Premature deaths of nursing home residents: an epidemiological analysis

In reply:

It is refreshing to see a high level of professional and community engagement in our recently published study.1 More research into the nature of premature deaths in residential aged care services is essential, in particular, on whether these deaths are preventable, and if so, whether this is attributable to care deficits or to residents taking calculated risks. It is unfortunate, however, that funding for studies into the quality of care in residential aged care services is not a research priority.

There is no doubt that premature deaths occur in older people — any person who dies from an injury does so before their time. However, policy makers, clinicians and academics sometimes challenge this view when applied to older people, an “ageist” approach that implies that the lives of older people have less value. The World Health Organization promotes injury-related mortality and morbidity as preventable. Older people with multiple comorbidities require a more nuanced multilayered approach,2 which should include the right of an older person to partake in activities that increase the risk of harm (“dignity of risk”) and their pathophysiological function and reserve as well as the actions or inactions of health professionals and residential aged care services staff in mitigating risk. In addition, adherence to the “dignity of risk” principle3 is crucial to improving the quality of life and respecting the rights, freedoms and choices of older people. Nevertheless, we need to exercise extreme caution when using maintenance of “dignity of risk” as a convenient excuse for not preventing premature deaths in residential aged care services or community dwellers.

Research evaluating the standard of care delivered in residential aged care services in Australia is hampered by a lack of readily available, uniform and objective measures for quality of care. Our study was only possible because we used information from coroners’ investigations, where mandated reporting of non-natural death, combined with the principle of open justice, means that these data are available to researchers. Australia needs national empirical research into the standard and quality of care provided within residential aged care services, as adverse events leading to premature mortality are likely to cause significant morbidity. Future research needs to examine a wider range of outcomes, including temporary and permanent resident harm, hospitalisation, serious adverse events and premature deaths. For example, instead of recording deaths from choking, the reports should specify whether the death was related to oral and dental care problems, aspiration pneumonia, malnutrition or sepsis; instead of reporting suicide, the levels of underdiagnosed or undertreated depression should be described; and instead of resident–resident aggression, the optimum management of residents with dementia should be put in place.

Another separate study should investigate institutional (ie, residential aged care services) and community-based services to determine if outcomes of care differ. It is important to understand that this comparison does not assess whether residential aged care services are providing optimal quality of care, as some commentators appear to contend. Health care providers and funders need greater information and transparency about quality of care in residential aged care services to implement lifesaving action. It is essential that access to confidential existing data about quality of care from the Australian Aged Care Quality Agency, the Department of Health, the Aged Care Complaints Commissioner and the Aged Care Funding Instrument be made available for independent and rigorous examination.