contribute to making caring for the dying even more challenging (Bloomer et al., 2013Bloomer M.J. Endacott R. O’Connor M. Cross W. The ‘dis-ease’ of dying: Challenges in nursing care of the dying in the acute hospital setting. A qualitative observational study.Palliative Medicine. 2013; 27: 757-764Crossref PubMed Scopus (48) Google Scholar). When talking about organisational processes and practices, consideration must be also be given to changing the culture in acute care if end of life care is to improve. The Consensus Statement of the ACSQHC, 2015Australian Commission on Safety and Quality in Health Care (ACSQHC) National consensus statement: Essential elements for safe and high-quality end-of-life care. ACSQHC, Sydney2015Google Scholar does acknowledge that for many acute care organisations, significant cultural change will be necessary. Of course, hand in hand with attempts to change culture must also come education, particularly if a change or improvement in clinical practice is desired. The Consensus Statement acknowledges that the provision of safe and high-quality end of life care requires all clinicians to be appropriately qualified and skilled to manage end of life care, but falls short in the detail. Many other publications have stressed the importance of education to creating practice change, but too little has been done. What is needed now is response to the recommendations made. To support those who will not recover from their illness and those who need high quality care at end of life, it is time for health service managers and policy makers; educators and those responsible for the provision of care to prioritise change. We need a call to action if we are going to meet and exceed the aspirations of the ACSQHC's Consensus statement, and more importantly, improve end of life care.