An observational study of survival outcomes of people referred for ‘fast-track’ end-of-life care funding in a District General Hospital; too little too late?

Abstract

ABSTRACTBackgroundEnd-of-life care frequently requires support for people to die where they feel safe and well-cared for. End-of-life care may require funding to support dying outside of hospital. In England, funding is procured through Continuing Healthcare Fast-Track funding, requiring assessment to determine eligibility. Anecdotal evidence suggested that Fast-Track funding applications were deferred where clinicians thought this inappropriate due to limited life-expectancy.AimTo evaluate overall survival after Fast-Track funding application.DesignProspective evaluation of Fast-Track funding application outcomes and survival.Setting/participantsAll people in 2021 who had a Fast-Track funding application from a medium-sized district general hospital in Southwest England.Results439 people were referred for Fast-Track funding with a median age of 80 years (range 31-100 years). 413/439 (94.7%) died during follow up, with a median survival of 15 days (range 0 to 436 days). Median survival for people with Fast-Track funding approved or deferred was 18 day and 25 days, respectively (P= 0.0056). 103 people (29%) died before discharge (median survival 4 days) and only 8.2% were still alive 90 days after referral for Fast-Track funding.ConclusionsFast-Track funding applications were deferred for those with very limited life-expectancy, with minimal clinical difference in survival (7 days) compared to those who had applications approved. This is likely to delay discharge to preferred place of death and reduce quality of end-of-life care. A blanket acceptance of Fast-Track funding applications, with review for those still alive after 60 days, may improve end-of-life care and be more efficient for the healthcare system.WHAT IS ALREADY KNOWN ABOUT THE TOPIC?People approaching the end-of-life may have rapidly deteriorating or fluctuating care needs, requiring a responsive care package to optimise care.Time to put in place care packages, to enable people to die in their preferred place, may be limited and so systems to facilitate care should be provided at speed.Continuing Healthcare Fast-Track (CHCFT) funding was designed to deliver person-centred care for people with ‘rapidly deteriorating condition, and where that condition may be entering a terminal phase’ without a specific measure of deterioration rate or prognostic expectation.WHAT THIS PAPER ADDSWhen clinical teams refer for CHCFT they are highly likely to be identifying someone who is in the last few days to weeks of life.Referral deferment (rejection) may correlate with survival statistically, but this was not a clinically meaningful difference.Local CHCFT eligibility interpretation inappropriately excluded people who need funding to be looked after in their preferred place of care in their last days of life.IMPLICATIONS FOR PRACTICE, THEORY OR POLICYThe current application process for funding may prevent rapid discharge to preferred place of care for those with only a few days to live.A blanket policy of acceptance of care needs, with review at 60 or 90 days if still required, may improve quality of end-of-life care for people and their families, and may have cost savings to the health and social care system as a whole.