Biases in palliative care access for elderly patients dying in hospital: A prospective study in acute care

Background: Patients in the terminal phase of chronic illnesses are often admitted to acute care wards, with the risk of receiving inappropriate intensive treatments as opposed to necessary palliative care (PC). Objective: To assess patient features and possible service biases in the activation of PC pathways, or lack thereof, for those dying in acute care. Design and setting: This was a prospective observational study of all patients admitted to our acute medical ward from the emergency department during 6 months. Measurements: Need for palliation was evaluated for all patients by a physician and a nurse of the Internal Medicine ward. Those proposed for PC were re-evaluated by a consultant and a nurse of the PC unit. Clinical and epidemiological data were obtained for those selected for PC, and those deceased in the acute ward without having received PC. Results: A total of 781 patients were admitted to the acute care ward and screened during the study period. Of the 56 patients assigned to the PC pathway, those that died in hospital (n = 30) had significantly poorer Karnofsky, Braden, and ECOG scores compared to those alive at discharge (n = 26). Forty-eight more patients died on the ward without having received PC. The prevalence of cardiopulmonary diseases was significantly higher in this group, while more oncologic patients died in the PC cohort. Conclusions: Palliative treatment needs to be augmented and better targeted in acute care settings. Special attention should be given to patients with cardiopulmonary illnesses, a possible bias preventing the activation of this type of care, and those at high risk of developing pressure ulcers. Further education and training in this field are crucial for healthcare professionals working in acute wards.