End-of life care for older adults: Hospital deaths, bedside decisions, and lessons learned from a mixed methods approach

Purpose: Problems encountered regarding consistency/quality of care at the end of life are often multidimensional and multidisciplinary, necessitating a research design that is broad and integrative. This study, therefore, employed a mixed methods approach to explore both the determinants and processes impacting care for older adults at the end of life. Design and Methods: Within Maricopa County, Arizona, hospital utilization data were obtained for inpatient deaths (n=3,409) for individuals 65 and older in 2006. In addition, for this timeframe/ region, an ethnographic study was conducted at one major acute care hospital to provide an in-depth evaluation of processes related to end-of-life decision-making. The results were triangulated to validate/corroborate the statistical trends with the qualitative themes and vice versa. Triangulation further served to foster a broader, deeper interpretation of results. Results: Triangulated findings indicate that age, race/ethnicity, health insurance type, and hospital capacity were significantly related to levels of acute care utilization at the end of life, as well as to the processes affecting decision-making at the patient bedside. Implications: Advanced age, race/ethnicity, insurance, and hospital capacity play a significant role regarding intensity of care delivered, regardless of patient diagnosis or prognosis. Dynamics at the patient bedside reveal contention among and between families and health providers as negotiations ensue to foster decisions regarding withdrawal/withholding of life sustaining measures. These findings, possible via a mixed methods approach, yield implications related to cultural competence, evidence based practice, continuity/consistency in service delivery, and the impact of consumerism on decisions at the end of life.