Dying in Hospitals – Multi-method Assessment of Care in the Dying Phase in German Hospitals

Background In Germany, most people die in hospitals, but providing optimal care in the dying phase remains deficient. Guidelines and recommendations on delivering best possible care in the dying phase exist but have not been implemented in routine care yet. Aim The aim of the present dissertation is the provision of a status assessment of hospital care in the dying phase in German hospitals as basis for care optimisation, guided by two research questions: (1) What are perceived barriers, facilitators, and improvement needs for optimal hospital care in the dying phase in Germany from the perspectives of health experts? (2) To what extent can medical records provide information on hospital care in the dying phase? Methods The mixed methods study “Dying in Hospitals – Optimisation of Care in the Dying Phase” provides the data basis. An expert online survey was conducted as project basis (publication 1). A data extraction tool was developed for the retrospective medical records analysis (publication 2). An employee-driven working group approach to develop targeted measures for improving care for dying patients and their informal caregivers (IC) was conducted and evaluated (publication 3). Bronfenbrenner’s ecological system approach was used to synthesise findings. Results The findings include barriers, facilitators and improvement needs across institutional, team and care level, including lacking institutional resources, insufficient communication between health care staff as well as with patients and their IC and insufficient symptom control. Medical records proved to be useful for providing clinical information on medication and interventions, but systematically underrepresented psychosocial, communicative and spiritual care aspects. The employee-driven approach showed to be feasible and generated context-specific solutions on ward-level, yet staff participation decreased over time. Discussion and conclusion Findings on known challenges of hospital care in the dying phase were replicated, advanced through a more detailed understanding of dynamics across ecological care levels. Medical records were found to provide valuable insights but are insufficient as a sole data source for care assessment. The employee-driven approach showed that ward-level interventions can engage staff and generate context-sensitive solutions. Sustainable optimisation of care in the dying phase should target tailored interventions on team-level supported by leadership support and institutional integration.