Many patients are transferred between care settings during the final phase of life [1–4]. In the final months of life, the most frequent trajectory of patients who die a non-sudden death is from home to hospital. The proportion following this trajectory ranges from 36 to 40% in the final three months of life in the Netherlands and Belgium to 68% in the final six months of life in Canada. The majority of patients who are transferred from home to hospital later die in hospital [5–7]. Two factors associated with hospital death are having spent at least one night in a hospital and the number of hospital admissions during the final year of life [8, 9].
Hospital transfer, time spent in hospital at the end of life and hospital deaths are mentioned in the literature as poor end-of-life outcome indicators [10–12]. Although some end-of-life hospital transfers are necessary and could benefit the patient, most patients prefer to receive care and die at home, and most families evaluate staying at home as a desirable palliative pathway [13–15].
General practitioners (GPs) are key professionals in providing continuity of care at the end of life [16, 17]. However, over the last two decades, the 24-hour availability of GPs has changed, with out-of-hours GP co-operatives at a greater distance and patients being more likely to receive care from a locum [18, 19]; these changes could reduce the continuity of care [20, 21]. Proper information transfer from the GP to the out-of-hours GP is an essential factor in optimizing continuity of care. In the Netherlands, 82% of GPs reported that they transferred information about terminally ill patients to out-of-hours GPs . However, various studies of chart analyses of palliative care patients for whom an out-of-hours GP was called have shown that information from the patients’ own GP was available only for a minority [22–25].
In a study of patients referred to a palliative care programme, it was found that symptoms other than pain increase the number of transfers to in-patient care at the end of life . However, no details were given about the type of symptoms. Other factors in addition to symptoms have also been found to increase the likelihood of hospital transfer at the end of life. Studies of general practices (not specifically limited to out-of-hours practices) show that age, gender, multiple morbidity, infections, respiratory problems, cardiovascular problems, a palliative treatment goal, GPs’ knowledge of patients’ wishes about the place of death and palliative treatment by the GP are all related to hospital transfers in the final three months of life [6, 26].
The aim of our study was to explore hospital referrals of palliative care patients for whom an out-of-hours GP was called, in recognition of the fact that hospital transfers at the end of life can be undesirable for patients and their families and that the out-of-hours service might be a critical period for these referrals. The research questions were as follows. What is the incidence of hospital referrals of palliative care patients by out-of-hours general practices? What sociodemographic and medical characteristics and what symptoms presented by palliative care patients as noted by an out-of-hours GP are associated with end-of-life hospital referrals? What reasons for referrals from home to hospital are noted by the out-of-hours GP?