Life In The Slower Lane

Here is the structured PICO analysis for the thirtieth article you uploaded:

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Full Title (verbatim and exact):

“Care to the end: a retrospective observational study of aged care facility residents transferred to hospital in the last day of life”

Brownstein H, Hayes B, Simadri A, Tacey M, Holbeach E

Internal Medicine Journal (2021); 51:27–32

DOI: https://doi.org/10.1111/imj.15084

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Type of Article:

Retrospective observational study

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PICO Analysis:

Population:

• 149 aged care facility (ACF) residents transferred to a metropolitan emergency department (ED) in Melbourne, Australia
• All died within 24 hours of hospital arrival (2012–2017)
• Median age: 87 years; 42% male; 46% from non-English speaking backgrounds (NESB)
• Median Charlson Comorbidity Index: 7, indicating complex health profiles 

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Intervention:

• Not an interventional study; the intervention of interest is the emergency hospital transfer, but the study also explores:
  • Availability of advance care planning (ACP) documents
  • Pre-emptive prescribing of palliative medications on RACF drug charts
  • Timing and quality of medical review before transfer 

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Comparator:

• No formal comparator group; however, subgroup comparisons were made within the cohort based on:
  • Presence vs absence of ACP documentation
  • Anticipatory prescribing vs no prescribing of end-of-life medications
  • In-hours vs out-of-hours transfers 

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Outcome:

1. Person-centred outcomes (proxy indicators):

• Only 8% had anticipatory opioid prescriptions on RACF medication charts
• 33% required hospital-administered benzodiazepines, but only 15% had anticipatory orders
• 42% of residents had ACP documents; 8% of transfers were inconsistent with their ACP
• 71% had no medical review within 12 hours of transfer
• Residents with ACP were more likely to have anticipatory symptom management prescribed (P = 0.023) 

2. Process outcomes:

• 56% of transfers occurred out-of-hours
• Median time to death after ED arrival was 8 hours
• Most common reasons for transfer: shortness of breath (46%) and altered conscious state (32%)
• Leading cause of death: pneumonia (37%) 

3. Health system outcomes:

• Only 0.5% of ED presentations by RACF residents involved death within 24 hours, but they accounted for 30% of all RACF hospital deaths over 5 years
• Suggests a significant mismatch between ACP intentions and execution when rapid deterioration occurs and access to skilled palliative care or symptom relief is limited in RACFs 

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Summary Conclusion:

This retrospective study highlights critical gaps in the palliative readiness of aged care facilities when residents experience rapid end-of-life deterioration. Key barriers to supporting dying in place include: lack of timely medical review, insufficient anticipatory prescribing of comfort medications, and variable application of ACPs. While ACP documentation was associated with better preparedness, it was not sufficient to prevent hospital transfers in many cases. Improving clinical recognition of dying, after-hours support, and access to medications are necessary to reduce potentially non-beneficial hospital transfers at the end of life.

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