Insights into End-of-Life Care Provision for Hospitalised Patient Groups Experiencing Vulnerability

Abstract

Objectives: Little research focuses on end-of-life care for patient groups experiencing vulnerability. Palliative care services are widely established in Victoria, Australia’s largest state, however access and experiences for prisoners and illicit drug users (IDUs) is largely unknown. Aim: To describe the end-of-life care experiences of prisoners and illicit drug users who die in the hospital setting. Methods: This exploratory, mixed methods study used a retrospective medical record audit of consecutive prisoners and IDUs who died in hospital. Descriptive statistics were used to describe outcomes extracted from records for the final 3-months of life, including: clinical and demographic characteristics; access and timing of palliative care; goals of care discussions; medication use; intensive care unit (ICU) and emergency department (ED) use; and place of death. An in-depth qualitative thematic analysis was conducted to supplement findings and highlight experiences, barriers and enablers to quality palliative care. Focus groups with health care professionals were conducted and thematically analysed. Results: Thirty patients including 10 prisoners, 17 IDUs, and 3 IDU prisoners were identified. Majority male (97%), aged 39-93yrs (median 55yrs), with two-thirds having a cancer diagnosis. Prisoners and IDUs had a total median length of stay (LOS) of 61 and 20 days respectively, with the majority (85% and 65%) having ≥1 hospital admission. Approximately half of prisoners and IDUs had ≥2 ED presentations, and 3 (23%) and 8 (40%) respectively had an ICU stay. Ten (77%) prisoners and 6 (60%) IDUs received access to palliative care consultation. Of these, half (n=5; 39% and n=6; 30%) were transferred to the palliative care unit, a median of 21 days after admission, where they died (median LOS prisoners = 5 days, IDUs = 15 days). Over half of prisoners (54%) died in the high security hospital ward. Qualitative themes around complexity of care included: constraints on provision and place of care; adequacy and suitability of pain management; restricted visitation; and late recognition of dying. Conclusion: This study demonstrated prisoners and IDUs with life limiting illnesses spend one or more of their final months of life in acute hospital care. Results provide important insights which can inform future service provision and improve the end-of-life experiences for patients experiencing vulnerability. Source of funding: Inclusive Health Innovation Fund, St Vincent’s Health Australia.