Time to rethink end-of-life care

Our health system supports a model of care that is strongly reliant on provision of services in hospital. Two studies reported in this issue of the Journal illustrate the dominance of this model, the increasing demands on the system, and the way that the quality of care provided may be inappropriate for two major groups in our community: the very old and those with terminal disease. An accompanying editorial by Abernethy (→ "Learning health care" for patients and poulations) calls for a patient-focused “learning” health system to facilitate care for these groups.

It has long been accepted that the majority of an individual’s health care costs are expended during the last few months of life. However, acknowledging the futility of this has not led to the development of effective alternatives. Little work has previously been done in Australia to examine the delivery of care for seriously ill Australians in their last months of life. The findings of Rosenwax and colleagues in this regard (→ Hospital and emergency department use in the last year of life: a baseline for future modifications to end-of-life care) are bleak, but perhaps not surprising. Of patients in their study who were suitable for palliative care, 70% had at least one visit to the emergency department and 96% were admitted to hospital during their last year of life, with an average of eight admissions and a mean length of stay of 6 days. Most of the admissions and time spent in hospital occurred within the last 3 months of life, and 62% of patients died in hospital. These are all markers of a poor standard of palliative care (J Clin Oncol 2003; 21: 1133-1138), which we accept too readily.

Lowthian and colleagues analysed the use of emergency ambulance transport in Melbourne (→ The challenges of population ageing: accelerating demand for emergency ambulance services by older patients, 1995–2015), showing an increasing demand for this service and, by implication, the hospital system, particularly by patients aged 85 years or older. Since 1994–95, the annual rate of emergency ambulance transfers increased by almost 5% beyond what could be explained by population changes. The authors project a further increase in usage to 2014–15 of up to nearly 70%. Although people aged 85 years or older comprised 1.6% of the population in 2007–08, they accounted for 13.6% of emergency transportations. As the authors point out, ambulance transportation most often results in emergency department attendance, with a high rate of subsequent hospital admission. Older patients are more likely to be admitted, and typically for longer, than other age groups. As our population ages, demand for both ambulance and hospital services will rise, and this will need to be factored into health planning.

At heart, both these studies identify a need for an alternative model of care. An aggressive-treatment, event-determined and hospital-centred model fails to give appropriate care to the terminally ill and older people who have complex chronic comorbidities. The articles canvass some alternative models, but neither suggests assessing whether good primary care can reduce demand on ambulance and hospital service use.

Palliative care and aged care should not primarily be the province of the hospital and the acute health care system, and our continued acceptance of this and of the concentration of health care spending in the last months of life is no longer tenable. It represents both bad care and a waste of money.