More than half of the over 65,000 people who died in Western Canada in 2003-2004 died in a hospital, according to a new report by the Canadian Institute for Health Information (CIHI). In-hospital deaths were more common in Manitoba (68%) and Alberta (65%) than in British Columbia (52%) or Saskatchewan (51%). Health Care Use at the End of Life in Western Canada is the first report of its kind to examine the use of health services by people nearing the end of their lives.
The study looked at four broad categories of patients who were nearing the end of their lives. Terminal Illness patients (68%), which include those with cancer, were the most likely to have died in a hospital, compared to Organ Failure (62%), Frailty (50%) or Sudden Death (29%) patients. Of the almost 37,000 people who died in hospital, just over a quarter received some form of palliative care, and the majority of these were terminally ill patients.
In B.C., 17% of deaths occurred at home, while 27% occurred in a long-term care facility; in Alberta, 15% of deaths occurred at home and 16% occurred in a long-term care facility; and in Manitoba, 11% of deaths occurred at home and 20% occurred in a long-term care facility. Data for Saskatchewan were not available.
Hospital use increases in the six months and 30 days before death
In the last 30 days before they died, 37% of western Canadian decedents were hospitalized at least once, and over half (57%) were hospitalized in the last six months of life. By province, those who died in B.C. were less likely to be hospitalized in the last month of their lives than those in Alberta, Saskatchewan or Manitoba.
In the last 30 days before death, patients in B.C. spent an average of 4.5 days in hospital, compared to 8.7 days in Manitoba, 8.4 days in Alberta and 7.3 days in Saskatchewan. The length of hospital stay varied within provinces, as decedents from smaller, rural or northern regional health authorities (RHAs) spent more days in hospital before death than decedents from larger, more urbanized RHAs.
While hospital use increased for most individuals in the last six months of life, it rose most rapidly for those in the Terminal Illness group. Within the six months before death, 75% of terminally ill patients were hospitalized, compared to 57% of those in the Organ Failure group and 43% of those in the Frailty group.
Pain management at the end of lifeThe study found marked differences in pain management at the end of life. Variations exist in the dispensing of morphine-equivalent (a standardized measure of pain medication) drugs in the community. Pain-medication use was lower in B.C. than in Saskatchewan and Manitoba (data for Alberta were not available), and Saskatchewan had the highest morphine-equivalent prescription drug use at all time periods during the last year of life. Examination of the most common pain medications used in the last six months revealed similar patterns in each of the three provinces, with morphine and acetaminophen with codeine the two most common drugs/chemicals used, as measured by the total number of claimants.
Patients dying of a terminal illness had the highest use of prescription drugs compared to other groups, particularly within 30 days before death, indicating a stronger reliance on drugs-including those used for pain management-as death approached. Further from death, particularly between 6 and 12 months before death, Organ Failure and Frailty decedents showed higher drug use. As expected, morphine-equivalent use was highest among the Terminal Illness decedent group.
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