Discussion

In this observational study in a large urban hospital, 37% of inpatients were assessed as high risk of dying in 12 months using a predefined 2-step combination of the SQ and two or more SPICT general indicators. These simple measures were feasible to collect from existing documentation and brief interview with bedside medical and nursing staff, making them potentially practical items for a hospital-based screening tool. High-risk patients were older, frailer and more functionally impaired and were most prevalent in general medical and geriatric services. Overall 18% of hospital inpatients died within 12 months, including 38% of those identified as high-risk.

We explored using 1-step or 3-step identification, compared with our 2-step tool. Using the SQ (by either medical or nursing staff) alone (1-step) would miss fewer patients who died in the next 12 months (higher sensitivity) but flag over half of inpatients as high risk, two-thirds of whom would still be alive at 12 months (figure 2). Although current evidence suggests more benefits than harm in discussing values and goals of care even in those patients who do not die within 12 months (‘false positives’),1 20 initiating advance care planning in this very large group would require substantial resources. Adding the advanced SPICT criteria to the 2-step tool would reduce the number of patients flagged at risk, with greater specificity and overall accuracy, but would miss about one-third of patients who died. This tool also required a detailed clinical assessment (adjudicated by senior medical registrars from chart information), which may make it impractical as a screening tool in a general hospital population.

The proposed predictive tool had moderate sensitivity (78%) and specificity (72%) for mortality, similar to the multi-item CARING tool in medical inpatients.21 We are not aware of any other study validating a 2-step combination of SQ plus general deterioration criteria. A large Spanish study22 reported a similar multistep tool (‘NEPCAL’) including the SQ, general and advanced indicators of disease and did not find significantly better performance of this complex tool compared with the SQ alone, where they identified a PPV of 31% and NPV of 92%, similar to our SQ findings. However, their study was conducted in an advanced chronic disease population in primary and hospital care, rather than a general hospital setting. They also found a level of agreement on SQ+ between medical and nursing staff similar to our study (kappa 0.48).23 Similarly, investigators comparing SQ alone or SQ plus several other clinical predictors in 207 older emergency department patients found sensitivity 77%, specificity 56%, PPV 32% and NPV 90% with both approaches, with a similar 12-month mortality to our study (21%); physicians identified 49% of patients at risk using SQ+ alone. In our hospital inpatient study, physicians’ predictive performance was very similar, although they identified somewhat fewer SQ+ (39%), which is comparable to another inpatient study.24 Studies using the SQ alone in various settings have recently been reviewed, with pooled sensitivity of 67% and specificity of 80% noted in one review10 and pooled accuracy of 74.8% in a second.14 In contrast to the latter review, which suggested greater accuracy of medical SQ prediction compared with nursing, we found very similar performance between disciplines in this inpatient setting, but using a combination of nursing and medical assessment increased sensitivity and decreased specificity.25 Although involving medical and nursing staff might make screening more complex, it aligns with a multidisciplinary approach to assessment and decision making.

Two point prevalence studies have used advanced SPICT criteria alone, assessed by specialist palliative care staff,13 26 to identify high risk patients. A New Zealand study26 identified 20% of participants as high risk, with 67% 12-month mortality in high-risk patients. They reported 63% sensitivity and 92% specificity, very similar to our 3-step findings (table 5). An Australian hospital study13 identified 27% at high risk, with 50% 12-month mortality in the high-risk group (similar to our findings) but did not report deaths in the low-risk group to allow calculation of performance measures.

The proportion of patients identified by the 1-step, 2-step or 3-step tool (24%–49% of inpatients) is likely to exceed the capacity of even the most well-resourced specialist palliative care or advance care planning service, highlighting the need to train all hospital staff in advance care planning, especially in general medicine and geriatrics. Importantly, high-risk participants had substantial contact with the treating hospital; 90% had had at least one admission in the previous 12 months and length of stay was protracted. Although this should provide opportunities for identifying, assessing and planning future care of these patients, less than half had an ARP completed during the study admission, one quarter had existing or new palliative care referral and only 5% had an AHD, suggesting that these opportunities are not always recognised and/or acted on. The high proportion of patients who required assisted decision making for their ARP illustrates the complexity of implementing advance care planning in high risk inpatients, who are elderly and frail with complex medical illnesses and high dependency on others. Similar hospital studies have shown ARP documented in 29%–35%, palliative care referral in 8%–32% and AHD use in 0%–1% of high-risk hospital patients.12 13 24 In our study, most deaths (68%) occurred in hospital, but more than half of these were in a different hospital, highlighting the need to hand over prognostic and planning information between care settings.

Our study adds to the literature identifying hospital inpatients who may benefit from discussion of goals of care and advance care planning. It is the first validation of the recommended GSF-PIG stepwise approach reported in hospital patients. The 2-step approach was simple for non-specialist staff to assess and presented a good trade-off between the acknowledged limited specificity of the SQ alone,10 and the lower sensitivity and greater complexity of advanced disease indicators. Strengths of the study include use of an existing consensus framework9 and tools; direct involvement of clinicians involved in care rather than specialist staff, which reflects clinical practice; small amounts of missing data and comparison of three related approaches within a consistent framework. We also recognise some limitations. The study is from a single site, although findings are similar to contemporary studies from other Australian and New Zealand hospitals suggesting findings are likely to be generalisable to similar health systems.13 26 The general criteria were collected by study assessors rather than staff, but assessors were clinical staff volunteers who required minimal training and items were simple to collect from the clinical record. We did not record the individual training level of medical and nursing staff completing the SQ, but our methods likely reflect the real-world availability of senior staff for making these assessments in clinical application. We did not directly involve consumers or their families. The cross-sectional recruitment means that assessments were performed on average 6 days into admission, when staff had more information for their clinical judgements than may be available at admission.

In summary, this study validates a method to identify general hospital patients likely to be in the last 12 months of life. Hospitals choosing the optimal approach to screening in practice will need to balance the costs, complexity and clinician acceptability of implementing screening approaches; the risk of failing to identify patients who might benefit from advance care planning; and the resources available for advance care planning. Future studies need to examine feasibility, acceptability, cost and impact of prospective use of validated screening approaches to improve advance care planning for hospital patients.