End-of-life care for older people in subacute care: a retrospective clinical audit

Background: With an ageing population and chronic illness the leading cause of death, challenges exist in meeting the healthcare needs of older people. For older people, care may be provided in subacute care services where, although the focus is on rehabilitation and optimisation of functioning, many older people will die. Aim: To investigate end-of-life care provision for older people in subacute care. Methods: A retrospective clinical chart audit of all subacute inpatient deaths in one year. Results: 54 inpatients died in subacute care and almost all had been transferred from an acute care setting. The mean age was 83 (SD = 9), patients had multiple diagnoses and were admitted for assessment or to establish a safe discharge destination. None were identified as 'terminal' on admission and none had an Advance Care Plan to guide care preferences. Prior to death, more than half (57.4%) received terminal care compliant with the Promoting Improved Care of the Dying (PICD) guideline. 53.7% were referred for specialist palliative care review, and despite a mean wait time of 0.6 days (SD = 0.8), 11.1% of patients died before specialist palliative care review. Documentation of communication with patients/family of the likelihood of death occurred in two key sequential time points; the first was information-related and the second decision-related. When these time points occurred impacted end-of-life care provision. Ambiguity in language used to communicate patient deterioration and dying with clinicians and family, impacted understanding and provision of end-of-life care. Conclusions: Education is needed to aid clinicians in subacute care to identify patient deterioration and dying and communicate the likelihood of death to the multidisciplinary team and with patients and families. Nursing and allied health clinicians are well placed to have greater involvement in communicating patient deterioration and likely death.