A case study approach to investigating end-of-life decision making in an acute health service.

Aim: To identify end-of-life (EOL) decision making processes for patients with non-cancer illnesses in a major metropolitan hospital.

Methods: A retrospective review using a case study framework of 47 randomly selected patient records over a 6-month period explored issues in EOL care planning.

Results: Reviewed charts represented 53% of total deaths in the study period. All patients (aged 66-99) had co-morbid conditions. In 64%, the first record of EOL discussions occurred in the last 24h of life. Four case groups were identified, ranging from a clear plan developed with patient/family involvement and fully implemented, to no plan with minimal patient/family involvement in decision making. Factors related to clearer EOL care planning according to expressed patient wishes included multiple previous admissions, shorter hospitalisations at EOL, living with a relative and involvement of family in decisions about care.

Conclusion: This study has shown that the development and effective implementation of EOL plans is associated with the active involvement of both family members and health professionals. It also draws attention to the risks of delaying EOL discussions until late in the illness trajectory or later in life as well as pointing to challenges in acting on EOL developed outside the hospital environment.