Barriers to providing palliative care for older people in acute hospitals

Abstract

the need for access to high-quality palliative care at the end of life is becoming of increasing public health concern. The majority of deaths in the UK occur in acute hospitals, and older people are particularly likely to die in this setting. However, little is known about the barriers to palliative care provision for older people within acute hospitals.
to explore the perspectives of health professionals regarding barriers to optimal palliative care for older people in acute hospitals.
fifty-eight health professionals participated in eight focus groups and four semi-structured interviews.
participants identified various barriers to palliative care provision for older people, including attitudinal differences to the care of older people, a focus on curative treatments within hospitals and a lack of resources. Participants also reported differing understandings of whose responsibility it was to provide palliative care for older people, and uncertainly over the roles of specialist and generalist palliative care providers in acute hospitals.
numerous barriers exist to the provision of high-quality palliative care for older people within acute hospital settings. Additional research is now required to further explore age-related issues contributing to poor access to palliative care.

Full text

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Age and Ageing 2011; 40: 233–238
doi: 10.1093/ageing/afq172 © The Author 2011. Published by Oxford University Press on behalf of the British Geriatrics Society.
All rights reserved. For Permissions, please email: journals.permissions@oup.com
Published electronically 20 January 2011
Barriers to providing palliative care for older
people in acute hospitals
CLARE GARDINER1,MARK COBB3,MERRYN GOTT2,CHRISTINE INGLETON1
1
University of Sheffield –School of Nursing & Midwifery, Sheffield, UK
2
University of Auckland –School of Nursing, Auckland, New Zealand
3
Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Address correspondence to: C. Gardiner. Tel: (+44) 114 262 0174 ext 31. Email: c.gardiner@sheffield.ac.uk
Abstract
Background: the need for access to high-quality palliative care at the end of life is becoming of increasing
public health concern. The majority of deaths in the UK occur in acute hospitals, and older people are particularly likely
to die in this setting. However, little is known about the barriers to palliative care provision for older people within acute
hospitals.
Objective: to explore the perspectives of health professionals regarding barriers to optimal palliative care for older people
in acute hospitals.
Methods: fifty-eight health professionals participated in eight focus groups and four semi-structured interviews.
Results: participants identified various barriers to palliative care provision for older people, including attitudinal differences
to the care of older people, a focus on curative treatments within hospitals and a lack of resources. Participants also
reported differing understandings of whose responsibility it was to provide palliative care for older people, and uncertainly
over the roles of specialist and generalist palliative care providers in acute hospitals.
Conclusions: numerous barriers exist to the provision of high-quality palliative care for older people within acute
hospital settings. Additional research is now required to further explore age-related issues contributing to poor access to
palliative care.
Keywords: palliative care, hospitals, older people, elderly
Background
Demographic trends coupled with a rise in long-term
health conditions and chronic diseases mean that the core
population of patients requiring palliative care is ageing [1].
This is a particular challenge for palliative care whose
demographic profile has tended to be younger and whose
historic disease focus has predominantly been cancer.
Ensuring that palliative care becomes more accessible to
older people and their particular complex and co-existing
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needs has been identified as an international public health
priority [2]. The care provided to people with advanced
progressive and incurable illness is also increasingly the
focus of debate regarding terminology [3]. In the UK,
recent policy has seen a shift that has attempted to separate
the term palliative care from dying [4]. Other countries
including the USA and Australia have also moved away
from associating palliative care with dying, particularly for
older people [5]. These definitional issues add to the com-
plexities of both researching and implementing good care
for the growing numbers of older people with advanced
progressive illness.
In 2008 in excess of a quarter million (56%) of all
deaths in England and Wales occurred in NHS hospitals [6]
and adults aged 75–84 years had the highest hospital death
rates [4]. Palliative care provision in acute hospitals in the
UK has been identified as an area of particular policy pri-
ority in light of a recent report identifying that a proportion
of patients dying in hospitals, the majority of whom are
older people, experience very poor care [7]. A survey of
complaints within the NHS revealed that half of complaints
made between 2004 and 2006 related to care given in acute
hospitals, and of these 54% related in some way to
end-of-life care [8].
The End of Life Care Strategy for England has high-
lighted the delivery of high-quality end-of-life care in
acute hospitals as a particular area of priority [4], acknowl-
edging that numbers of people dying in acute hospitals
are increasing [9]. Whilst for many patients home is the
preferred choice for end-of-life care and death [10], for
some patients hospital is the preferred setting. Older
people in particular have identified significant barriers to
dying at home and often report preferences for care in
hospital, feeling reassured by the presence of medical
expertise and technologies [11]. There are currently 314
hospital-based specialist palliative care (SPC) services in
the UK; these services comprise professionals with
specialist training in palliative care whose remit is to care
for patients who require continuous or high levels of
support [12]. However, the majority of older patients
dying in hospital will receive palliative care from ‘general-
ist’providers, i.e. professionals working within specialties
such as Geriatric Medicine who will not have undertaken
specialist training in palliative care and who provide this
care as a routine part of their ‘usual’care [13,14].
Whilst there is continuing evidence of inequalities in
referral to and use of SPC services for older people [15],
reasons for this are unclear and recent evidence has
suggested that for patients within the specialist cancer care
system, age is not associated with access to SPC [16,17].
Barriers to providing palliative care in acute hospitals are
not well understood and there is a paucity of published lit-
erature in this area, particularly in relation to older people.
This study contributes to the limited UK evidence base by
exploring the perspectives of health professionals regarding
barriers to optimal palliative care for older people in acute
hospitals.
Methods
Given the exploratory nature of the enquiry and the limited
existing evidence base, a qualitative study design was
adopted. Four focus groups were held at general practices
(n= 28), and four focus groups (n= 26) and four inter-
views (n=4)
1
were held in two acute hospitals and two
hospices in UK cities selected to maximise socio-
demographic diversity of patient populations (Sheffield and
Lancaster). The acute hospitals were large city hospitals
both providing geriatric medicine services (one of the hos-
pitals housed an SPC inpatient unit, the other had no inpa-
tient SPC provision but had access to outreach services).
Participants from a range of disciplinary backgrounds and
care settings were selected in order to achieve the
maximum possible variation of experience and opinion
(Table 1). The focus group and interview guide was devel-
oped following a review of the literature and relevant policy
(Table 2). Focus groups and interviews were conducted and
led by CG. The study received ethical approval from the
Sheffield Research Ethics Committee and all participants
gave written informed consent.
Analysis
Focus group and interview transcripts were recorded and
transcribed verbatim, field notes were included where
appropriate. To address issues of rigour and trustworthi-
ness, transcripts were read by three of the authors (C.G.,
M.G., C.I.) and core themes were identified. A coding fra-
mework was developed by consensus and was grounded in
the data rather than decided a priori. Sub-themes were then
identified with the assistance of the data analysis pro-
gramme NVivo 8. The themes and sub-themes discussed
in this article were then further analysed by C.G. Direct
quotations have been selected to illustrate the issues raised
by participants and they are indicative both of typical
responses and of the diversity of views obtained.
Findings
Whilst participants agreed that high numbers of predomi-
nantly older inpatients in acute hospital settings have pallia-
tive care needs, understandings regarding whose
responsibility it was to address those palliative care needs
differed. Participants reported that amongst some health
professionals, palliative care was seen as a service to be
delivered by specialists and was not seen to be in the remit
of those providing acute care in hospitals.
Clinical nurse specialist:‘I think there’s some real atti-
tudes within medical teams or surgical teams as well,
1
Individual interviews were held in cases where participants were unable for
practical reasons to attend a focus group; the same question guide was used
for all focus groups and interviews.
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that it’s not really their business to deal with that …to
deal with palliative care.’[focus group 5]
The prevailing view amongst geriatricians was that the nature
of their speciality gave them some experience in the care of
dying patients. However, they were uncertain as to whether or
not to claim expertise in this area and did not view palliative
care as a core part of their role, there was also a tendency to
equate palliative care with the dying patient.
Registrar in geriatrics:‘surely we have some specialism in
dying, in older people dying? We have a bit of experi-
ence of that? Again where do you fit that into your
programme...to do it justice and do it properly’[focus
group 4]
Other participants, particularly those specialising in pallia-
tive care, believed that basic palliative care could, and
should, be provided by all health professionals involved in
caring for patients reaching the end of life, as an important
component of routine care.
Consultant in Palliative Medicine:‘palliative care is not
only the business of specialist teams...everyone should
be able to deliver the basic, generic palliative care...you
will be facing death and dying whatever speciality you
choose, so those skills have to be had by everyone
and not just by the specialists’[focus group 8].
However, significant barriers were identified to generalists
providing palliative care and instigating referrals to SPC
teams. Whilst some were common to patients of all ages,
the majority had particular resonance for older patients.
Barriers to ensuring appropriate palliative
care provision for older patients
Several participants acknowledged that an older patient with
palliative care needs elicited a different response from them
than a younger patient with comparable needs, and that this
had implications for clinical practice. For example, a term-
inal diagnosis in an older person was seen as less ‘shocking’
and more expected than in a younger person.
Consultant Geriatrician:‘I think it’s possibly the case
that …it’s more acceptable in older people …it’s the
good innings argument...you know they’ve had their
innings, they’re old so they’ve perhaps got less to live
for’[interview 3]
Limited social and family support was also identified as
contributing to a lack of palliative care provision for older
people. Younger people were seen to have more compre-
hensive support networks, as well as often having an advo-
cate who could demand best quality care on their behalf.
The role that family and support networks could play in
facilitating access to services such as SPC was seen as com-
pounding the lack of psychosocial support available to
older people, particularly those who live alone.
Hospice Nurse:‘There’s often a lot more support for
younger people as far as families and people go. With
younger people nearly always family members, friends,
neighbours will rally round. Often with old people
there’s no one.’[focus group 8]
Lack of resources, particularly for people
dying from conditions other than cancer
Both generalist and SPC provision within acute hospitals
were identified as particularly deficient for the population
of predominantly older people dying from conditions other
than cancer. It was reported that patients with non-
malignant disease were less likely to be referred to SPC
Table 1. Descriptive information for focus group
participants (n= 58)
Male 12 (20.7%)
Mean age 46.3 years (SD = 9.92)
Age range 28–69 years
Job title
Consultant 4 (6.9%)
Junior doctor 9 (15.5%)
General practitioner 6 (10.3%)
Practice nurse 4 (6.9%)
Clinical nurse specialist 11 (19.0%)
Other nurse 19 (32.7%)
Allied health professional 5 (8.6%)
Place of work
Acute hospital 10 (17.2%)
GP practice 28 (48.3%)
Hospice 15 (25.9%)
SPC unit 5 (8.6%)
Table 2. Interview and focus group question guide
Understanding and experience of palliative care and end of life care
What do you understand by the terms palliative care and end-of-life care?
Are you regularly involved in providing palliative and end-of-life care?
Do you think many inpatients in acute hospitals have palliative and
end-of-life care needs?
Management and organisation of care
Thinking about the management and organisation of care and the way
palliative care is currently managed in acute hospitals: what are the main
barriers and facilitators to providing palliative care in acute hospitals?
Do you think palliative care management is approached differently in older
people when compared with younger people?
Transitions and communication
Are there issues surrounding the transmission of information about patients
with palliative care needs from the acute hospital into the community?
What are your thoughts on how transitions to palliative care management
within acute hospitals are currently managed?
What sort of decisions made in acute hospitals indicates that a palliative
care approach to patient management has been adopted?
In your experience is a palliative care approach adopted alongside active
curative treatment: (a) within primary care; (b) within acute hospitals?
Is prognosis routinely discussed with patients in acute hospitals? Do you
feel it ought to be?
Are decisions about adopting a palliative approach to patient management
disclosed to patients and/or their families?
What would trigger such discussions? Who would be involved in these
discussions?
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services, in part due to the historical link between cancer
and palliative care.
Practice nurse 1:‘They don’t admit them to the palliative
care unit do they …the COPD and heart failure?’
Practice nurse 2:‘They go on to the general ward’
[focus group 3]
Generalist palliative care provision within acute hospitals
was seen as being particularly susceptible to resource
restrictions. It was acknowledged that inadequate staffing
levels and increased time pressures on generalists impacted
on the ability of staff to provide good palliative care.
Psychosocial palliative care in particular was rarely priori-
tised under these circumstances.
Hospice Social Worker:‘The staffing levels there [hospi-
tal] are often so poor that it isn’t a question of not
wanting to do it, it’s not being able to do it. They’re
not even able to satisfy the basic requirements, much
less go in and listen to people in the way that they’d
like to.’[focus group 5]
A focus on acute or interventionist care
Participants reported that both generalist palliative care, and
timely referral to SPC, could be compromised by an inap-
propriate focus on interventionist care with a curative
intent. This was described in some instances as a reluctance
of ‘doctors to let patients die’. The widespread public
expectation that hospital is a place ‘where ill people go to
get better’was cited as a further justification for the focus
on acute care, with physicians not wanting to seem as if
they had ‘given up’on patients.
Consultant Geriatrician:‘I think some doctors find it dif-
ficult to let go, some doctors find it uncomfortable to
admit that the patient is going to die, they feel that
they should carry on, doing all they can for them in
terms of investigations and treatment’[interview 3]
Discussion
This qualitative study confirms that significant barriers exist
to the provision of optimum palliative care for older people
within acute hospital settings. The finding that older age
can act as a barrier to accessing SPC resonates with pre-
vious research findings [16]. Despite substantial evidence
suggesting inequalities in access to SPC for older patients,
there is little consensus as to why this should be the case,
and in addition whether inequality in access to care necess-
arily implies inequity in care [16,18]. Indeed, a recent study
exploring equity of use of SPC in lung cancer clinic patients
found that age was not associated with the receipt of SPC
services, and referral was based on the need [17]. However,
health professionals in our study reported that they often
believed older people to be less requiring of palliative care
than younger people, as a consequence of death being
more expected in an older person, and the perception that
older people find it easier to come to terms with a terminal
diagnosis. It seems that, for a proportion of health pro-
fessionals, the belief that older people have fewer require-
ments for SPC may be a factor affecting referral patterns
and leading to reduced utilisation of specialist care.
Provision of good palliative care for older people is also
crucially mediated by a situation where the role of the first line
of health professionals for older people, specifically geriatri-
cians, is ill-defined in terms of responsibility for providing pal-
liative care [19]. A further debate surrounds the definitional
and conceptual issues relating to palliative care for older
people. The findings show that, for generalists in particular,
palliative care is often equated with dying. This conceptual
issue may present a further barrier to optimum care, particu-
larly for patients with non-malignant disease where ‘dying’
may not be diagnosed until close to death. At both practice
and policy levels, there is a tendency to compartmentalise
chronic disease management and end-of-life care. This com-
plicates the implementation of ‘continuous palliation’for older
people, as advocated within Geriatric Medicine [20]. Ensuring
both the early introduction of palliative care and continuous
palliation is central to achieving improvements in the
end-of-life experiences of older people. Indeed, overall, there
is an urgent need to clarify the terminology used within pallia-
tive care in order to ensure consistency in clinical practice.
Findings from this study indicate a situation where special-
ist palliative care services are still inextricably linked with
cancer, despite substantial evidence to suggest that patients
with advanced non-malignant disease would benefitfromthis
care [21]. Older people are proportionally more likely to die
from conditions other than cancer, and hence are disadvan-
taged in access to SPC by diagnosis [22]. A focus on interven-
tionist care with curative intent was also identified as
contributing to a delay in the implementation of appropriate
palliative care within acute hospitals. This finding has particu-
lar resonance in the context of recent UK guidelines pro-
duced by the General Medical Council regarding Treatment
and Care Towards the End of Life [23]. The guidelines
acknowledge that the most challenging decisions in this area
are generally regarding withdrawing or not starting a treat-
ment when it has the potential to prolong a patient’slife.
Findings from this study confirm the difficulties faced by
health professionals when making decisions about adopting a
palliative care approach. Evidence has suggested that earlier
integration of palliative care as part of a multidisciplinary
team can facilitate optimum patient care [24]. However, recog-
nition is required, particularly by generalist palliative care pro-
viders within acute hospitals, that a focus on interventionist
care may not always be appropriate for patients with life-
limiting conditions.
Additional research is now required to further explore
the issues identified in this paper. At policy level, there is
much to support palliative care for older people, but there
are clearly challenges in translating this into practice. Part of
the challenge arises because of the traditional palliative care
model and its institutional and cancer focus. Further
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challenges result from the definitional and conceptual
issues surrounding palliative care, and its relevance for
older people. An ageing population with chronic con-
ditions, co-morbidities and complex social circumstances
may be better served by a more dispersed model of pallia-
tive care with case management across the pathway.
Evidence suggests that comprehensive case management
can be effective in the management of chronic long-term
conditions [25]. Further research should seek to explore the
appropriateness of the expansion of these services to incor-
porate palliative care, and facilitate the implementation of
continuous palliation. In addition, culture change is
required in order that ageist attitudes are replaced with
optimal palliative care regardless of age. As evidence
suggests that education alone may be insufficient to effect a
significant culture change [26], further research should seek
to explore practical and policy-driven initiatives that more
effectively moderate attitudes and behaviour.
Key points
•This study confirms that numerous barriers exist to the
provision of optimum palliative care for older people in
acute hospitals.
•There is some evidence of ageism in relation to equitable
access to palliative care in hospitals.
•Differing understandings were reported regarding the role
of specialist and generalist palliative care for older people.
Conflicts of interest
None declared.
Funding
This study was funded by the National Institute for Health
Research (NIHR), under the Service Delivery and
Organisation (SDO) stream. The views and opinions
expressed herein are those of the authors and do not
necessarily reflect those of the Department of Health.
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Received 3 June 2010; accepted in revised form
10 November 2010
Age and Ageing 2011; 40: 238–242
doi: 10.1093/ageing/afq179 © The Author 2011. Published by Oxford University Press on behalf of the British Geriatrics Society.
All rights reserved. For Permissions, please email: journals.permissions@oup.com
Published electronically 13 January 2011
Angiotensin-converting enzyme gene and
plasma protein level in Alzheimer’s disease in
Taiwanese
YUAN-HAN YANG1,2,3,CHIOU-LIAN LAI 1,3,YU-CHANG TYAN4,5,MEI-CHUAN CHOU 3,LING-CHUN WANG6,
MING-HUI YANG7,CHING-KUAN LIU1,2,8
1
Department of and Master’s Program in Neurology, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung City,
Taiwan (R.O.C.)
2
Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan (R.O.C.)
3
Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan (R.O.C.)
4
National Sun Yat-Sen University-Kaohsiung Medical University Joint Research Center, Kaohsiung City, Taiwan (R.O.C.)
5
Department of Medical Imaging and Radiological Sciences, Kaohsiung Medical University, Kaohsiung City, Taiwan (R.O.C.)
6
Department of Biological Sciences and Technology, National University of Tainan, Tainan City, Taiwan (R.O.C.)
7
Department of Chemistry, National Sun Yat-Sen University, Kaohsiung City, Taiwan (R.O.C.)
8
Department of Neurology, Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung City, Taiwan (R.O.C.)
Address correspondence to: C.-K. Liu. Tel: (+886) 73121101 6760; Fax: (+886) 73162158. Email: ckliu@kmu.edu.tw
Abstract
Background: angiotensin-converting enzyme (ACE) gene insertion/deletion (indel) polymorphism is considered a bio-
marker for Alzheimer’s disease (AD). However, the associations of ACE gene and protein level to AD are undetermined
among Taiwanese.
Methods: this study investigated 257 Taiwanese cases with AD and 137 ethnically matched controls using ACE gene indel gen-
otype association methods with logistic regression adjusted for other variables. Besides, 65 out of 257 AD patients, 11 with D/
D genotype, 28 with I/I genotype and 26 with I/D genotype were recruited. Their plasma ACE protein levels were measured
by enzyme-linked immuno-sorbent assay and compared for their corresponding ACE gene indel polymorphism.
Results: patients with ACE-I/I homozygote were less likely to be associated with AD, compared with both I/D and D/D
(OR: 0.601; 95% CI: 0.372–0.969; P= 0.037), or only I/D genotype (OR: 0.584; 95% CI: 0.349–0.976; P= 0.040). There were
significantly different plasma ACE protein levels among these three different genotype groups (P= 0.023). The I/I genotype
group had significantly lower ACE plasma levels [114.79 ± 31.32 ng/ml (mean ± SD)], compared with D/D (164.07 ±
86.36 ng/ml; P= 0.010), but not I/D (141.45 ± 51.50 ng/ml; P=0.064).
Conclusion: ACE-I/I homozygote corresponds to lower plasma ACE protein level and it is independently but less likely to be
associated with AD. These findings signal the importance of ACE indel polymorphisms to their corresponding protein levels
and to AD.
Keywords: angiotensin-converting enzyme, Alzheimer’s disease, Taiwanese, elderly
238
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