Dying in Hospital in Ireland: An Assessment of the Quality of Care in the Last Week of Life, Final Synthesis Report

The context of this report is set by the fact that most people die in a hospital or similar setting, outside the home. When you consider that most people are also born in hospital, and may spend some time there over the course of a lifetime, it becomes clear that hospitals are central to our passage into life and out of it, touching people at the most important and intimate moments of their lives. In this sense, the work of hospitals mirrors the cycle of life and the expectations of society about its role at each stage of the life cycle.The report assesses the quality of care provided by Irish hospitals in the last week of life. The word 'hospital' shares a common linguistic root with words like hospice and hospitality. Hospitality -- understood as being welcomed and cared for with kindness and attentiveness -- is still what everyone seeks when they come to hospital, including patients and their families who are going through the journey of dying, death and bereavement. That is why the Hospice Friendly Hospitals Programme (2007-2012) commissioned this first ever national audit of end-of-life care in Irish hospitals.This report contributes to the growing practice within the Irish hospital system of auditing performance against standards in order to ensure that every aspect of its work meets, and even exceeds, the highest standards of care and excellence. Given that end-of-life care standards did not exist at the time the audit -- but have since been published as Quality Standards for End-of-Life Care in Hospitals1 -- it may be more appropriate to regard this report as a "pre-audit" or "baseline-audit". It is Government policy, since February 2009, to introduce a mandatorylicensing system whereby each hospital will only be allowed to practice if, on the basis of audited performance, it meets acceptable quality standards of service

Dying in hospital in Ireland: an assessment of the quality of care in the last week of life: National audit of end-of-life care in hospitals in Ireland, 2008/9

The context of this report is set by the fact that most people die in a hospital or similar setting, outside the home. When you consider that most people are also born in hospital, and may spend some time there over the course of a lifetime, it becomes clear that hospitals are central to our passage into life and out of it, touching people at the most important and intimate moments of their lives. In this sense, the work of hospitals mirrors the cycle of life and the expectations of society about its role at each stage of the life cycle. The report assesses the quality of care provided by Irish hospitals in the last week of life. The word ‘hospital’ shares a common linguistic root with words like hospice and hospitality. Hospitality – understood as being welcomed and cared for with kindness and attentiveness - is still what everyone seeks when they come to hospital, including patients and their families who are going through the journey of dying, death and bereavement. That is why the Hospice Friendly Hospitals Programme (2007-2012) commissioned this first ever national audit of endof-life care in Irish hospitals. This report contributes to the growing practice within the Irish hospital system of auditing performance against standards in order to ensure that every aspect of its work meets, and even exceeds, the highest standards of care and excellence. Given that end-of-life care standards did not exist at the time the audit – but have since been published as Quality Standards for End-of-Life Care in Hospitals1 – it may be more appropriate to regard this report as a ‘pre-audit’ or ‘baseline-audit’. It is Government policy, since February 2009, to introduce a mandatory licensing system whereby each hospital will only be allowed to practice if, on the basis of audited performance, it meets acceptable quality standards of service

Management of death rattle at end of life

Noisy breathing or death rattle is a common clinical sign in the final days of life. When it occurs, the level of consciousness is usually low and it is generally assumed that patients are not distressed by it. Despite the assumption that patients are not distressed, death rattle is usually actively treated in palliative care settings through a combination of pharmacological and non-pharmacological measures. Anti-cholinergic or anti–muscarinic medications are the drugs of choice in practice, even in the absence of patient distress, despite there being no conclusive evidence to suggest that any drug is superior to placebo. In addition, a recent Cochrane review suggested that there is a lack of supporting evidence for the use of anti-cholinergics to treat death rattle (Wee and Hillier, 2010). The choice of drug is based on the various properties of the drug and the desired effects. However, treatment is focused on alleviating the perceived distress of family members rather than aimed specifically at benefiting the patient. Moreover, anti-cholinergic drugs can result in unpleasant side-effects such as urinary retention and dry mouth for patients who are probably unable to report symptoms. Recent research calls for prescribers to consider carefully why they are treating death rattle. Moreover, families need to be reassured and have it explained to them that it is unlikely that the patient is distressed and why this is the case.peer-reviewe

Management of death rattle at end of life

Noisy breathing or death rattle is a common clinical sign in the final days of life. When it occurs, the level of consciousness is usually low and it is generally assumed that patients are not distressed by it. Despite the assumption that patients are not distressed, death rattle is usually actively treated in palliative care settings through a combination of pharmacological and non-pharmacological measures. Anti-cholinergic or anti–muscarinic medications are the drugs of choice in practice, even in the absence of patient distress, despite there being no conclusive evidence to suggest that any drug is superior to placebo. In addition, a recent Cochrane review suggested that there is a lack of supporting evidence for the use of anti-cholinergics to treat death rattle (Wee and Hillier, 2010). The choice of drug is based on the various properties of the drug and the desired effects. However, treatment is focused on alleviating the perceived distress of family members rather than aimed specifically at benefiting the patient. Moreover, anti-cholinergic drugs can result in unpleasant side-effects such as urinary retention and dry mouth for patients who are probably unable to report symptoms. Recent research calls for prescribers to consider carefully why they are treating death rattle. Moreover, families need to be reassured and have it explained to them that it is unlikely that the patient is distressed and why this is the case

Determinants of care outcomes for patients who die in hospital in Ireland: A retrospective study

More people die in hospital than in any other setting which is why it is important to study the outcomes of hospital care at end of life. This study analyses what influenced outcomes in a sample of patients who died in hospital in Ireland in 2008/9. The study was undertaken as part of the Irish Hospice Foundation’s Hospice Friendly Hospitals Programme (2007–2012). Methods: Outcomes of care were assessed by nurses, doctors and relatives who cared for the patient during the last week of life. Multi-level modelling was used to analyse how care outcomes were influenced by care inputs. Results: The sample of 999 patients represents 10% of acute hospital deaths and 29% of community hospital deaths in Ireland in 2008/9. Five care outcomes were assessed for each patient: symptom experience, symptom management, patient care, acceptability of the way patient died, family support. Care outcomes during the last week of life tended to be better when: the patient had cancer; admission to hospital was planned rather than emergency; death occurred in a single room or where privacy, dignity and environment of the ward was better; team meetings were held; there was good communication with patients and relatives; relatives were facilitated to stay overnight and were present at the time of death; nursing staff were experienced and had training in end-of-life care; the hospital had specific objectives for developing end-of-life care in its service plan. Conclusions: The study shows significant differences in how care outcomes, including pain, were assessed by nurses, doctors and relatives. Care inputs operate in a mutually reinforcing manner to generate care outcomes which implies that improvements in one area are likely to have spillover effects in others. Building on these findings, the Irish Hospice Foundation has developed an audit and review system to support quality improvement in all care settings where people die

Dying in Hospital in Ireland: An Assessment of the Quality of Care in the Last Week of Life, National Audit Report 5: Final Synthesis Report

This publication draws together the key findings from the first-ever National Audit of End-of-Life Care in Hospital in Ireland, 2008/9, commissioned by the Irish Hospice Foundation. The audit system of the Hospice friendly Hospitals Programme (HfF) is the first major initiative in an EU country to develop a comprehensive assessment of standards for end-of-life care in the hospital setting. The study involved the detailed capture of information on the end-of-life care experience of over 1,000 patients in 43 participating acute and community hospitals throughout Ireland. The first phase of the study commenced in November 2008 and finished at the end of 2009. The Evaluation was co-ordinated by Dr. Kieran McKeown. Trutz Haase and Jonathan Pratschke were responsible for all data analysis