Achieving the preferred place of care for hospitalized patients at the end of life.

BACKGROUND: The Department of Health end-of-life strategy contains a number of quality markers which include taking into account patients' wishes for their final place of care. There is a wide variation in how this information is recorded. METHODS: An audit was conducted on discussion of preferred place of care (PPC) for all patients referred to the hospital palliative care team who died during the audit period. Barriers to achieving PPC and the efficacy of a fast track discharge service were also monitored. The audit was first done in 2007 and was repeated in 2009. RESULTS: There was an increase in recording PPC. Overall PPC wishes were ascertained for 87% of the patients seen by the team. The PPC was achieved in 76% of cases. The number of patients wishing to die in hospital significantly increased over the audit cycle (from 10% to 30%). Approximately one-third of patients changed their minds regarding PPC. CONCLUSIONS: The data highlights the need to distinguish between preferred place of care and preferred place of death. Patients' wishes regarding PPC change as death approaches. A greater number of patients wished to die in hospital than was expected.

Evaluating a fast-track discharge service for patients wishing to die at home.

BACKGROUND: The UK Department of Health's End of Life Care Strategy highlighted the low percentage of patients who achieve their wish to die at home (~20%). Figures in south west London were below the London regional average. This paper reports an attempt to improve the proportion of patients from one hospital in the area achieving their preferred place of death. METHODOLOGY: A funded initiative by two local primary care trusts allowed the development of a 7-day-per-week fast-track discharge service provided by the hospital palliative care team. The hospital team acted as coordinators, ensured that the correct medication and equipment would be available at the home, and personally transferred the patients to community services. RESULTS: Data is presented from the first representative period of fast-track discharging (June 2009-July 2010). A total of 110 discharges were facilitated over this time, with the rate increasing as the service developed. The vast majority of discharges occurred within 72 hours, and a significant number (~20%) occurred within 24 hours. CONCLUSIONS: The data indicate that the new service is effective. There are logistical problems in providing such a service and these are discussed. Further work is required to determine the feasibility of extending this service model to other acute hospitals and to evaluate its health-economic impact.