Palliative approach remains lacking in terminal hospitals admissions for rural chronic disease – multi-site audit

Assoc/Prof Disler is an Australian Research Council Discovery DECRA Fellow from Monash University. Through her research, she leads improvement in access to care and models of care for people living with advanced chronic disease, particularly in rural settings. Rebecca is funded by a prestigious ARC Fellowship to address end-stage chronic disease in rural Australia. As Fellow of the American and ANZ Thoracic Societies, Convenor of the Symptom Support and Palliative Care group for ANZ Thoracic Society, and as a Cochrane review author, her work has been included in several international and national guidelines, including NICE UK and global GOLD strategies.

Despite clear benefit from palliative care in end-stage chronic disease, access is often limited, and rural access largely unknown.

This study sought to determine if a palliative approach is present in final hospital admissions for chronic disease.

Retrospective medical record audit from five rural Australian hospitals, for patients who died from chronic obstructive pulmonary disease (COPD), chronic cardiac failure (CCF) and end-stage renal failure (ESRF) over 2019. The state of Victoria has a population of 6.61 million people, with 24.5% living in regional and rural areas.

Of 241 patients, 143 (59.3%) were male, with median age 82.5 years (IQR 74.25-88.75), and with diagnoses of COPD (n=56, 23.2%), CCF (n=56, 23.2%), ESRF (n=24, 10.0%) or multimorbidity (n=105, 43.6%).

Outpatient chronic disease care was largely evident (n=171, 73.7%), however, contact with a private physician (n=91,37.8%), chronic disease program (n=61, 25.3%), or specialist nurse (n=17, 7.1%) were less apparent.

“Not-for-resuscitation” orders were common (n=139, 57.7%), however, advance care planning (n=71, 29.5%), preferred place of death (n=18, 7.9%), spiritual support (n=18, 7.5%), and multidisciplinary planning meetings (n=7, 2.9%) were sparse. Referral to and input from palliative care were also low (n=74, 30.7% and n=49, 20.3%, respectively), as was review of non-essential medications and routine blood tests (n=86, 35.7%, and n=78, 32.4%, respectively). Opioids were prescribed in 45.2% (n=109) of patients, most commonly for pain (n=28, 25.7%) and dyspnoea (n=9, 9.3%).

Hospital site and diagnosis were significantly associated with outpatient care and palliative approach.

While it is evident that end-of-life planning and palliative care involvement in chronic disease are limited more broadly, this situation was found to be more pronounced within five rural sites. Targeted strategies are necessary to improve care for these prevalent and high needs rural populations.