Findings from a Canadian national workshop: Delays in transfers from acute care to a palliative care unit/hospice

INTRODUCTION

There is growing concern about the quality of end-of-life (EOL) care provided in acute care hospital settings in Canada, as there are more patients receiving EOL care in acute care hospitals than in any other healthcare setting (Ó Coimín et al., 2019). Dying in an acute care setting is a matter of national importance, and respecting a patient’s wish regarding their preferred place of death has become a central outcome measure of quality end-of-life care (Vidal et al., 2020). Furthermore, the Canadian healthcare system is functioning under significant strain and increasing occupancy pressures due, in part, to the overwhelming number of Canadians who continue to receive their EOL care in the acute hospital setting (Fraser, 2016).

The Palliative Care Consult Team (PCCT) at Sunnybrook Health Science Centre (SHSC), a large tertiary care facility in Toronto, Ontario, has seen a reduction in the number of patient deaths occurring in acute care. Between 2017–2022, 38% of patients referred to the PCCT died in hospital – a 12% reduction from 2012–2016 (Chakraborty & Stilos, 2024). A significant contributor to this outcome was the commitment by the hospital and the PCCT to the development of an initiative aligned with the Health Quality Ontario’s (HQO) quality standard –”place of death.” The SHSC Strategic Plan for 2021–2025 included ‘Improving quality by creating better care experiences to achieve the best possible outcome for patients, while exceeding the care expectations.’ The specific objectives in the SHSC Plan were:

1. Demonstrably achieve excellent patient and family experiences

2. Ensure seamless, high quality patient transitions within Sunnybrook, our community, and across the Ontario health care system.

Unique to SHSC is its affiliation with an adjacent Palliative Care Unit (PCU). The PCU staff aids in the facilitation of safe and timely transfers for those patients admitted to Sunnybrook’s acute care setting who choose to transfer to this PCU for EOL care. Additionally in 2022, Bottoms et al. examined factors that delayed transfers from acute care to SHSC PCU by conducting a retrospective chart review of 130 patients requiring palliative care, of whom 31% died in acute care. Several barriers impacting timely transfers to the PCU were identified, including disposition planning, behavioral changes – specifically terminal agitation that required acute monitoring – patients identified as imminently dying, and those awaiting Medical Assistance in Dying (MAID).

Subsequently, the PCCT examined the processes and barriers that impact patient transitions from acute care to the PCU, as identified by Bottoms et al., (2022), and sought to understand the generalizability of these local findings. Members of the PCCT conducted an interdisciplinary workshop at the Canadian Hospice Palliative Care Association (CHPCA) Conference on October 13, 2023, with the intent of understanding common barriers and facilitators to timely transfers to palliative care units across the country.

Our workshop, entitled Delays in Transfers from Acute Care to Palliative Care Units: Closing the Gap, saw 45 attendees representing various disciplines including, physicians, nurses, social workers, administrators, government, and agency employees from across multiple regions and practice settings across Canada. The objectives of the workshop were:

1. Describe/share factors that delay transfers from acute care to PCU/Hospice across municipalities and provinces across Canada

2. Identify opportunities for quality improvement in reducing deaths in acute care, and understand their barriers/facilitators.

The workshop aimed to build on the findings of Bottoms et al.’s (2022) paper and to engage the participants in identifying factors that delay transfers in their own local geographic practice setting, working through a quality improvement lens. The workshop discussions

reinforced the findings from the Bottom et al. (2022) paper and highlighted the multifaceted nature of factors that delay an individual’s transfer from acute care to PCU. These factors pertain to the patient/family, healthcare providers, system processes, local policies, the local environment, as well as current societal values (Figure 1). Each will be highlighted below with the intent of sharing the findings with others who are facing similar issues.

Figure 1.

Delays in Transfer from Acute Care to PCU/Hospice

Patient and Family Factors

Our 2024 PCCT’s Quality Improvement Metrics review revealed that PCU applications were typically being submitted with a median wait time for acceptance and bed offer of a day, with an average length of stay in the PCU being less than a week. The most prevalent factor that delayed transfers from acute care to PCU was identified as patients who were deemed unstable for transfer by their family and/or their healthcare providers, specifically those patients who were identified as imminently dying. This may reflect that patients are often accepting a comfort-only-based care plan (Lau et al., 2017) and transferring from acute care to a PCU late in their disease trajectory.

In the workshop, an additional factor identified was the patient and family’s fear of care team transition, particularly at EOL. Some may have had a positive experience with the staff in acute care and are reluctant to change their care providers at EOL. This factor points to the importance of having early goals of care discussions for patients in acute care with advanced illness to establish expectations, and starting the transition process as early as possible.

Provider Factors

The workshop at the CHPCA confirmed several provider factors originally identified by Bottoms et al. (2022) that contribute to delay in transfer to PCU. These include a lack of knowledge of PCU/hospice admission and transfer criteria/procedures, as well as a lack of knowledge, skills, experience, across disciplines in providing comfort care for patients at EOL. This knowledge and skill deficit may lead to deviation away from palliation towards a more medically active approach to care in the face of evolving symptoms at EOL. Such an approach may, in turn, compound the family’s distress regarding the decision to pursue a comfort care only approach to EOL for their loved one.

System Factors, Institutional Policies & Environmental Factors

Several system factors identified by Bottoms et al. (2022) were mentioned during the workshop as commonly occurring issues across Canada and delaying transfer to PCU. These included infrastructure requirements such as infection control for patients requiring isolation, housekeeping short-falls, and PCU/hospice’s lack of ability to support medical procedures that contribute to comfort at EOL (e.g. transfusions, insertion of peritoneal catheters). Additional factors were identified as primarily associated with the lack of centralized governance and process for PCU/hospice applications and admission criteria. This included inconsistent criteria for admission across different PCU/hospices, inconsistent policies around medical interventions offered, as well as inconsistent access to MAID across PCU/hospices. From a patient flow perspective, lack of centralized governance is also exemplified by the lack of a centralized infrastructure (such as a dashboard) to coordinate access to available regional or provincial PCU/hospice beds. Patients in the community are often being prioritized over patients waiting in acute care. Additionally, there is a lack of an established process to activate pre-existing PCU/hospice applications for patients presenting to acute care. The consequences of this are magnified when patients require specialized limited resources including the availability of certain specialized equipment (e.g., high-flow oxygen, bariatric beds) or infrastructure (e.g. availability of security and locked units). Given the availability of such resources differs among institutions and across geography, the lack of a centralized admission monitoring system results in potentially longer waiting times for those requiring these resources. Unexpected barriers identified at the workshop were the potential additional costs (e.g., for transport, additional care/PSW support) that vary across institutions/facilities and contributed to delays in transfers to PCU/hospice.

Societal Issues

Overarching the previously identified factors is the ongoing overall discomfort with death and dying in today’s society and the societal notion that ‘home is best’ at EOL, even when it is not always achievable (Government of Canada, 2023). Since the establishment in 2018 of a national framework to advance palliative care, many initiatives have focused on enhancing and improving home care (Government of Canada, 2023) on a broad scale. However, to date, little attention has been given to the operations around transitions from acute care to PCUs/hospices. Additionally, the home care initiative highlights the inequity within the system, a system that favors individuals who have a stable home, a network of family/friends who are willing and able to care for them at home; it does not consider individuals who do not have these resources.

The societal notion of “home is best” is also undoubtedly influenced by multiple factors that were not captured within the workshop. These include the patient’s wishes, a Power of Attorney’s (POA’s) preferences, health literacy, cultural differences, language, communication, and relationship with healthcare providers. These factors can further contribute to inequitable understanding and access to PCU at EOL. The participants in this workshop helped to highlight the health inequities rooted in healthcare systems and societal values that many Canadians are experiencing. Having a better understanding of these factors will help generate quality improvement initiatives to improve equitable access to PCU at EOL.

CONCLUSION

Honoring a patient’s wish for their preferred location of death is of paramount importance. It also holds the potential to improve hospital occupancy pressures and optimize acute care resources, while ensuring that all patients receive the best care at EOL. Bottoms et al. (2022) provides a foundation for outlining the factors that delay transfers from acute care to the local PCU in one setting. Our workshop, held at a national Canadian palliative care conference, brought together the voices of palliative care providers from various professions, clinical settings, and geographic locations across Canada and contemporaneously confirmed and expanded the list of factors that may delay transfers from acute care to palliative care units or hospices across the country. Our collective voices provide an invaluable and robust record with the potential to inform and inspire palliative care leaders to question, challenge and implement policies to affect change – at the micro, meso, and macro level – aimed toward the ultimate goal that every person receives the ‘right care’, in the ‘right place’, by the ‘right people’ at the end of their life.