The decision-making process for unplanned admission to hospital unveiled in hospitalised older adults: a qualitative study

Abstract

Background: The hazards of hospitalisation, and the growing demand for goal-oriented care and shared decision making, increasingly question whether hospitalisation always aligns with the preferences and needs of older adults. Although decision models are described comprehensively in the literature, little is understood about how the decision for hospitalisation is made in real life situations, especially under acute conditions. The aim of this qualitative study was to gain insight into how the decision to hospitalise was made from the perspective of the older patient who was unplanned admitted to hospital.

Methods: Open interviews were conducted with 21 older hospitalised patients and/or their next of kin about the decision-making process leading to hospitalisation. Data were analysed according to the Constructivist Grounded Theory approach.

Results: Although a period of complaints preceded the decision to unplanned hospitalisation, ranging from hours to years, the decision to hospitalise was always taken acutely. In all cases, there was an acute moment in which the home as a care environment was no longer considered adequate. This conclusion was based on a combination of factors including factors related to complaints, general practitioner and home environment. Three parties were involved in this assessment: the patient, his next of kin and the general practitioner. At the same time, a very positive value was attributed towards the hospital. Depending on the assessment of the home as care environment by the various parties, there were four routes to hospitalisation: referral, shared, demanding and bypassing.

Conclusions: For all participants, the decision to hospitalisation was taken acutely, even if the problems evoking admission were not acute, but present for a longer period. Participants saw admission as inevitable, due to the negative perceptions of the care environment at home at that moment, combined with the positive expectations of hospital care. Advance care planning, nor shared decision making were rarely seen in these interviews. An ethical dilemma occurred when the next of kin consented to hospitalisation against the wishes of the patient. More attention for participation of older adults in decision making and their goals is recommended.

Keywords: Decision making; Grounded theory; Hospitalisation; Older adults; Patient perspective; Primary care; Qualitative research.

Fig. 1

Graphical summary of the four stages of the decision making process. The arrow in the top of the figure represents the period of complaints preceding the decision to hospitalisation ranging from hours to years and ends in an acute moment for all cases, when the decision moment takes place. In the decision moment, the home situation as a care environment was no longer considered adequate. At the same time, a very positive value was attributed to the hospital. Three parties were involved in this assessment: the patient, his next of kin and the general practitioner. Depending on the assessment of the home situation as a care environment by the three parties, there were four routes to hospitalisation: Referral, Demanding, Shared, Bypassing. Only the category “Shared” was not saturated