Hospitalisation, care plans and not for resuscitation orders in older people in the last year of life

Background: Over 60% of older people have at least one admission to hospital in their last year of life, with the majority of people having multiple admissions. In Bankstown, New South Wales, Australia, we have a diverse ethnic and cultural population. We were interested in bed utilisation, documentation, and follow through of 'care plans' as well as 'not for resuscitation' orders in the last year of life of the older people in our area.

Methods: We reviewed and collected data from the medical records of patients over 65 years of age who died in our hospital. Reviewers included a medical registrar, a research officer and two geriatricians. We collected a wide range of information pertaining to the 12 months before death. This included demographics, chronic illnesses, geriatric syndromes, number of admissions, bed days, care plans, and not for resuscitation orders as well as other relevant data.

Results: 110 patients' records were reviewed. The mean age was 80 years and 31% were from a non English-speaking background. The average number of admissions was 2.4 and the average number of bed days in the last year of life was 25. Sixty-one of the patients had a care plan and a not for resuscitation order, 91% of which were written shortly before death. Using bi-variate analysis of old age (over 80), number of chronic illnesses, or geriatric syndromes present, the number of bed days was positively correlated to care plan and not for resuscitation orders. Logistic multivariate analysis of chronic illnesses revealed that stroke (P = 0.024) as well as stroke and fracture (P = 0.008) were strongly correlated with care plan and not for resuscitation orders. Only 8 patients had an advanced care plan documented prior to last admission. When advanced care plans were documented, they were generally clearly written and followed through appropriately (7 out of 8). Conclusion: This study showed that in our diverse population there were multiple admissions and utilisation of hospital beds for older people in their last year of life. Care plans and not for resuscitation orders were rarely documented prior to last admission. However, when advanced care plans were done, they were usually well documented and followed through appropriately.