An increasing number of older people are using hospital emergency departments (EDs) despite their wish to be treated at home (Marie Curie, 2018). Bone et al (2019a) examined the evidence from 21 published studies comprising over 1 million participants to understand the factors associated with ED attendance in the months preceding death from non-cancer conditions. They found a strong association between lower ED attendance and palliative/hospice care and between higher attendance and non-white ethnicity, male gender, non-cancer diagnoses and rural areas. Interestingly, non-cancer diagnoses attract less palliative care, which suggests that greater access to care and support may reduce ED visits. This review did not include access to generalist nurses or doctors.
Bone et al (2016) explored the factors associated with end-of-life transition from preferred place of care to hospital as place of death among 443 participants over 75 years of age, of whom 146 (32.3%) transferred to hospital and died there in two contrasting geographical areas in southern England. As in the review, non-cancer disease, particularly, respiratory disease and severe breathlessness, was associated with higher hospital admissions with known advance care preferences, and having a key health professional being associated with lower transfer rates. Thus, good district nursing support with appropriate advance care planning may enable people to die at home. McNamara et al's (2018) audit of frequent ED attendance (over four attendances) over 12 months among those aged 65 years and over found that deprivation, dependency, number of long-term conditions and polypharmacy were significant predictors, indicating the importance of social determinants as well as health factors in understanding the use of EDs.
Bone et al's (2019b) latest study examined ED attendance in the last 3 months of life in those aged 65 years or over and found that 12.1% of their study population (80/661) had attended an ED over three times. Their statistical modelling indicated that more frequent ED attendance was associated with respiratory disease, more than two comorbidities and more than seven community nursing contacts, while lower attendance was associated with having an identified key health professional. The respondents reported inadequate community care and poor care coordination together with untimely hospital discharge as contributing to ED attendance. Having an identified health professional, which could be a district nurse, may help mitigate these issues, as appears to be the case with those receiving palliative care for cancer.
The evidence appears to suggest that the use of EDs and transfer to hospital could be mitigated if clients towards the end of their lives and their families feel well supported at home. The presence of a key health professional, previously known as a key worker, who manages care coordination and ensures that clients and their families have discussed and agreed an advance care plan offers district nursing services a potential model for care delivery that prevents avoidable hospital attendance and enables death at home. Of course, the delivery of high-quality home care tests the adequacy of district nursing staffing levels, as it entails overcoming the challenges of meeting expectations regarding continuity of carer as well as continuity of care when different staff are on duty.
‘The evidence appears to suggest that the use of emergency departments and transfer to hospital could be mitigated if clients towards the end of their lives and their families feel well supported at home.’