“Last Orders”: Dying in a Hospital Setting

Abstract

Advanced care planning and end-of-life decision making are part of contemporary debates about death and dying. A data-mining study reviewing medical records of patient deaths in hospital investigated these issues and the utilisation of social work services. Findings indicated that the majority of records included some form of documentation about end-of-life care, including cardio pulmonary resuscitation (CPR) orders and that family members and surrogate decision makers were more likely to be consulted than patients about these plans. The incidence of referrals to social workers was found to be highest “out-of-hours”. Key social work interventions were identified, including establishing the reliability of surrogates' decisions through social work assessment. This paper discusses elements that contribute to a supportive environment for patients and family members to facilitate the decision making process, including the need for a broader ethical discourse to accommodate the increasing complexity of end-of-life decision making in hospital settings.

Keywords:

• Advanced Care Planning
• CPR Orders
• End-of-Life Decision Making

Acknowledgements

The authors wish to thank the following departments and staff for their support and involvement in this study: the Social Work Department, Westmead Hospital; reviewers Alison Andrews, Jyoti Chandna, Nicole Karklins, and Gay Shanahan for their meticulous audit of medical records and expert input and advice in understanding the data; administrative staff from the social work and medical record departments for their tireless efforts in the retrieval and management of the medical records reviewed.

Notes

¹The “Respecting Patient Choices” program is funded by the Australian Government, Department of Health and Ageing. Further information about this program can be found at: http://www.respectingpatientchoices.org.au

²Each episode of care is reviewed and coded by expert coders in hospital medical records departments using the International Statistical Classification of Diseases & Related Health Problems. Tenth Revision, Australian Modified Version (ICD-10-AM) Diagnostic and Procedure Manuals. These manuals are produced by the National Centre for Classification in Health [NCCH] under contract to the Commonwealth Department of Health and Ageing who hold the World Health Organization licence. This data is collected as part of larger national data sets collected by the ABS, AIHW, and Commonwealth and state health departments. Hospital funding is tied to the mix of cases and the weighting of diagnostic and procedure categories.

³ http://www.nahcc.org.au