Fiona Graham

Imminence of death among hospital inpatients: Prevalent cohort study:

Background: There is a dearth of evidence on the proportion of the hospital population at any one time, that is in the last year of life, and therefore on how hospital policies and services can be oriented to their needs. Aim: To establish the likelihood of death within 12 months of a cohort of hospital inpatients on a given census date. Design: Prevalent cohort study. Participants: In total, 10,743 inpatients in 25 Scottish teaching and general hospitals on 31 March 2010. Results: In all, 3098 (28.8%) patients died during follow-up: 2.9% by 7 days, 8.9% by 30 days, 16.0% by 3 months, 21.2% by 6 months, 25.5% by 9 months and 28.8% by 12 months. Deaths during the index admission accounted for 32.3% of all deaths during the follow-up year. Mortality rose steeply with age and was three times higher at 1 year for patients aged 85 years and over compared to those who were under 60 years (45.6% vs 13.1%; p < 0.001). In multivariate analyses, men were more likely to die than women (odds ratio: 1.18, 95% confidence interval: 0.95–1.47) as were older patients (odds ratio: 4.99, 95% confidence interval: 3.94–6.33 for those who were 85 years and over compared to those who were under 60 years), deprived patients (odds ratio: 1.17, 95% confidence interval: 1.01–1.35 for most deprived compared to least deprived quintile) and those admitted to a medical specialty (odds ratio: 3.13, 95% confidence interval: 2.48–4.00 compared to surgical patients). Conclusion: Large numbers of hospital inpatients have entered the last year of their lives. Such data could assist in advocacy for these patients and should influence end-of-life care strategies in hospital.

Predictors of place of death in South West Scotland 2000-2010: Retrospective cohort study.

Background: Surveys suggest most people would prefer to die in their own home. Aim: To examine predictors of place of death over an 11-year period between 2000 and 2010 in Dumfries and Galloway, south west Scotland. Design: Retrospective cohort study. Setting/Participants: 19,697 Dumfries and Galloway residents who died in the region or elsewhere in Scotland. We explored the relation between age, gender, cause of death (cancer, respiratory, ischaemic heart disease, stroke and dementia) and place of death (acute hospital, cottage hospital, residential care and home) using regression models to show differences and trends. The main acute hospital in the region had a specialist palliative care unit. Results: Fewer people died in their own homes (23.2% vs 29.6%) in 2010 than in 2000. Between 2007 and 2010, men were more likely to die at home than women (p < 0.001), while both sexes were less likely to die at home as they became older (p < 0.001) and in successive calendar years (p < 0.003). Older people with dementia as the cause of death were particularly unlikely to die in an acute hospital and very likely to die in a residential home (p < 0.001). Between 2007 and 2010, an increasing proportion of acute hospital deaths occurred in the specialist palliative care unit (6% vs 11% of all deaths in the study). Conclusion: The proportion of people dying at home fell during our survey. Place of death was strongly associated with age, calendar year and cause of death. A mismatch remains between stated preference for place of death and where death occurs.

Irish Hospice Friendly Hospitals programme

Ellershaw and colleagues champion the importance of structured approaches to improving end of life care as part of the core business of hospitals.1 An audit of end of life care in 999 patients across 43 Irish hospitals, conducted as part of the Hospice Friendly Hospitals programme,2 found that …

Likelihood of Death Within One Year Among a National Cohort of Hospital Inpatients in Scotland

To the Editor: We thank Beas and Dı́az-Pardav e for their continued interest in our article demonstrating high burnout among palliative care clinicians. Burnout is ultimately a complex, multifaceted syndrome characterized by varying degrees of emotional exhaustion, depersonalization, and low sense of personal accomplishment. As the authors highlight, a variety of approaches have been used to assess and report on burnout in the literature. Burnout is best considered a continuous variable and the experience of burnout a continuum. A dichotomous categorization (burned out vs. not burned out) is, however, a commonly accepted and practical approach to describe the prevalence of burnout. We applied the most widely used convention to categorize burnout, which considers those with high scores on either the emotional exhaustion and/or depersonalization domain to be experiencing at least one symptom of burnout. Evidence indicates that high scores on either the depersonalization or emotional exhaustion subscales have high discriminatory ability and that a high score in either of these two domains identifies individuals whose degree of burnout results in adverse personal and professional consequences. Evidences also suggest that this approach better identifies those individuals experiencing the adverse consequences of burnout than more restrictive approaches to categorization. Accordingly, there is strong evidence for the way burnout was categorized in our study and the high prevalence of this syndrome among palliative care professionals is cause for concern. Additional studies are now needed to identify practical approaches for health care organizations to reduce burnout and promote engagement in the palliative care workforce.

Changing technologies of cancer pain relief: case studies of innovation

In a previous article (1), we presented the first phase of a project within the International Observatory on End of Life Care that is seeking to develop an analysis of the specific problem of cancer pain relief in its historical and cultural context (2). We offered a historical overview of major themes in cancer pain relief in the 20th century by exploring the interplay of regulatory, scientific, clinical, cultural and ethical dimensions – themes which continue to shape contemporary debate and practice. In this article, we present an overview of the second phase of the study in which we explore contemporary debate and practice in case studies of three fields of innovation that emerged from our earlier analysis of the history of cancer pain relief since 1945.