A smooth transition towards the end of life – Illusion or Reality?

Summary Background Previous research has indicated relatively short hospice admissions and high frequency of transfers in the last phase of life, which causes an enormous impact on the life of patients and relatives. In the Netherlands, limited figures on length of stay and number of transfers are available. Furthermore, the most appropriate moment to transfer patients to hospices and the factors associated with the moment of transfer have not been assessed. Therefore, it is unclear whether the introduction of the trajectory model by the Dutch government, which reflects the ambition to provide continuous end-of-life care, seems to be an illusion or reality. Aim 1) To examine the number of transfers in the last three months of life and the length of stay in a hospice. 2) To explore what professionals define as the most appropriate moment to transfer patients to the hospice and to explore which factors influence the moment of transfer. Study setting & Design The study was conducted in a hospice in Rotterdam, the Netherlands. The study was performed as a two phase, sequential mixed method design. Sample Phase 1: Random sample of one hundred patients over 18 years of age who had been admitted in the hospice and who died between 2009 - 2011. Phase 2: Nine professionals who had been involved with transfers of patients in the hospice or referring hospital. Methods & Analysis Phase 1: Retrospective review of patient files was performed to gather data on the following variables: gender, age, diagnosis, number of transfers in the last three months of life, referral source and length of stay (LOS). Descriptive statistics, Mann-Whitney tests and a Kruskal – Wallis test hasve been performed. Phase 2: Semi-structured interviews were held to acquire data on the moment of transfer, information accompanied with transfers and the awareness of the transition from life to death. Data were analyzed using thematic analysis. Results Phase 1: The mean number of transfers in the last three months of life was 2.0 ± 1.0. The average LOS was 21 days (SD 29.0, median 13.0). A higher number of transfers was significantly (p<0.01) associated with referral source. LOS was not found to be associated with the number of transfers nor with referral source. Phase 2: The most appropriate moment to transfer was defined as a transfer resulting in a length of stay between 3 weeks till 3 months and in which there was sufficient time to provide palliative care. Clinical, patient/family, physician and institutional factors were found to be associated with the moment of transfer. Conclusion The majority of patients were transferred twice or more times and the length of stay was relatively short. However, it seems difficult to define the most appropriate moment to transfer on forehand since the moment of transfer is dependent on clinical, patient/family, physician and institutional factors. Therefore, continuous end-of-life care as depicted in the trajectory model still remains an ambition.