Influence of patient preferences and local health system characteristics on the place of death. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Risks and Outcomes of Treatment

Standardized Criteria for Palliative Care Consultation on a Solid Tumor Oncology Service Reduces Downstream Health Care Use

PURPOSE

Hospitalized patients with advanced cancer have a high symptom burden and need for support. Integration of palliative care (PC) improves symptom control and decreases unwanted health care use, yet many patients are never offered these services. In 2016, ASCO called for incorporation of PC into oncologic care for all patients with metastatic cancer. To improve the quality of cancer care, we developed standardized criteria, or triggers, for PC consultation on the inpatient solid tumor service.

METHODS

Patients were eligible for this prospective cohort study if they met at least one of the following eligibility criteria: had an advanced solid tumor; prior hospitalization within 30 days; hospitalization > 7 days; and active symptoms. During the intervention, patients who met the criteria received automatic PC consultation.

RESULTS

When we compared patients in the intervention group with control subjects, there were increases in PC consultations (19 of 48 [39%] to 52 of 65 [80%]; P ≤ .001) and hospice referrals (seven of 48 [14%] to 17 of 65 [26%]; P = .03), and there were declines in 30-day readmission rates (17 of 48 [35%] to 13 of 65 [18%]; P = .04) and receipt of chemotherapy after discharge (21 of 48 [44%] to 12 of 65 [18%]; P = .03). There was an overall increase in support measures following discharge ( P = .004). Length of stay was unaffected.

CONCLUSION

To our knowledge, this is the first study to demonstrate that among patients with advanced cancer admitted to an inpatient oncology service, the standardized use of triggers for PC consultation is associated with substantial impact on 30-day readmission rates, chemotherapy following discharge, hospice referrals, and use of support services following discharge. Expansion of this model to other hospitals and health systems should improve the value of cancer care.

Early Palliative Care Reduces End-of-Life Intensive Care Unit (ICU) Use but Not ICU Course in Patients with Advanced Cancer

BACKGROUND

Early palliative care for advanced cancer patients improves quality of life and survival, but less is known about its effect on intensive care unit (ICU) use at the end of life. This analysis assessed the effect of a comprehensive early palliative care program on ICU use and other outcomes among patients with advanced cancer.

PATIENTS AND METHODS

A retrospective cohort of patients with advanced cancer enrolled in an early palliative care program (n = 275) was compared with a concurrent control group of patients receiving standard care (n = 195) during the same time period by using multivariable logistic regression analysis. The multidisciplinary outpatient palliative care program used early end-of-life care planning, weekly interdisciplinary meetings to discuss patient status, and patient-reported outcomes assessment integrated within the electronic health record.

RESULTS

Patients in the control group had statistically significantly higher likelihood of ICU admission at the end of life (odds ratios [ORs]: last 6 months, 3.07; last month, 3.59; terminal admission, 4.69), higher likelihood of death in the hospital (OR, 4.14) or ICU (OR, 5.57), and lower likelihood of hospice enrollment (OR, 0.13). Use of chemotherapy or radiation did not significantly differ between groups, nor did length of ICU stay, code status, ICU procedures (other than cardiopulmonary resuscitation), disposition location, and outcomes after ICU admission.

CONCLUSION

Early palliative care significantly reduced ICU use at the end of life but did not change ICU events. This study supports early initiation of palliative care for advanced cancer patients before hospitalizations and intensive care. The Oncologist 2017;22:318-323 IMPLICATIONS FOR PRACTICE: Palliative care has shown clear benefit in quality of life and survival in advanced cancer patients, but less is known about its effect on intensive care. This retrospective cohort study at a university hospital showed that in the last 6 months of life, palliative care significantly reduced intensive care unit (ICU) and hospital admissions, reduced deaths in the hospital, and increased hospice enrollment. It did not, however, change patients' experiences within the ICU, such as number of procedures, code status, length of stay, or disposition. The findings further support that palliative care exerts its benefit before, rather than during, the ICU setting.

Costs of care at the end of life among elderly patients with chronic kidney disease: patterns and predictors in a nationwide cohort study

Background

Despite the urgent need for evidence to guide the end-of-life (EOL) care for patients with chronic kidney disease (CKD), we have limited knowledge of the costs and intensity of EOL care in this population. The present study examined patterns and predictors for EOL care intensity among elderly patients with CKD.

Methods

We conducted a retrospective nationwide cohort study utilizing the Taiwan National Health Insurance (NHI) Research Database. A total of 65,124 CKD patients aged ≥ 60 years, who died in hospitals or shortly after discharge between 2002 and 2012 were analyzed. The primary outcomes were inpatient expenses and use of surgical interventions in the last 30 days of life. Utilization of intensive care unit (ICU), mechanical ventilation, resuscitation, and dialysis was also examined in a sub-sample of 2072 patients with detailed prescription data. Multivariate log-linear and logistic regression analyses were performed to assess patient-, physician-, and facility-specific predictors and the potential impact of a 2009 payment policy to reimburse hospice care for non-cancer patients.

Results

During the last 30 days of life, average inpatients costs for elderly CKD patients were approximately US$10,260, with 40.9% receiving surgical interventions, 40.2% experiencing ICU admission, 45.3% undergoing mechanical ventilation, 14.7% receiving resuscitation and 42.0% receiving dialysis. Significant variability was observed in the inpatient costs and use of intensive services. Costs were lower among individuals with the following characteristics: advanced age; high income; high Charlson Comorbidity Index scores; treatment by older physicians, nephrologists, and family medicine physicians; and treatment at local hospitals. Similar findings were obtained for the use of surgical interventions and other intensive services. A declining trend was detected in the costs of EOL care, use of surgical interventions and resuscitation between 2009 and 2012, which is consistent with the impact of a 2009 NHI payment policy to reimburse non-cancer hospice care.

Conclusions

Overall EOL costs and rates of intensive service use among older patients with CKD were high, with significant variability across various patient and provider characteristics. Several opportunities exist for providers and policy makers to reduce costs and enhance the value of EOL care for this population.

Physician Characteristics Strongly Predict Patient Enrollment In Hospice

Individual physicians are widely believed to play a large role in patients' decisions about end-of-life care, but little empirical evidence supports this view. We developed a novel method for measuring the relationship between physician characteristics and hospice enrollment, in a nationally representative sample of Medicare patients. We focused on patients who died with a diagnosis of poor-prognosis cancer in the period 2006-11, for whom palliative treatment and hospice would be considered the standard of care. We found that the proportion of a physician's patients who were enrolled in hospice was a strong predictor of whether or not that physician's other patients would enroll in hospice. The magnitude of this association was larger than that of other known predictors of hospice enrollment that we examined, including patients' medical comorbidity, age, race, and sex. Patients cared for by medical oncologists and those cared for in not-for-profit hospitals were significantly more likely than other patients to enroll in hospice. These findings suggest that physician characteristics are among the strongest predictors of whether a patient receives hospice care-which mounting evidence indicates can improve care quality and reduce costs. Interventions geared toward physicians, both by specialty and by previous history of patients' hospice enrollment, may help optimize appropriate hospice use.

Predictors of Place of Death of Individuals in a Home-Based Primary and Palliative Care Program

OBJECTIVES

To investigate factors associated with place of death of individuals in the Mount Sinai Visiting Doctors Program (MSVD).

DESIGN

A retrospective chart review was performed of all MSVD participants who died in 2012 to assess predictors of place of death in the last month of life.

SETTING

MSVD, a home-based primary and palliative care program in New York.

PARTICIPANTS

MSVD participants who were discharged from the program because of death between January 2012 and December 2012 and died at home, in inpatient hospice, or in the hospital (N = 183).

MEASUREMENTS

Electronic medical records were reviewed to collect information on demographic characteristics, physician visits, and end-of-life conversations.

RESULTS

Of 183 participants, 103 (56%) died at home, approximately twice the national average; 28 (15%) died in inpatient hospice; and 52 (28%) died in the hospital. Bivariate analyses showed that participants who were white, aged 90 and older, non-Medicaid, or had a recorded preference for place of death were more likely to die outside the hospital. Diagnoses and living situation were not significantly associated with place of death. Multivariate logistic regression analysis showed no statistical association between place of death and home visits in the last month of life (odds ratio = 1.21, 95% confidence interval = 0.52-2.77).

CONCLUSION

Home-based primary and palliative care results in a high likelihood of nonhospital death, although certain demographic characteristics are strong predictors of death in the hospital. For MSVD participants, home visits in the last month of life were not associated with death outside the hospital.

The Cost of Home Hospice Care for Terminal Patients in Israel

This study examined and compared the cost of care provided to terminal metastatic cancer patients by home hospices and by conventional health services. The study population included 146 patients with metastatic cancer. Half received home hospice services, and the other half received conventional services. The average overall per-patient cost of care was, respectively, $4761 (operating costs included) and $12 434. On average, the costs were lower for older patients. A multiple regression analysis revealed that treatment units per patient, care framework, and patient age significantly contributed to explaining the cost variance. The findings suggest a financial advantage for home hospice care for terminal patients. This should be investigated further, as should the cost of informal caregivers and patient and caregiver satisfaction with the quality of care in both frameworks.

Trends in hospice discharge, documented inpatient palliative care services and inpatient mortality in ovarian carcinoma

OBJECTIVE

To investigate the trends in discharge to hospice, documented inpatient palliative care services, and inpatient mortality in metastatic ovarian cancer (mOvCa) patients.

METHODS

Patients≥18years with mOvCa and a non-elective admission between January 1, 2006 and December 31, 2011 were identified from the National Inpatient Sample (NIS). The primary outcome of interest was the temporal trend in the annual proportion of hospitalizations for mOvCa where discharge destination was hospice. Secondary outcomes included temporal trend of inpatient mortality and documented palliative care services. Multivariable logistic regression models were used to ascertain independent factors predictive of hospice discharge and documented palliative services across the clusters of hospitals.

RESULTS

A total of 106,203 non-elective hospitalizations were identified. The rate of hospice discharge increased from 9.2% in 2004 to 11.1% in 2011 (p^trend<0.001). Similarly, the rate of documented palliative care services increased from 2.7% in 2004 to 10.4% in 2011 (p^trend<0.001). The inpatient mortality decreased from 9.6% in 2004 to 7.4% in 2011 (p^trend<0.001). In a subset of hospitalizations with extreme risk of dying, 22% were discharged to hospice and 11% received documented palliative care services. One fifth of the patients who died in the hospital received documented palliative care services.

CONCLUSIONS

The use of hospice as a discharge destination and documented palliative care services is relatively low but appears to be increasing over time for mOvCa patients. Monitoring this data is vital to plan educational programs regarding palliative care approaches in this at-risk population.

Coping with Bereavement among Elderly Widowers

A Dual Process Model of Bereavement, which considers the impact of loss- and restoration-oriented variables on widowers' levels of well-being, is tested on 200 widowed men during the second year of bereavement. Those who were widowed less than 500 days exhibited significantly more negative affect, less positive affect, and lower well-being that those widowed more than 500 days. Multiple regression analyses revealed that both loss and restoration variables were important throughout bereavement. Loss variables influenced negative affect and were especially critical during the early stages. Restoration variables significantly affected positive affect and had greater impact on the later bereaved. The results support a dual process model of bereavement, but also suggest that certain events, such as circumstances of death, are more important during early bereavement while reinvestment activities, such as dating, become relevant later. Some circumstances, such as a wife's suffering, have prolonged effects.

Factors Associated With Place of Death Among the Chinese Oldest Old

Based on 6,444 deceased respondents ages 80 to 105 years from the first three waves of the Chinese Longitudinal Healthy Longevity Survey, the authors use multilevel modeling to examine how community development, individual sociodemographic characteristics, health conditions, and health resources affect place of death. Results show that 92% of Chinese oldest old die at home, with 7% dying in hospitals and 1% at institutions. Analyses indicate that residents from relatively developed communities in China tend to have a higher chance of hospital and/or institutional deaths; individuals with higher socioeconomic status (SES) and worsening health are more likely to experience hospital deaths; those who have pension and/or public and/or collective free medical services are more likely to die in hospitals and/or institutions. The authors also propose a theory about place of death consisting of three evolutionary stages, which might explain the disparity in patterns of place of death in different societies.

Transition Management: A New Paradigm for Home Care of the Chronically Ill Near the End of Life

Patients with advanced chronic illness receive increasingly fragmented care as they near the end of life. Multiple hospital readmissions are the rule, followed by intermittent episodes of home health care. Pain management, advance care planning, and preparation for dying may be lacking. Because prognosis is uncertain, particularly in noncancer cases, access to hospice and palliative care services is often denied to these patients until they are very near death. Home-based transition management can provide high-risk chronically ill patients better continuity of care until they are eligible and emotionally ready for hospice, and can manage their dying if referral to hospice is refused. Home care is positioned to provide innovative services that would increase access to end of life care. This paper outlines limitations of current approaches to end of life care, proposes potential components of transition management services, and discusses operational, regulatory, and reimbursement challenges to implementation.

Advance directives and the family: French and American perspectives

Several studies have explored differences between North American and European doctor-patient relationships. They have focused primarily on differences in philosophical traditions and historic and socio-economic factors between these two regions that might lead to differences in behaviour, as well as divergent concepts in and justifications of medical practice. However, few empirical intercultural studies have been carried out to identify in practice these cultural differences. This lack of standard comparative empirical studies led us to compare differences between France and the USA regarding end-of-life decision making. We tested certain assertions put forward by bioethicists concerning the impact of culture on the acceptance of advance directives in such decisions. In particular, we compared North American and French intensive care professional's attitudes toward: 1) advance directives and 2) the role of the family in decisions to withhold or withdraw life-support.

Palliative Care Teams' Cost-Saving Effect Is Larger For Cancer Patients With Higher Numbers Of Comorbidities

Patients with multiple serious conditions account for a high proportion of health care spending. Such spending is projected to continue to grow substantially as a result of increased insurance eligibility, the ever-rising cost of care, the continued use of nonbeneficial high-intensity treatments at the end of life, and demographic changes. We evaluated the impact of palliative care consultation on hospital costs for adults with advanced cancer, excluding those with dementia. We found that compared to usual care, the receipt of a palliative care consultation within two days of admission was associated with 22 percent lower costs for patients with a comorbidity score of 2-3 and with 32 percent lower costs for those with a score of 4 or higher. Earlier consultation was also found to be systematically associated with a larger cost-saving effect for all subsamples defined by multimorbidity. Given ongoing workforce shortages, targeting early specialist palliative care to hospitalized patients with advanced cancer and higher numbers of serious concurrent conditions could improve care while complementing strategies to curb the growth of health spending.

Differences in Physicians' Verbal and Nonverbal Communication With Black and White Patients at the End of Life

CONTEXT

Black patients are more likely than white patients to die in the intensive care unit with life-sustaining treatments. Differences in patient- and/or surrogate-provider communication may contribute to this phenomenon.

OBJECTIVES

To test whether hospital-based physicians use different verbal and/or nonverbal communication with black and white simulated patients and their surrogates.

METHODS

We conducted a randomized factorial trial of the relationship between patient race and physician communication using high-fidelity simulation. Using a combination of probabilistic and convenience sampling, we recruited 33 hospital-based physicians in western Pennsylvania who completed two encounters with prognostically similar, critically and terminally ill black and white elders with identical treatment preferences. We then conducted detailed content analysis of audio and video recordings of the encounters, coding verbal emotion-handling and shared decision-making behaviors, and nonverbal behaviors (time interacting with the patient and/or surrogate, with open vs. closed posture, and touching the patient and physical proximity). We used a paired t-test to compare each subjects' summed verbal and nonverbal communication scores with the black patient compared to the white patient.

RESULTS

Subject physicians' verbal communication scores did not differ by patient race (black vs. white: 8.4 vs. 8.4, P-value = 0.958). However, their nonverbal communication scores were significantly lower with the black patient than with the white patient (black vs. white: 2.7 vs. 2.9, P-value 0.014).

CONCLUSION

In this small regional sample, hospital-based physicians have similar verbal communication behaviors when discussing end-of-life care for otherwise similar black and white patients but exhibit significantly fewer positive, rapport-building nonverbal cues with black patients.

Quality of end-of-life cancer care in Canada: a retrospective four-province study using administrative health care data

BACKGROUND

The quality of data comparing care at the end of life (eol) in cancer patients across Canada is poor. This project used identical cohorts and definitions to evaluate quality indicators for eol care in British Columbia, Alberta, Ontario, and Nova Scotia.

METHODS

This retrospective cohort study of cancer decedents during fiscal years 2004-2009 used administrative health care data to examine health service quality indicators commonly used and previously identified as important to quality eol care: emergency department use, hospitalizations, intensive care unit admissions, chemotherapy, physician house calls, and home care visits near the eol, as well as death in hospital. Crude and standardized rates were calculated. In each province, two separate multivariable logistic regression models examined factors associated with receiving aggressive or supportive care.

RESULTS

Overall, among the identified 200,285 cancer patients who died of their disease, 54% died in a hospital, with British Columbia having the lowest standardized rate of such deaths (50.2%). Emergency department use at eol ranged from 30.7% in Nova Scotia to 47.9% in Ontario. Of all patients, 8.7% received aggressive care (similar across all provinces), and 46.3% received supportive care (range: 41.2% in Nova Scotia to 61.8% in British Columbia). Lower neighbourhood income was consistently associated with a decreased likelihood of supportive care receipt.

INTERPRETATION

We successfully used administrative health care data from four Canadian provinces to create identical cohorts with commonly defined indicators. This work is an important step toward maturing the field of eol care in Canada. Future work in this arena would be facilitated by national-level data-sharing arrangements.

Does hospital need more hospice beds? Hospital charges and length of stays by lung cancer inpatients at their end of life: A retrospective cohort design of 2002-2012

BACKGROUND

Previous studies found that hospice and palliative care reduces healthcare costs for end-of-life cancer patients.

AIM

To investigate hospital inpatient charges and length-of-stay differences by availability of hospice care beds within hospitals using nationwide data from end-of-life inpatients with lung cancer.

DESIGN

A retrospective cohort study was performed using nationwide lung cancer health insurance claims from 2002 to 2012 in Korea.

SETTING AND PARTICIPANTS

Descriptive and multi-level (patient-level and hospital-level) mixed models were used to compare inpatient charges and lengths of stay. Using 673,122 inpatient health insurance claims, we obtained aggregated hospital inpatient charges and lengths of stay from a total of 114,828 inpatients and 866 hospital records.

RESULTS

Hospital inpatient charges and length of stay drastically increased as patients approached death; a significant portion of hospital inpatient charges and lengths of stay occurred during the end-of-life period. According to our multi-level analysis, hospitals with hospice care beds tend to have significantly lower end-of-life hospital inpatient charges; however, length of stay did not differ. Hospitals with more hospice care beds were associated with reduction in hospital inpatient charges within 3 months before death.

CONCLUSION

Higher end-of-life healthcare hospital charges were found for lung cancer inpatients who were admitted to hospitals without hospice care beds. This study suggests that health policy-makers and the National Health Insurance program need to consider expanding the use of hospice care beds within hospitals and hospice care facilities for end-of-life patients with lung cancer in South Korea, where very limited numbers of resources are currently available.

Life-sustaining treatment orders, location of death and co-morbid conditions in decedents with Parkinson's disease

INTRODUCTION

End-of-life care in Parkinson's Disease (PD) is poorly described. Physician Orders for Life Sustaining Treatment (POLST) forms specify how much life-sustaining treatment to provide. This study aims to better understand end-of-life care in PD using data from the Oregon POLST and Death Registries.

METHODS

Oregon death certificates from the years 2010-2011 were analyzed. Death certificates were matched with forms in the Oregon POLST Registry. Descriptive analyses were performed for both the full PD dataset as well as those with POLST forms.

RESULTS

There were 1073 (1.8%) decedents with PD listed as a cause of death and 56,961 without. Three hundred and seventy three (35%) decedents with PD had a POLST form. POLST preferences were not significantly different between those with or without PD, however location of death was; hospital (13% PD vs 24% without p < 0.01), home (32% vs 40% p < 0.01) and care facility (52% vs 29% p < 0.01). Compared to those without a POLST or those without a Comfort Measures Only (CMO) order, decedents with PD and a CMO order were less likely to die in a hospital (5.4% vs 14.7% p < 0.01) and more likely to die at home (39.1% vs 29.1% p < 0.01). In those with PD, dementia was the most common comorbid condition listed on death certificates (16%).

CONCLUSION

Decedents with PD die less frequently at home than the general population. POLST forms mitigate some of this discrepancy. While not often thought to be terminal, PD and its complications are commonly recorded causes of death.

Predictors of Place of Death for Those in Receipt of Home-Based Palliative Care Services in Ontario, Canada

Many cancer patients die in institutional settings despite their preference to die at home. A longitudinal, prospective cohort study was conducted to comprehensively assess the determinants of home death for patients receiving home-based palliative care. Data collected from biweekly telephone interviews with caregivers (n = 302) and program databases were entered into a multivariate logistic model. Patients with high nursing costs (odds ratio [OR]: 4.3; confidence interval [CI]: 1.8-10.2) and patients with high personal support worker costs (OR: 2.3; CI: 1.1-4.5) were more likely to die at home than those with low costs. Patients who lived alone were less likely to die at home than those who cohabitated (OR: 0.4; CI: 0.2-0.8), and those with a high propensity for a home-death preference were more likely to die at home than those with a low propensity (OR: 5.8; CI: 1.1-31.3). An understanding of the predictors of place of death may contribute to the development of effective interventions that support home death.

Limitation of care orders in patients with a diagnosis of dementia

The prevalence of dementia is growing with an ageing population. Most persons with dementia die of acute illness and many are hospitalised at the end of life. In the acute hospital setting, limitation of care orders (LCOs) such as Do Not Attempt CPR and Physician Orders For Life Sustaining Treatment (POLST), appear to be underused in patients with dementia. These patients receive the same aggressive life-prolonging therapies as any other patient, despite drastically higher mortality. However, limitation of care orders in patients with dementia is not addressed by current guidelines or policies. Systems and processes for obtaining and documenting LCO need improvement at the individual, organisational and societal level. The issue is controversial amongst the public and poorly understood by clinicians. Balanced and empathetic decision-making requires an individualised approach and recognition of the complexities (legal, ethical and clinical) of this issue. We examine the domains of: (a) treatment effectiveness, (b) burden of care and quality of life and (c) patient autonomy and capacity.

Honoring Choices Minnesota: preliminary data from a community-wide advance care planning model

Advance care planning (ACP) increases the likelihood that individuals who are dying receive the care that they prefer. It also reduces depression and anxiety in family members and increases family satisfaction with the process of care. Honoring Choices Minnesota is an ACP program based on the Respecting Choices model of La Crosse, Wisconsin. The objective of this report is to describe the process, which began in 2008, of implementing Honoring Choices Minnesota in a large, diverse metropolitan area. All eight large healthcare systems in the metropolitan area agreed to participate in the project, and as of April 30, 2013, the proportion of hospitalized individuals 65 and older with advance care directives in the electronic medical record was 12.1% to 65.6%. The proportion of outpatients aged 65 and older was 11.6% to 31.7%. Organizations that had sponsored recruitment initiatives had the highest proportions of records containing healthcare directives. It was concluded that it is possible to reduce redundancy by recruiting all healthcare systems in a metropolitan area to endorse the same ACP model, although significantly increasing the proportion of individuals with a healthcare directive in their medical record requires a campaign with recruitment of organizations and individuals.

Racial disparities in outcomes following PEA and asystole in-hospital cardiac arrests

AIM

To define the racial differences present after PEA and asystolic IHCA and explore factors that could contribute to this disparity.

METHODS

We analyzed PEA and asystolic IHCA in the Get-With-The-Guidelines-Resuscitation database. Multilevel conditional fixed effects logistic regression models were used to estimate the relationship between race and survival to discharge and return of spontaneous circulation (ROSC), sequentially controlling for hospital, patient demographics, comorbidities, arrest characteristic, process measures, and interventions in place at time of arrest.

RESULTS

Among the 561 hospitals, there were 76,835 patients who experienced IHCA with an initial rhythm of PEA or asystole (74.8% white, 25.2% black). Unadjusted ROSC rate was 55.1% for white patients and 54.1% for black patients (unadjusted OR: 0.94 [95% CI, 0.90-0.98], p=0.016). Survival to discharge was 12.8% for white patients and 10.4% for black patients (unadjusted OR: 0.83 [95% CI, 0.78-0.87], p<0.001). After adjusting for temporal trends, patient characteristics, hospital, and arrest characteristics, there remained a difference in survival to discharge (OR: 0.85 [95% CI, 0.79-0.92]) and rate of ROSC (OR: 0.88 [95% CI, 0.84-0.92]). Black patients had a worse mental status at discharge after survival. Rates of DNAR placed after survival from were lower in black patients with a rate of 38.3% compared to 44.5% in white patients (p<0.001).

CONCLUSION

Black patients are less likely to experience ROSC and survival to discharge after PEA or asystole IHCA. Individual patient characteristics, event characteristics, and hospital characteristics don't fully explain this disparity. It is possible that disease burden and end-of-life preferences contribute to the racial disparity.

Shared decision making and the use of a patient decision aid in advanced serious illness: provider and patient perspectives

OBJECTIVE

Patients with advanced serious illness face many complex decisions. Patient decision aids (PtDAs) can help with complex decision making but are underutilized. This study assessed barriers and facilitators to the use of a PtDA designed for serious illness.

METHODS

Providers and patients were asked about their experiences in making decisions around serious illness and their opinions towards the PtDA. Seven focus groups were digitally recorded, transcribed and analysed using a general qualitative inductive method.

RESULTS

Domain 1 - clinical context within which the PtDA would be utilized including three themes: (1a) role: PtDA might compete with the physician's role; (1b) logistics: it was unclear when and how such a PtDA should be implemented; and (1c) meaning: what it will mean to the patient if the physician recommends viewing of this PtDA. Domain 2 - broader global context: (2a) death-denying culture; and (2b) physician concerns that the PtDA was biased towards palliative care.

CONCLUSION

Physicians' concerns were rooted in deeper concerns about palliative care and a death-denying culture. Patients were more open to using the PtDA than physicians, suggesting 'it's never too early'.

PRACTICE IMPLICATIONS

PtDAs for serious illness can maximize early opportunities for goals of care conversations and shared decision making.

Increasing inpatient hospice use versus patient preferences in the USA: are patients able to die in the setting of their choice?

BACKGROUND

Growth in hospice utilisation has been accompanied by an increase in the proportion of hospice patients who die in an inpatient hospice setting rather than at home.

OBJECTIVE

To determine whether this increase in inpatient utilisation is consistent with patient preferences.

DESIGN

Retrospective cohort study.

SETTING

Seven hospices in the Coalition of Hospices Organised to Investigate Comparative Effectiveness (CHOICE) network.

PATIENTS

70 488 patients admitted between 1 July 2008 and 31 May 2012.

MEASUREMENTS

We measured changes in patients' stated preferences at the time of admission regarding site of death, including weights to adjust for non-response bias. We also assessed patients' actual site of death and concordance with patients' preferences.

RESULTS

More patients died receiving inpatient care in 2012 as compared to 2008 (1920 (32.7%), 2537 (18.5%); OR 1.21; 95% CI 1.19 to 1.22; p<0.001). However, patients also expressed an increasing preference for dying in inpatient settings (weighted preferences 27.5% in 2012 vs 7.9% in 2008; p<0.001). The overall proportion of patients who died in the setting of their choice (weighted preferences) increased from 74% in 2008 to 78% in 2012 (p<0.001).

LIMITATIONS

This study included only seven hospices, and results may not be representative of the larger hospice population.

CONCLUSIONS

Although more patients are dying while receiving inpatient care, these changes in site of death seem to reflect changing patient preferences. The net effect is that patients in this sample were more likely to die in the setting of their choice in 2012 than they were in 2008.

Financial hardship and the intensity of medical care received near death

BACKGROUND

Although end-of-life (EOL) care can present a substantial financial burden for the household, the influence of this burden on the intensity of care received at the EOL remains unknown. The goal of this study was to determine the association between financial hardship and intensive care in the last week of life.

METHODS

The Coping with Cancer (CwC) Study is a longitudinal, multisite cohort study of terminally ill cancer patients and their informal caregivers, September 2002-February 2008. Patients (N = 281) were followed from baseline to death, a median of 4.4 months after baseline assessment. Intensive care was defined as the use of resuscitation and/or ventilation in the patient's last week of life. Financial hardship was measured at study baseline as a positive response to whether the household had to use all or most of their savings because of the family member's illness.

RESULTS

Twenty-nine percent reported financial hardship, and 9% received intensive EOL care. Patients reporting financial hardship had a 3.22 (95% CI: 1.38, 7.53) higher likelihood of receiving intensive EOL care compared with patients not reporting financial hardship. After adjusting for sociodemographic characteristics and patient preferences, patients reporting financial hardship had a 3.05 (95% CI: 1.22, 7.62) higher likelihood of receiving intensive EOL care.

CONCLUSION

The depletion of a family's financial resources is a significant predictor of intensive EOL care, over and above the influence of sociodemographic characteristics and patient preferences.

Terminal cancer patients' and their primary caregivers' attitudes toward hospice/palliative care and their effects on actual utilization: A prospective cohort study

BACKGROUND

Previous studies on hospice/palliative care indicated that patients' socio-demographic factors, disease status, and availability of health-care resources were associated with hospice/palliative care utilization. However, the impact of family caregivers on hospice/palliative care utilization has not been thoroughly investigated.

AIM

To evaluate the association between attitudes toward hospice/palliative care of both patients with terminal cancer (defined as progressive, advanced cancer in which the patient will die within months) and their family caregivers and utilization of inpatient hospice/palliative care facilities.

DESIGN

A prospective observational cohort study was performed in 12 hospitals in South Korea. Attitude toward hospice/palliative care was assessed immediately after terminal cancer diagnosis. After the patient's death, caregivers were interviewed whether they utilized hospice/palliative care facilities.

PARTICIPANTS

A total of 359 patient-caregiver dyads completed baseline questionnaires. After the patients' death, 257 caregivers were interviewed.

RESULTS

At the baseline questionnaire, 137/359 (38.2%) patients and 185/359 (51.5%) of caregivers preferred hospice/palliative care. Preference for hospice/palliative care was associated with awareness of terminal status among both patients (adjusted odds ratio: 1.87, 95% confidence interval: 1.16-3.03) and caregivers (adjusted odds ratio: 2.14, 95% confidence interval: 1.20-3.81). Religion, metastasis, and poor performance status were also independently associated with patient preference for hospice/palliative care. At the post-bereavement interview, 104/257 (40.5%) caregivers responded that they utilized hospice/palliative care facilities. Caregiver's preferences for hospice/palliative care were significantly associated with actual utilization (adjusted odds ratio: 2.67, 95% confidence interval: 1.53-4.67). No patient-related factors were associated with hospice/palliative care utilization.

CONCLUSION

Promoting awareness of prognosis and to improve communication between doctors and families is important for facilitating the use of hospice/palliative care.

Costs of care for lung and colon cancer patients receiving chemotherapy following FDA policy changes

PURPOSE

Use of erythropoiesis-stimulating agents (ESAs) in US cancer care declined amidst post-marketing evidence of adverse effects and the Food and Drug Administration's (FDA) addition of a "black-box" warning to product labeling in March 2007. Because reduced ESA use may have led to more transfusions or increased anemia-related health care needs, we measured the policy's impact on health care costs of lung and colon cancer patients receiving chemotherapy.

METHODS

In a retrospective cohort study of 13,630 lung and 3,198 colon cancer patients in the Department of Veterans Affairs (VA) between 2002 and 2008, we calculated anemia treatment (ESA and transfusion), cancer- and non-cancer-related, and total health care costs for the chemotherapy episode of care. We used multivariable regression to examine health care costs and utilization between patients whose chemotherapy was administered before (PRE) or after (POST) March 1, 2007.

RESULTS

ESA costs declined and transfusion costs were similar, resulting in lower overall POST-period anemia treatment costs (lung, $526 lower, P < 0.01; colon, $504 lower, P < 0.01). Other cancer-related health care costs increased, resulting in markedly higher POST-period total health care costs (lung, $4,706 higher, P < 0.01; colon, $11,414 higher, P < 0.01).

CONCLUSIONS

Although chemotherapy episode anemia treatment costs declined after the black-box warning, the savings were offset by increases in other cancer-related costs. Those increases were mainly in outpatient services and pharmacy, suggesting that likely drivers include adoption of new high-cost diagnostic approaches and therapeutic modalities. Additional research is needed to determine the effects of anemia management changes on patient outcomes and to more fully understand cost-benefit relationships in cancer treatment.

Characteristics and outcomes of patients admitted to the acute palliative care unit from the emergency center

CONTEXT

Most patients admitted to acute palliative care units (APCUs) are transferred from inpatient oncology units. We hypothesized that patients admitted to APCUs from emergency centers (ECs) have symptom burdens and outcomes that differ from those of transferred inpatients.

OBJECTIVES

The purpose of this retrospective cohort study was to compare the symptom burdens and survival rate of patients admitted to an APCU from an EC with those of inpatients transferred to the APCU.

METHODS

Among the 2568 patients admitted to our APCU between September 1, 2003 and August 31, 2008, 312 (12%) were EC patients. We randomly selected 300 inpatients transferred to the APCU as controls (The outcome data were unavailable for two patients). We retrieved data on patient demographics, cancer diagnosis, Edmonton Symptom Assessment System scores, discharge outcomes, and overall survival from time of admission to the APCU.

RESULTS

The EC patients had higher rates of pain, fatigue, nausea, and insomnia and were less likely to be delirious. They were more than twice as likely to be discharged alive than transferred inpatients. Kaplan-Meier plot tests for product-limit survival estimate from admission to APCU for EC patients and inpatients were statistically significant (median survival 34 vs. 31 days, P<0.0001). In multivariate analysis, EC admission (odds ratio [OR]=1.8593, 95% confidence interval [CI] 1.1532-2.9961), dyspnea (OR=0.8533, 95% CI 0.7892-0.9211), well-being (OR=1.1192, 95% CI 1.0234-1.2257), and delirium (OR=0.3942, 95% CI 0.2443-0.6351) were independently associated with being discharged alive.

CONCLUSION

The EC patients have a higher acute symptom burden and are more likely to be discharged alive than transferred inpatients. The APCU was successful at managing symptoms and facilitating the discharge of both inpatients and EC patients to the community although the patients had severe symptoms on admission.

Patterns of care at end of life for people with primary intracranial tumors: lessons learned

To determine the variability in processes of care in the last 6 months of life experienced by patients dying of primary intracranial tumors and potential predictors of place of death, a death-backwards cohort was assembled using historical data and 1,623 decedents were identified. 90 % of people had ≥ 1 admission to an acute care hospital and 23 % spent ≥ 3 months of their last 6 months of life in acute care. 44 % had ≥ 1 ER visits and 30 % were admitted ≥ 1 times to ICU. Only 18 % had a home visit by a physician. 10 % died at home but 49 % died in hospital, while 40 % died in a palliative care facility. Age, comorbidities, and being diagnosed with grade 4 astrocytoma were associated with greater burden of care. Level of care burden and age were associated with higher odds of dying in a treatment intensive place of death, being diagnosed with grade 4 astrocytoma had opposite effect. Despite valuable research efforts to improve the treatment of primary intracranial tumors that focus on biology, refinements to surgery, radiation, and chemotherapy, there is also room to improve aspects of care at the end of life situation. An integrative approach for this patients' population, from diagnosis to death, could potentially reduce the care burden in the final period on the health care system, patient's family and improve access to a better place of death.

Identification of potentially avoidable hospitalizations in patients with GI cancer

PURPOSE

To identify and characterize potentially avoidable hospitalizations in patients with GI malignancies.

PATIENTS AND METHODS

We compiled a retrospective series of sequential hospital admissions in patients with GI cancer. Patients were admitted to an inpatient medical oncology or palliative care service between December 2011 and July 2012. Practicing oncology clinicians used a consensus-driven medical record review process to categorize each hospitalization as "potentially avoidable" or "not avoidable." Patient demographic and clinical data were abstracted, and quantitative and qualitative analyses were performed to identify patient characteristics and outcomes associated with potentially avoidable hospitalizations.

RESULTS

We evaluated 201 hospitalizations in 154 unique patients. The median age was 62 years, and colorectal cancer was the most common diagnosis (32%). The majority of hospitalized patients had metastatic cancer (81%). In all, 53% of hospitalizations were attributable to cancer symptoms, and 28% were attributable to complications of cancer treatment. Medical oncologists identified 39 hospitalizations (19%) as potentially avoidable. Hospitalizations were more likely to be categorized as potentially avoidable for patients with the following characteristics: age ≥ 70 years (odds ratio [OR], 2.63; 95% CI, 1.15 to 6.02), receipt of an oncologist's advice to consider hospice (OR, 6.09; 95% CI, 2.54 to 14.58), or receipt of three or more lines of chemotherapy (OR, 2.68; 95% CI, 1.01 to 7.08). Ninety-day mortality was higher after avoidable hospitalizations compared with hospitalizations that were not avoidable (OR, 6.4; 95% CI, 1.8 to 22.3).

CONCLUSION

Potentially avoidable hospitalizations are common in patients with advanced GI cancer. The majority of potentially avoidable hospitalizations occurred in patients with advanced treatment-refractory cancers near the end of life.

When the Care Ends: Emotional State of Spanish Bereaved Caregivers of Persons with Dementia

Several researchers have found that caring for relatives with dementia has negative consequences on the caregiver’s physical and emotional health during the caregiving period. However, less attention has been paid to caregiver´s emotional state after the patient´s death. The aims of this study are 1) to evaluate the emotional state of the Spanish former caregivers after the care recipient death, and 2) to analyze the patient’s death circumstances and their influence in the current emotional state of caregivers. The sample was composed of 50 former caregivers of relatives diagnosed with Alzheimer’s disease. The dependent variables were assessed using the Beck Depression Inventory and the Texas Revised Inventory of Grief. Most of the caregivers did not develop a complicated grief or depressive symptoms. However, caregivers are not uniform in their responses to bereavement. Specifically, grief was higher in spouses than in adult child, even after controlling the effect of gender and age. Furthermore, this study provides first evidence of the positive relationship between saying good-bye to the patient and caregivers’ emotional status.

Dying at home--is it better: a narrative appraisal of the state of the science

BACKGROUND

Achieving home care and home death is increasingly used as an outcome measure of palliative care services.

AIM

To appraise the state of the science on dying at home.

METHODS

Appraisal and narrative review developed from a plenary presentation at the European Association for Palliative Care (EAPC) 2012 meeting examining the research on variations and trends in place of death, factors associated with dying in the preferred place, presenting evidence on outcomes for those dying at home and suggesting future research questions.

RESULTS

Meeting patients' preferences and creating home-like environments has been a major concern for hospice and palliative care since its inception. During the 20(th) century, in many countries, hospital deaths increased and home deaths reduced. Despite the fact that this trend has been halted or reversed in some countries (notably the United States, Canada and, more recently, the United Kingdom) in the last 5-20 years, a home death is still a distant reality for the majority, even though evidence shows it is the most commonly preferred place to die. Epidemiological studies identified factors associated with home death, including affluence, patients' preferences, provision of home care and extended family support. Evidence about the benefits of home care is conflicting, but recent data suggest that holistic well-being may be greater at home.

IMPLICATIONS

We call for further analyses of variations in place of care and place of death and robust studies on how patients and families formulate and change preferences over time. Regular monitoring of outcomes, quality and costs of palliative home care is urged.

Living through the end: The phenomenon of dying at home

Objectives:

To explore the unique lived experiences of one patient who died at home and her family members, and to interpret how dying at home influenced patterns of bereavement for this patient's family.

Methods:

Benner's (1985) interpretive phenomenological approach was employed to get at the embedded nature of the social phenomenon of dying at home, uncovering what may be taken for granted by participants — in this case, during and after the patient's home hospice course. The participants were a 78-year-old female diagnosed with amyotrophic lateral sclerosis six months prior to death, her husband, and three of her four children. In line with the patient's wish to die at home, she voluntarily forewent food and drink when she no longer wished to watch her body deteriorate and felt that her life had run its course. She informed her family of this plan, and all were supportive. For data collection, separate single in-depth interviews were conducted with the deceased three months prior to death, and after death with three of her four children and her spouse of 60 years. For data analysis, the interview transcripts were coded for paradigm cases, exemplars, and themes.

Results:

The paradigm case, “The Meaning of Being at Home,” revealed that for study participants, remaining home with hospice provided a richly familiar, quiet, and safe environment for being together over time and focusing on relationships. Exemplars included “Driving Her Own Course” and “Not Being a Burden.” Salient themes encompassed patient and family characteristics, support, emotions, the value of time, and aspects of the healthcare team.

Significance of results:

End-of-life care providers need to hold a patient-centered, family-focused view to facilitate patient and family wishes to remain home to die. Investigation into family relationships, from the perspectives of both patient and family members, longitudinally, may enrich understanding and ability and help patients to die at home.

Race and residence: intercounty variation in black-white differences in hospice use

CONTEXT

Although blacks use hospice at lower rates than whites in the U.S., racial differences in hospice use vary by geographic area.

OBJECTIVES

To describe intercounty variability in black-white differences in hospice use and the association with the supply of health care resources.

METHODS

Subjects were a retrospective cohort of Medicare beneficiaries in North and South Carolina who died in 2008. Using Wilcoxon tests and logistic regression, we examined the differences in the supply of health care resources (hospital beds and physicians per population age 65 years and older, percentage of generalists, etc.) between counties with and without racial disparity in hospice use. Counties with a racial disparity had significantly (P < 0.05) higher rates of hospice use among whites than blacks.

RESULTS

Of 76,283 decedents in 128 counties, 19.78% were black. In the 39 counties (30.47%) with racial disparity in hospice use, the mean proportion of whites who enrolled in hospice was 41.3% vs. 28.66% of blacks (P < 0.0001). Counties with more hospital beds per population age 65 years and older had a higher odds (OR, 1.39; 95% confidence interval [CI] 1.04-1.86) and those with a larger proportion of generalists had a lower odds (OR, 0.01; 95% CI 0.001-0.476) of having a racial disparity in hospice use.

CONCLUSION

In most counties, the rates of hospice use were similar for blacks and whites. In counties with a racial disparity, there were more resources to deliver aggressive care (i.e., hospital beds and specialists). Because of a greater preference for life-sustaining therapies, blacks may be more likely to use acute care services at the end of life when resources for the delivery of these services are readily available.

Where do you want to spend your last days of life? Low concordance between preferred and actual site of death among hospitalized adults

BACKGROUND

Death in the U.S. frequently occurs in institutions despite the overwhelming majority of persons who state that they prefer to die at home. Little research to date has examined how well individual preferences compare to actual site of death.

OBJECTIVES

Determine the concordance between preferred and actual place of death and examine independent predictors for concordance.

DESIGN

Observational cohort study.

SETTING

Three area hospitals including a safety net hospital, veterans' hospital, and academic tertiary referral center.

PATIENTS

458 adult patients admitted to the general medical service from 2003-2005.

MEASUREMENTS

Patients were asked where they preferred to spend their last days of life. Data on date and actual site of death from 2005-2009 was collected from hospital records and death certificates.

RESULTS

The majority of patients preferred to die at home (75% n = 343). Low income and being married were significantly associated with a preference to die at home compared to nursing home or inpatient hospice (OR 2.71 95% CI 1.30-5.67 and OR 2.44 95% CI 1.14-5.21 respectively). Of the 123 patients who died during the follow up period, most (66% n = 80) died in an institutional setting. Overall concordance between preferred and actual site of death was only 37% (n = 41). Female gender was significantly associated with concordance between preferred and actual site of death (OR 3.30 95% CI 1.25-8.72).

CONCLUSIONS

Concordance between preferred and actual site of death is low and female gender was the sole patient level variable associated with concordance.

Nurse executives' perceptions of end-of-life care provided in hospitals

CONTEXT

With the aging of our population, almost one in five adults, or 19% of the population, will be older than 65 years by 2030. Many persons have expressed concern about the inadequate preparation of hospitals to provide high-value end-of-life care for the current and anticipated population of older adults.

OBJECTIVES

The purpose of this study was to explore the perceptions of nurse executives about the provision of end-of-life care in the hospital setting.

METHODS

We conducted a pilot, descriptive, naturalistic, qualitative study using in-person interviews to capture nurse executives' understandings, beliefs, and perceptions of end-of-life care in their facilities.

RESULTS

Data were collected from 10 nurse executives. We identified five major factors, three barriers and two facilitators, in their descriptions of provision of end-of-life care provided in the hospital: 1) communication inadequacies, 2) education inadequacies, 3) hospital system constraints, 4) hospice services availability, and 5) nurse executive advocacy.

CONCLUSION

These findings highlight the need for interventions that focus on improving communication at the bedside and in transitions of care, enhancing educational interventions, and developing patient-centered care systems, which translate into a higher quality end-of-life experience for patients and their family members. Nurse executives are currently an underused resource in end-of-life care but are poised to be able to champion innovative models and a culture of change that integrates high-value care for patients with serious and chronic illnesses.

The association between in-patient death, utilization of hospital resources and availability of palliative home care for cancer patients

BACKGROUND

The impact of palliative home care programs on in-patient admissions and deaths has not been appropriately established.

AIM

The main objectives of this study have been to evaluate the frequency of in-patient hospital deaths and the use of hospital resources among cancer patients in two areas of the Madrid Region, as well as to assess differences between one area with and one without a palliative home care team (PHCT) in those variables.

DESIGN AND SETTING

We conducted a population-based study comparing two adjacent metropolitan areas of approximately 200,000 inhabitants each in the Madrid Region, Spain, measuring in-patient deaths, emergency room admissions and in-patient days among cancer patients who died in 2005. Only one of the two areas had a fully established PHCT.

RESULTS

524/549 cancer patients (95%) had an identified place of death: 74% died in hospital, 17% at home, 6% in an in-patient hospice and 3% in a nursing home. The frequency of hospital deaths was significantly lower among patients of the PHCT area (61% versus 77%, p < 0.001), as well as the number of patients using emergency and in-patient services (68% versus 79%, p = 0.004, and 66 versus 76%, p = 0.012, respectively). After adjusting for other factors, the risk of hospital death was lower among patients older than 80 (OR, 95% CI, 0.3, 0.1-0.5), higher among patients with hematological malignancies (OR 6.1, 2.0-18.9) and lower among patients of the PHCT area (OR 0.4, 0.2-0.6).

CONCLUSIONS

Our findings suggest that a PHCT is associated with reduced in-patient deaths and overall hospitalization over the last two months of life.

End-of-life care for Medicare beneficiaries with cancer is highly intensive overall and varies widely

Studies have shown that cancer care near the end of life is more aggressive than many patients prefer. Using a cohort of deceased Medicare beneficiaries with poor-prognosis cancer, meaning that they were likely to die within a year, we examined the association between hospital characteristics and eleven end-of-life care measures, such as hospice use and hospitalization. Our study revealed a relatively high intensity of care in the last weeks of life. At the same time, there was more than a twofold variation within hospital groups with common features, such as cancer center designation and for-profit status. We found that these hospital characteristics explained little of the observed variation in intensity of end-of-life cancer care and that none reliably predicted a specific pattern of care. These findings raise questions about what factors may be contributing to this variation. They also suggest that best practices in end-of-life cancer care can be found in many settings and that efforts to improve the quality of end-of-life care should include every hospital category.

Reduced overall and event-free survival among colon cancer patients using dual system care

BACKGROUND

Many veterans have dual Veterans Administration (VA) and Medicare healthcare coverage. We compared 3-year overall and cancer event-free survival (EFS) among patients with nonmetastatic colon cancer who obtained substantial portions of their care in both systems and those whose care was obtained predominantly in the VA or in the Medicare fee-for-service system.

METHODS

We conducted a retrospective observational cohort study of patients older than 65 years with stages I to III colon cancer diagnosed from 1999 to 2001 in VA and non-VA facilities. Dual use of VA and non-VA colon cancer care was categorized as predominantly VA use, dual use, or predominantly non-VA use. Extended Cox regression models evaluated associations between survival and dual use.

RESULTS

VA and non-VA users (all stages) had reduced hazard of dying compared with dual users [e.g., for stage I, VA HR 0.40, 95% confidence interval (CI): 0.28-0.56; non-VA HR 0.54, 95% CI: 0.38-0.78). For EFS, stage I findings were similar (VA HR 0.47, 95% CI: 0.35-0.62; non-VA HR 0.64, 95% CI: 0.47-0.86). Stage II and III VA users, but not non-VA users, had improved EFS (stage II: VA HR 0.74, 95% CI: 0.56-0.97; non-VA HR 0.92, 95% CI: 0.69-1.22; stage III: VA HR 0.73, 95% CI: 0.56-0.94; non-VA HR 0.81, 95% CI: 0.62-1.06).

CONCLUSIONS

Improved survival among VA and non-VA compared with dual users raises questions about coordination of care and unmet needs.

IMPACT

Additional study is needed to understand why these differences exist, why patients use both systems, and how systems may be improved to yield better outcomes in this population.

Norms of decision making in the ICU: a case study of two academic medical centers at the extremes of end-of-life treatment intensity

PURPOSE

To explore norms of decision making regarding life-sustaining treatments (LSTs) at two academic medical centers (AMCs) that contribute to their opposite extremes of end-of-life ICU use.

METHODS

We conducted a 4-week mixed methods case study at each AMC in 2008-2009 involving direct observation of patient care during rounds in the main medical ICU, semi-structured interviews with staff, patients, and families, and collection of artifacts (e.g., patient lists, standardized forms). We compared patterns of decision making regarding initiation, continuation, and withdrawal of LST using tests of proportions and grounded theory analysis of field note and interview transcripts.

RESULTS

We observed 80 patients [26 (32.5 %) ≥65 years old] staffed by 4 attendings, and interviewed 23 staff and 3 patients/families at the low-intensity AMC (LI-AMC), and observed 73 patients [26 (35.6 %) ≥65 years old] staffed by 4 attending physicians and interviewed 26 staff and 4 patients/families at the high-intensity AMC (HI-AMC). LST initiation among patients over 65 was similar, except feeding tubes (0 % LI-AMC versus 31 % HI-AMC, p = 0.002). The LI-AMC was more likely to use a time-limited trial of LST, followed by withdrawal (27 vs. 8 %, p = 0.01) and to have a known outcome of death (31 vs. 4 %, p < 0.001). We identified qualitative differences in goals of LST, the determination of "dying," concern about harms of commission versus omission, and physician self-efficacy for LST decision making.

CONCLUSIONS

Time-limited trials of LST at the LI-AMC and open-ended use of LST at the HI-AMC explain some of the AMCs' nationally profiled differences in end-of-life ICU use.

Predictors of home care expenditures and death at home for cancer patients in an integrated comprehensive palliative home care pilot program

PURPOSE

Empirical understanding of predictors for home care service use and death at home is important for healthcare planning. Few studies have examined these predictors in the context of the publicly funded Canadian home care system. This study examined predictors for home care use and home death in the context of a "gold standard" comprehensive palliative home care program pilot in Ontario where patients had equal access to home care services.

METHODS

Secondary clinical and administrative data sources were linked using a unique identifier to examine multivariate factors (predisposing, enabling, need) on total home care expenditures and home death for a cohort of cancer patients enrolled in the HPCNet pilot.

RESULTS

SUBJECTS WITH GASTROINTESTINAL SYMPTOMS (OR: 1.64; p=0.03) and those with higher income had increased odds of dying at home (OR: 1.14; p<0.001), whereas age, number of GP visits, gastrointestinal symptoms (i.e., nausea, vomiting, bowel obstruction) and eating problems (i.e., anorexia/cachexia) predicted home care expenditures.

CONCLUSIONS

Predictors of home death found in earlier studies appeared less important in this comprehensive palliative home care pilot. An income effect for home death observed in this study requires examination in future controlled studies.

RELEVANCE

Access to palliative home care that is adequately resourced and organized to address the multiple domains of issues that patients/families experience at the end of life has the potential to enable home death and shift care appropriately from limited acute care resources.

The end-of-life experience for a cohort of patients with pulmonary arterial hypertension

INTRODUCTION

Pulmonary arterial hypertension (PAH) is a progressive and ultimately fatal disease of the pulmonary circulation. There has never been an investigation of the end-of-life symptoms in patients with PAH. In this investigation, we surveyed surrogates of recent decedents with PAH. We evaluate their responses to better understand the end-of-life experience of patients with PAH.

METHODS

The survey instrument includes demographic information and the Edmonton Symptoms Assessment Scale. Accredo Therapeutics mailed the survey to surrogates of recent decedents with PAH, and responses were anonymously returned to investigators at Virginia Commonwealth University and used in our descriptive analysis.

RESULTS

Of 100 surveys distributed over 24 months (February 2009 to February 2011), we obtained 36 responses (response rate 36%). We found that most patient deaths (90%) were related to PAH, that the majority of patients died in the hospital (67%), with the majority of in-hospital deaths (83%) occurring in intensive care. Palliative care was infrequently involved in patients' care, and many surrogates were unaware of palliative care and hospice services available to the decedents. Patients died with a high symptom burden, especially dyspnea.

CONCLUSION

In this cohort, patients with PAH usually died from their disease, often in the hospital setting with a high symptom burden. Further study will be needed to confirm the findings from this study and to better understand the forces leading to the trends uncovered in this investigation.