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

Living wills and the Mental Capacity Act: a postal questionnaire survey of UK geriatricians

OBJECTIVE

To determine geriatricians' experience of and views on living wills, National Health Service Trusts' support of advance end-of-life health care planning and geriatricians' views on related legal changes in the Mental Capacity Act.

DESIGN

Anonymous postal questionnaire survey of all 1,426 British Geriatrics Society members in England, Wales and Northern Ireland.

RESULTS

A total of 842 (59%) questionnaires were returned. Of 811 geriatricians, 454 (56%) had cared for patients with living wills. Of the 280 who cared for patients when the living will had come into effect, 108 (39%) had changed treatment because of the living will and 84 (78%) of those felt that decisions had been easier to make. Living wills not already in effect made discussions with patients [171 of 178 (96%)] and families [135 of 178 (76%)] easier. Of 779 geriatricians, 713 (92%) saw advantages of older people using living wills; 467 of these also expressed concerns. Only 16 (2%) geriatricians who had concerns said that there were no advantages. A total of 214 (27%) were aware that their Trust had a form to help with discussions about cardiopulmonary resuscitation. Fewer [126 of 781 (16%)] were aware of a Trust policy on living wills. The proposal, in the Mental Capacity Bill, for advance refusals of treatment was supported by 59% (476 of 801), yet the proposal for a lasting power of attorney (LPA) covering health care was only supported by 47% (382 of 806).

CONCLUSION

Many geriatricians have positive experiences of caring for patients with living wills. Despite recognising potential problems, most geriatricians support the use of living wills by older people. However, most believe that their Trust does not have a policy to support advance health care planning. Geriatricians have reservations about LPAs covering health care.

Comparison of Medical Treatments for the Dying in a Hospice and a Geriatric Hospital in Japan

CONTEXT

Most older adults who die in Japan do so in the hospital without receiving hospice or palliative care. While there are some hospices in Japan, little is known about the care they provide to the elderly.

OBJECTIVE

To clarify how the care of dying patients differs in a hospice and a geriatric hospital in Japan.

DESIGN

Cohort study.

SETTING

A hospice and a geriatric hospital in Japan.

PARTICIPANTS

One hundred ninety-one inpatients aged 65 or older.

MAIN OUTCOME

Areas of our interest: (1) gender and age; (2) primary disease(s) and cause of death; (3) observed symptoms/conditions and medical treatment or care conducted within 48 hours prior to death; (4) the actual topics leading to disclosure; and (5) whether or not advance directives had been given.

RESULTS

The X2 test determined that there were statistically significant differences between a geriatric hospital and a hospice, with respect to mean age, diagnoses on admission, primary cause of death, symptoms/conditions, and the practice of medical interventions. However, controlling for patient characteristics and assuming a bivariate distribution between the probabilities of choosing a facility and of undergoing a medical procedure, we found that patients at the hospice were more likely to undergo treatment with opioids, urethral catheter, and oral medicine; such patients were less likely to undergo oxygen inhalation, total parenteral nutrition, and other intravenous drips.

CONCLUSION

The hospice examined in this study was similar to the approach regarding medical treatments observed at the geriatric hospital.

The growth of palliative care programs in United States hospitals

BACKGROUND

Palliative care programs are becoming increasingly common in U.S. hospitals.

OBJECTIVE

To quantify the growth of hospital based palliative care programs from 2000-2003 and identify hospital characteristics associated with the development of a palliative care program.

DESIGN AND MEASUREMENTS

Data were obtained from the 2001-2004 American Hospital Association Annual Surveys which covered calendar years 2000-2003. We identified all programs that self-reported the presence of a hospital-owned palliative care program and acute medical and surgical beds. Multivariate logistic regression was used to identify characteristics significantly associated with the presence of a palliative care program in the 2003 survey data.

RESULTS

Overall, the number of programs increased linearly from 632 (15% of hospitals) in 2000 to 1027 (25% of hospitals) in 2003. Significant predictors associated with an increased likelihood of having a palliative care program included greater numbers of hospital beds and critical care beds, geographic region, and being an academic medical center. Compared to notfor- profit hospitals, VA hospitals were significantly more likely to have a palliative care program and city, county or state and for-profit hospitals were significantly less likely to have a program. Hospitals operated by the Catholic Church, and hospitals that owned their own hospice program were significantly more likely to have a palliative care program than non- Catholic Church-operated hospitals and hospitals without hospice programs respectively.

CONCLUSIONS

Our data suggest that although growth in palliative care programs has occurred throughout the nation's hospitals, larger hospitals, academic medical centers, not-for-profit hospitals, and VA hospitals are significantly more likely to develop a program compared to other hospitals.

Influence of hospice use on hospital inpatient mortality: a state-level analysis

This study tests the hypothesis that high hospice enrollment is associated with lower Medicare inpatient mortality. The results show that Medicare inpatient mortality in a state can be explained by hospice enrollment and a host of demographic and market environment variables. An increase in hospice population by 100 individuals is associated with a reduction of 28 inpatient deaths, ceteris paribus. The results suggest, among other things, that opportunities exist for greater expansion of hospice capacity in low-use states to reduce deaths in the expensive hospital setting and improve the quality of end-of-life care for terminally ill patients.

Dying at home or in an institution using death certificates to explore the factors associated with place of death

INTRODUCTION

The knowledge of determinants of place of death is important for public health policy aimed at improving the quality of end-of-life care.

METHODS

We investigated the influence of clinical, socio-demographic, residential and health care system factors on the place of death, using data from all 55,759 deaths in 2001 in Flanders (Belgium), gathered via official death certificates and data from anonymously linked health care statistics. A multivariate logistic regression was used to examine the associated factors (home versus hospital as dependent categories).

RESULTS

Of all deaths in Flanders, 53.7% took place in hospital, 24.3% at home and 19.8% in a care home. The probability of home deaths varied by region, by rural or urban residence and by the hospital bed availability in the region and dying at home was less likely among those suffering from certain non-malignant chronic diseases, the less educated and those living alone.

CONCLUSION

Although most people wish to die at home, most deaths in Flanders (Belgium) in 2001 did not take place there. The clinical, socio-demographic and residential factors found to be associated with the place of death could serve as focal points for a policy to facilitate dying in the place of choice, including at home.

Factors predicting home death for terminally ill cancer patients receiving hospital-based home care: the Lyon comprehensive cancer center experience

This study aimed to determine factors favoring home death for cancer patients in a context of coordinated home care. A retrospective study was conducted among patients followed up by the home care coordinating unit of the cancer center of Lyon. The main endpoint was place of death. Univariate analysis included general characteristics (age, gender, rural or urban residence, disease), Karnofsky Index (KI), type of care at referral (chemotherapy, palliative care, or other supportive care), and coordinating medical oncologist (MCO) home visits. Significant factors were used in a logistic regression analysis. Of 250 patients, 90 (36%) had home death. Low KI and MCO home visit were correlated with home death (odds ratio, respectively, 2.1 and 3.1). These results indicate that health care support favors home death. A hospital-based home care unit is effective for bridging the gap between community and hospital. MCO home visits offer concrete support to health care professionals, patients, and relatives.

Ethnic Differences in the Place of Death of Elderly Hospice Enrollees

Elderly minorities are more likely to die in inpatient settings than their Caucasian counterparts. It is not known whether this difference is due to cultural preferences for place of death or decreased access to hospice. This analysis examines ethnic differences in the place of death of elderly hospice patients. Using data from a large, national hospice provider, elderly (> or = 65) African-American, Hispanic, and Caucasian decedents admitted to hospice between January 1, 2000, and December 31, 2003, were identified. Of the 115,854 eligible decedents, 78.3% were Caucasian, 10.7% African American, and 11% Hispanic. Hispanics and African Americans were more likely to die in inpatient hospice settings than Caucasians (38.5%, 38.5%, and 32%, respectively). After adjustment for demographic and hospice use variables, older African Americans had higher odds than older Caucasians of dying in an inpatient hospice setting than a nursing home (odds ratio (OR)=1.12, 95% confidence interval (CI)=1.07-1.19). However, African-American ethnicity was not a significant predictor of death in an inpatient setting versus home (OR=1.03, 95% CI=0.97-1.08)). Hispanics had lower odds than Caucasians of death in an inpatient hospice setting than at home (OR=0.88, 95% CI=0.84, 0.93) and higher odds of death in an inpatient setting than a nursing home (OR=1.45, 95% CI=1.37-1.53). Admission to hospice reduces but does not eliminate ethnic differences in place of death. Further research should examine the effect of individual and cultural preferences for place of death on decisions to enroll in hospice.

Discrepancy in the preferences of place of death between terminally ill cancer patients and their primary family caregivers in Taiwan

There is a worldwide common preference for dying at home. However, death at home does not come without significant challenges and potential consequences for families. Given the interactive nature of decisions regarding the place of death, the family's perspective is important and needs to be investigated. The purposes of this study were to compare (1) Taiwanese terminally ill cancer patients' and their family caregivers' preferences for the patient's place of death; and (2) important factors that are considered in choosing the preferred place of death from both points of view. A total of 617 dyads of terminally ill cancer patients and their family caregivers were surveyed. The majority of both terminally ill cancer patients and their family caregivers preferred to die at home (61.0% and 56.9%, respectively). A higher proportion of the family caregivers indicated a preference for hospital death for the patients. There was a moderate association between the two respondents in the preferences of place of death. Results underscore discrepancies between patients and their families in the importance given to cultural concerns, quality of health care, worries of being a burden to others, lack of availability of families, relationships with health care providers, and being surrounded by the home environment. Effective interventions need to be developed which can lighten the caregiving burden and help families retain dying patients at home, avoid unnecessary re-hospitalizations and unfavorable hospital deaths, and improve accordance with the patient's wishes.

Terminal Care: The Last Weeks of Life

BACKGROUND

The care of patients in their last weeks of life is a fundamental palliative care skill, but few evidence-based reviews have focused on this critical period.

METHOD

A systematic review of published literature and expert opinion related to care in the last weeks of life.

RESULTS

The evidence base informing terminal care is largely descriptive, retrospective, or extrapolated. While home deaths and hospice use are increasing, medical care near death is becoming more aggressive and hospice lengths of stay remain short. Though the prediction of impending death remains imprecise, studies have identified several common terminal signs and symptoms. Decreased communication near death complicates the determination of patient wishes, and advanced directives prior to the terminal stage are recommended. Anorexia and cachexia are common in dying patients but there is no evidence that this process is painful or responsive to intervention. While there is general consensus that artificial nutrition is not beneficial in dying patients, the use of artificial hydration is controversial, especially in the setting of delirium. Breathlessness has been shown to benefit from oral and parenteral opioids but not anxiolytics. Accumulation of respiratory tract secretions (death rattle) is common and usually responds to antimuscarinics. Physical pain typically decreases toward death but its assessment in dying patients is difficult. Terminal delirium may occur in up to one-third of patients, may have a reversible cause, and may respond to antipsychotics or benzodiazepines. Palliative sedation is controversial but widely used, especially internationally. Caregiver stress and bereavement may benefit from improved communication and hospice involvement.

CONCLUSION

While the terminal care literature is characterized by varying quality, numerous knowledge gaps, and frequent inconsistencies, it supports several common clinical interventions. More research is needed to resolve controversies, define effective therapies, and improve the outcomes of dying patients.

Ethnic Variation in Site of Death of Older Adults Dually Eligible for Medicaid and Medicare

This is a retrospective study using secondary data to investigate variation in site of death by ethnicity and to determine how hospice enrollment affects site of death. Data for this study were obtained between 1996 and 2000 from linked Medi-Cal and Medicare claims from 18 California counties participating in a state legislated effort to improve chronic care services in California. Subjects examined in this study included 38,519 decedents aged 65 and older who died between 1997 and 2000 and were dually eligible the entire year immediately before death. Demographic variables were site of death, cause of death, hospice use, and care setting in the year before death. Results revealed that blacks and Latinos were significantly more likely than whites to die at home, although being black or Asian was negatively associated with hospice use. This variation did not change when hospice use was controlled. Thus, although minorities were more likely to die at home, they were less likely to receive hospice care. Because patients dying at home without hospice care report higher rates of pain than those who have hospice care, physicians must work to ensure that minority patients understand all end-of-life care options, including hospice, and how these care options can be delivered in a culturally competent manner.

Determinants of death in an inpatient hospice for terminally ill cancer patients

Objective:Despite the strong emphasis on home-based end-of-life care in the United States and the recognition of dying at home as a gold standard of quality of care, hospice home care is not a panacea and death at home may not be feasible for every terminally ill cancer patient. Admission to an inpatient hospice and dying there may become a necessary and appropriate solution to distressing patients or exhausted families. However, the factors associated with death in an inpatient hospice have not been examined in previous studies.

Methods:A prospective cohort study was conducted to investigate the determinants of death in an inpatient hospice for terminally ill cancer patients. Approximately two-fifths (40.8%) of the 180 terminally ill cancer patients in this study died in inpatient hospices over the 3-year study period.

Results:Results from Cox proportional hazards model with adjustment for covariates revealed several factors that were significantly associated with dying in inpatient hospice, as opposed to home, in a nursing home, or in the hospital. Patients were more likely to die in an inpatient hospice if they received hospice care before death (hazard ratio [HR] = 7.32, 95% confidence interval [CI]: 3.21–16.67), if they had a prestated preference to die in an inpatient hospice (HR = 4.86, 95% CI: 2.24–10.51), if they resided in New Haven County (HR = 1.70, 95% CI: 1.00–2.93), or if they experienced higher levels of functional dependency (HR = 1.05, 95% CI: 1.02–1.08).

Significance of results:The high prevalence of inpatient hospice deaths for terminally ill cancer patients in this study was related to the local health care system characteristics, health care needs at the end of life, and personal preference of place of death. Findings from this study may shed light on future directions for developing end-of-life care tailored to the needs of cancer patients who are admitted to hospices and eventually die there.

How much is postacute care use affected by its availability?

OBJECTIVE

To assess the relative impact of clinical factors versus nonclinical factors-such as postacute care (PAC) supply-in determining whether patients receive care from skilled nursing facilities (SNFs) or inpatient rehabilitation facilities (IRFs) after discharge from acute care.

DATA SOURCES AND STUDY SETTING

Medicare acute hospital, IRF, and SNF claims provided data on PAC choices; predictors of site of PAC chosen were generated from Medicare claims, provider of services, enrollment file, and Area Resource File data.

STUDY DESIGN

We used multinomial logit models to predict PAC use by elderly patients after hospitalizations for stroke, hip fractures, or lower extremity joint replacements.

DATA COLLECTION/EXTRACTION METHODS

A file was constructed linking acute and postacute utilization data for all medicare patients hospitalized in 1999.

PRINCIPAL FINDINGS

PAC availability is a more powerful predictor of PAC use than the clinical characteristics in many of our models. The effects of distance to providers and supply of providers are particularly clear in the choice between IRF and SNF care. The farther away the nearest IRF is, and the closer the nearest SNF is, the less likely a patient is to go to an IRF. Similarly, the fewer IRFs, and the more SNFs, there are in the patient's area the less likely the patient is to go to an IRF. In addition, if the hospital from which the patient is discharged has a related IRF or a related SNF the patient is more likely to go there.

CONCLUSIONS

We find that the availability of PAC is a major determinant of whether patients use such care and which type of PAC facility they use. Further research is needed in order to evaluate whether these findings indicate that a greater supply of PAC leads to both higher use of institutional care and better outcomes-or whether it leads to unwarranted expenditures of resources and delays in returning patients to their homes.

Clinical, sociodemographic, and local system factors associated with a hospital death among cancer patients

OBJECTIVE

The study was conducted to examine factors associated with hospital deaths among a group of cancer patients.

PATIENTS AND METHODS

A retrospective chart review of the M. D. Anderson Cancer Center Tumor Registry was conducted. Participants were all adult cancer patients, residents of the State of Texas diagnosed and treated since January 1, 1990, and who died during the years 1999 and 2000. The study outcome was the site of death.

MAIN RESULTS

The inclusion criteria were met by 866 patients of whom 504 (58%) died in a hospital. The group included 489 (56%) men. A number of 641 (74%) were White, 104 (12%) Hispanic, 92 (11%) Black, and 29 (3%) of other origin. The majority, 501 (58%), had been diagnosed with stage IV disease, and the median survival time was 14 months. Multivariate logistic regression analysis showed patients diagnosed with hematologic cancers to be significantly more likely (p<0.001) of dying in hospitals, odds ratio [OR 2.88] and confidence interval [95% CI 1.79-4.63], women diagnosed with breast and gynecological cancers were significantly less likely (p=0.03) of dying at hospitals odds ratio [OR 0.64] and confidence interval [95% CI 0.42-0.96], when compared with patients diagnosed with other cancers. Lower household income per zip code of residency was marginally associated (p=0.06) with hospital deaths.

CONCLUSIONS

The study identified groups of cancer patients at risk of hospital death. These results should account when planning the allocation of hospital palliative care services as well as when informing policy decisions about health care financing and delivery of these services.

Kokua Mau: A Statewide Effort to Improve End-of-Life Care

BACKGROUND

Many Americans die in pain, without hospice, and without regard to advance directives, suggesting a need to improve end-of-life (EOL) awareness and services.

OBJECTIVE

This paper describes Kokua Mau, a community-state partnership to improve EOL in Hawaii funded by The Robert Wood Johnson Foundation (RWJF). Coalition activities were guided by innovation-diffusion theory, targeting "innovators" and "change agents" within communities and organizations willing to learn about and facilitate improvements to EOL care.

DESIGN

Evaluation of a community-wide intervention to improve EOL care.

SETTING/SUBJECTS

Honolulu, Hawaii.

MEASUREMENTS

We tracked dissemination of campaign messages by counting numbers of coalition members (including innovators and change agents to carry on the work), individuals reached through awareness and educational offerings, and new EOL projects initiated during and after the initial 3-year RWJF funding. To measure change, we counted the number of legislative policies that were modified by the coalition as well as indicators of hospice utilization, advance directive (AD) completion, support for physician-assisted death, and place of death.

RESULTS

In the first 3 years of the project: coalition membership grew to 350 members; EOL care curricula were developed and offered to various target audiences; 17,000 individuals attended educational events; policy changes were facilitated; decreases were seen in proportions of residents supporting physician-assisted suicide; and increases were seen in advance directive completion rates and hospice utilization. Most importantly, after the grant period, coalition members went on to develop and implement new programs to improve care to the dying.

CONCLUSIONS

Although it will take several years to effect comprehensive and sustained changes in the way death is perceived and the dying process is facilitated, findings suggest that programs based on innovation-diffusion theory can increase EOL awareness and help develop the change agents and role models needed to affect community-wide change over the long term.

Dying to be home? Preferred location of death of first-generation black Caribbean and native-born white patients in the United Kingdom

Although preference for location of death has been studied in the general population little is known about the experience of people from different ethnic backgrounds and nothing about the black Caribbean population living in the United Kingdom. Over 13 months we surveyed the family and friends of deceased first-generation black Caribbean and native-born white patients with advanced disease. Of the 106 black Caribbean and 110 white patients identified, 50 interviews per ethnic group were conducted, a response rate of 47% and 45%. It was found that 21% of all patients surveyed died in their own home, 61% in hospital, 12% in a hospice, and 6% in a residential/nursing home. Thirty-four percent of black Caribbean compared to 27% native-born white patients were reported to have expressed a preference for location of death and of these over 80% of all patients wanted to die at home. Similar proportions of patients from the Caribbean (53%) and white (56%) patient groups who wanted to die at home did so. This was not related to restrictions in patients' activities of daily living or self-reported caregiver burden. Fewer respondents representing Caribbean than white patients stated that neither they (chi(2) = 8.9, p = 0.01) or the deceased patients (chi(2) = 8.6, p = 0.03) were given sufficient choice about the location of death. Our findings suggest: (1) a need to improve training in discussing care and treatment choices, including location of death, and (2) a deeper qualitative understanding of the cultural and other factors that may facilitate or prevent home deaths.

Variations in and factors influencing family members' decisions for palliative home care

The purpose of this paper is to describe the variations in and factors influencing family members' decisions to provide home-based palliative care. Findings were part of a larger ethnographic study examining the social context of home-based palliative caregiving. Data from participant observations and in-depth interviews with family members (n=13) providing care to a palliative patient at home, interviews with bereaved family members (n=47) and interviews with health care providers (n=25) were subjected to constant comparative analysis. Findings indicate decisions were characterized by three types. Some caregivers made uninformed decisions, giving little consideration to the implications of their decisions. Others made indifferent decisions, whereby they reluctantly agreed to provide care at home, and still others negotiated decisions for home care with the dying person. Decisions were influenced by three factors: fulfilling a promise to the patient to be cared for at home, desiring to maintain a 'normal family life' and having previous negative encounters with institutional care. Findings suggest interventions are needed to better prepare caregivers for their role, enhance caregivers' choice in the decision-making process, improve care for the dying in hospital, and consider the development of alternate options for care.

All aboard: advancing the social work research agenda in end-of-life and palliative care

Social workers in all practice areas have the potential to contribute to the National Agenda for Social Work Research in Palliative and End-of-Life Care. The purpose of this article is to invite social work practitioners and researchers to identify research needs and work with others to address them. We offer a conceptualization of the broad scope of social work's involvement in end-of-life issues, and articulate the difference between end-of-life care and end-of-life issues in social work. Suggestions are offered to advance the national research agenda.

The place of death of cancer patients: can qualitative data add to known factors?

Research on the distribution of cancer deaths by setting-hospital, hospice, home, other--is longstanding, but has been given fresh impetus in the UK by policy commitments to increase the proportion of deaths occurring in patients' homes. Studies of factors associated with the location of cancer deaths fall into two main categories: geo-epidemiological interrogations of routinely collected death registration data, and prospective and retrospective cohort studies of terminally ill cancer patients. This paper summarises the findings of these studies and considers the place of death factors that are generated in semi-structured interviews with 15 palliative care service providers working in the Morecambe Bay area of north-west England. These qualitative data are found not only to confirm and considerably enrich understanding of known factors, but also to bring new factors into view. New factors can be grouped under the headings: service infrastructure, patient and carer attitudes, and cultures of practice. Such an approach provides useful information for policy makers and practitioners in palliative care.

Types and Rate of Implementation of Palliative Care Team Recommendations for Care of Hospitalized Veterans

BACKGROUND

Hospital-based interdisciplinary palliative care teams (PCTs) are increasingly being established to meet the growing demand for high quality care for patients with life-limiting illnesses in which the goal is comfort rather than cure. Two recent studies suggest that PCTs teams are highly effective in influencing care of patients within large academic medical centers. The current study examines whether the previously demonstrated success of palliative care teams within subspecialty academic health centers could be replicated in an urban Veterans Affairs medical center (VAMC).

OBJECTIVE

To describe the characteristics of patients referred to, recommendations made by, and implementation rate of an interdisciplinary PCT in an urban VAMC.

DESIGN

Retrospective, observational study.

SETTING/SUBJECTS

One hundred patients referred by inpatient doctor to the PCT between October 1999 and March 2002 in a 214-bed VA hospital in the New York City area.

MEASUREMENTS

Patient demographics, prevalence of five types of recommendations by the PCT and implementation rate by primary physician: (1) advance directives; (2) discharge planning; (3) pain management; (4) symptom management of dyspnea, delirium, constipation, nausea, anxiety, and depression; and (5) consultation orders for other services.

RESULTS

The average number of recommendations per patient was 2.84 and 84.2% were implemented. The most frequent recommendations concerned discharge plans. The reasons recommendations were not implemented included: (1) patient or family refusal noted in the medical record, (2) the patient's clinical status changed, including patient death, and (3) the attending physician chose a different dose, medication, or route of administration than was recommended.

CONCLUSIONS

Overall, most recommendations were implemented by the referring physicians. This finding is consistent with several prior studies demonstrating that PCTs in acute care can and do influence processes of care for hospitalized patients. Well-designed observational studies and randomized controlled trials of specific palliative care interventions and their effect on patient, family, and health care system outcomes are needed.

Admission to intensive care unit at the end-of-life: is it an informed decision?

There is a major deficiency in the end-of-life care offered to patients dying in the intensive care unit (ICU).

HYPOTHESIS

Hospitalized dying patients had informed discussions on end-of-life and palliative care options before admission to ICU.

PATIENTS AND METHODS

A descriptive non-interventional study was performed at a teaching hospital to examine if patients who died in hospital had informed discussions on end-of-life care before admission to ICU. The impact of these discussions on subsequent patient care: aggressive therapy in the ICU, the quality of palliation, use of hospice care services and utilization of hospital resources were examined. Data were collected from medical records for all hospital deaths over 24 months.

RESULTS

Of 252 hospital deaths, 196 (78%) were treated and subsequently 165 (65%) died in the ICU. Patients treated either in the ICU or general hospital wards had similar frequency of ultimately or rapidly fatal pre-existing disease (47% versus 62%, P: ns) and readmission to hospital within one year before death (43% versus 57%, P, ns). The median age (10-90% percentile) was slightly younger for the ICU than hospital wards patients: 73 (45-85) versus 76 (55-91) years, P < 0.01. Of the 156 patients who were transferred to ICU from hospital wards: 136 (87%) were managed by house staff on teaching services and 20 (13%) were managed by attending staff hospitalists, P < 0.01. None of those transferred to the ICU who subsequently died had discussion of palliation or end-of-life care as an alternative treatment. Of those who died who were treated on general wards, 14 (25%) patients had discussion of palliation as an alternative treatment option before death. Do-not-resuscitate decisions were made in 48% of cases two days before death. Patients who were treated in the ICU had more invasive tests performed on them and were less likely to have adequate pain control or referral to hospice care services than on a general ward. Median hospital charge was much higher for patients who received ICU versus general ward care (33,252 dollars versus 8549 dollars, P < 0.001).

CONCLUSIONS

Patients who died in the ICU did not have informed discussions of end-of-life or palliative care as an alternative treatment option before admission. The quality of end-of-life care was disrupted for patients with fatal pre-existing chronic disease who were admitted to the ICU before death. Lack of clinical experience, knowledge and competency with end-of-life care influenced admission of patients to ICU regardless of poor prognosis. Decisions regarding the pursuit of aggressive therapy versus palliative care must be addressed with patients by physicians who are competent and experienced in end-of-life care as this will have a profound impact on both the quality of care delivered and effective use of limited hospital resources.

Terminal Care for Persons with Advanced Dementia in the Nursing Home and Home Care Settings

BACKGROUND

Many older persons with advanced dementia receive terminal care in nursing homes, others remain in the community with home care services.

OBJECTIVES

To describe and compare the end-of-life experience of persons dying with advanced dementia in the nursing home and home care settings.

DESIGN

Retrospective cohort study.

SETTING/SUBJECTS

Persons 65 years or older with advanced dementia who died within 1 year of admission to either a nursing home in Michigan between July 1, 1998 until December 31, 2000 (n = 2730), or the state's publicly funded home and community-based services from October 1, 1998 until December 31, 2001 (n = 290).

MEASUREMENTS

Data were derived from the Minimum Data Set (MDS)-Nursing home Version 2.0 for the institutionalized sample, and the MDS-Home Care for the community-based sample. Variables from the MDS assessment completed within 180 days of death were used to describe the end-of-life experiences of these two groups.

RESULTS

Nursing home residents dying with advanced dementia were older, had greater functional impairment, and more behavior problems compared to home care clients. Few subjects in the nursing home (10.3%) and home care (15.6%) cohorts were perceived to have less than 6 months to live. Only 5.7% of nursing home residents and 10.7% home care clients were referred to hospice. Hospitalizations were frequent: nursing home, 43.7%; home care, 31.5%. Pain and shortness of breath were common in both settings. End-of-life variables independently associated with nursing home versus home care included: hospice (adjusted odds ratio [AOR] 0.26, 95% confidence interval [CI], 0.16-0.43), life expectancy less than 6 months (AOR 0.31; 95% CI, 0.20-0.48), advance directives (AOR, 1.48; 95% CI, 1.11-1.96), pain (AOR, 0.38; 95% CI, 0.29-0.50), shortness of breath (AOR 0.20; 95% CI (0.13-0.28), and oxygen therapy (AOR, 2.47; 95% CI, 1.51-4.05).

CONCLUSIONS

Persons dying with advanced dementia admitted to nursing homes have different characteristics compared to those admitted to home care services. Their end-of-life experiences also differ in these two sites of care. However, palliative care was not optimal in either setting.

Palliative care in hospitals

Hospital-based palliative care teams have evolved as a natural outgrowth of the modern hospice movement. This article examines why these hospital-based palliative care programs have proliferated, how they typically function, and what data exist as to their effectiveness. Crucial steps necessary for the design and implementation of a successful hospital-based palliative care service also are reviewed.

Pattern of Care at the End of Life: Does Age Make a Difference in What Happens to Women With Breast Cancer?

Purpose

In the last 40 years, palliative care has become the standard of care at the end of life. However, there are limited data about the degree of access to such care at the population level.

Methods

Using administrative databases, a care-oriented profile score was created to describe the care received during the last 6 months of life for 2,291 women who were dying of breast cancer in the province of Quebec, Canada, during the years 1992 to 1998. The care received was described through indicators of care that would reflect a palliative care philosophy. An ordinal score was developed for comparisons among age groups of women using a proportional odds ordinal regression model.

Results

We found that only 6.9% of women died at home, while 69.6% of them died in acute care beds. While most women (75%) had few indicators indicating provision of palliative care during the last 6 months of life, younger women (< 50 years) were even less likely (odds ratio, 0.70; 95% CI, 0.54 to 0.90) to receive such care compared with middle aged women (50 to 59 years; serving as the reference group), while older women (> 70 years) were more likely (odds ratio, 1.85; 95% CI, 1.49 to 2.29).

Conclusion

Our study indicates that a sizeable proportion of women terminally ill from breast cancer do not have access to palliative care—an issue that health care policy makers may wish to explore further.

Site of Death in the Hospital Versus Nursing Home of Medicare Skilled Nursing Facility Residents Admitted Under Medicare's Part A Benefit

OBJECTIVES

To determine factors that predict site of death (hospital vs nursing home (NH)), related costs, and geographic variation in site of death of NH residents admitted under the Medicare Part A Benefit.

DESIGN

Retrospective cohort study.

SETTING

NHs located in the United States (N=13,146).

PARTICIPANTS

All persons admitted to skilled nursing facilities (SNFs) in 2001 who died in a SNF (n=101,307) or hospital (n=51,187).

MEASUREMENTS

Patient, facility, and geographic characteristics associated with death in a hospital and receipt of Medicare payment.

RESULTS

Absence of a do-not-resuscitate order, non-Caucasian ethnicity, greater functional independence, and higher cognitive status correlated with hospital as the site of death. Rural, hospital-based, and government-owned facilities had the lowest in-hospital death rates. Site of death varied widely from state to state. Of those who died in a hospital, 24.2% (12,410) died within 24 hours of transfer. The average daily combined stay Medicare payment for those who died in the hospital was $969, versus $300 for those who died in a NH.

CONCLUSION

Patient and facility characteristics predict site of death of Medicare NH patients, but in-hospital death rather than NH death varies geographically and is associated with higher daily Medicare payment.

Hospice Admission Practices: Where Does Hospice Fit in the Continuum of Care?

OBJECTIVES

To evaluate selected hospice admission practices that could represent barriers to hospice use and the association between these admission practices and organizational characteristics.

DESIGN

From December 1999 to March 2000, hospices were surveyed about selected admission practices, and their responses were linked to the 1999 California Office of Statewide Health Planning and Development's Home and Hospice Care Survey that describes organizational characteristics of California hospices.

SETTING

California statewide.

PARTICIPANTS

One hundred of 149 (67%) operational licensed hospices.

MEASUREMENTS

Whether hospices admit patients who lack a caregiver; would not forgo hospital admissions; or are receiving total parenteral nutrition (TPN), tube feedings, radiotherapy, chemotherapy, or transfusions.

RESULTS

Sixty-three percent of hospices restricted admission on at least one criterion. A significant minority of hospices would not admit patients lacking a caregiver (26%). Patients unwilling to forgo hospitalization could not be admitted to 29% of hospices. Receipt of complex medical care, including TPN (38%), tube feedings (3%), transfusions (25%), radiotherapy (36%), and chemotherapy (48%), precluded admission. Larger program size was significantly associated with a lower likelihood of all admission practices except restricting the admission of patients receiving TPN or tube feedings. Hospice programs that were part of a hospice chain were less likely to restrict the admission of patients using TPN, radiotherapy, or chemotherapy than were freestanding programs.

CONCLUSION

Patients who are receiving complex palliative treatments could face barriers to hospice enrollment. Policy makers should consider the clinical capacity of hospice providers in efforts to improve access to palliative care and more closely incorporate palliation with other healthcare services.

Use of hospitals, physician visits, and hospice care during last six months of life among cohorts loyal to highly respected hospitals in the United States

OBJECTIVE

To evaluate the use of healthcare resources during the last six months of life among patients of US hospitals with strong reputations for high quality care in managing chronic illness.

DESIGN

Retrospective cohort study based on claims data from the US Medicare programme.

PARTICIPANTS

Cohorts receiving most of their hospital care from 77 hospitals that appeared on the 2001 US News and World Report "best hospitals" list for heart and pulmonary disease, cancer, and geriatric services.

MAIN OUTCOME MEASURES

Use of healthcare resources in the last six months of life: number of days spent in hospital and in intensive care units; number of physician visits; percentage of patients seeing 10 or more physicians; percentage enrolled in hospice. Terminal care: percentage of deaths occurring in hospital; percentage of deaths occurring in association with a stay in an intensive care unit.

RESULTS

Extensive variation in each measure existed among the 77 hospital cohorts. Days in hospital per decedent ranged from 9.4 to 27.1 (interquartile range 11.6-16.1); days in intensive care units ranged from 1.6 to 9.5 (2.6-4.5); number of physician visits ranged from 17.6 to 76.2 (25.5-39.5); percentage of patients seeing 10 or more physicians ranged from 16.9% to 58.5% (29.4-43.4%); and hospice enrollment ranged from 10.8% to 43.8% (22.0-32.0%). The percentage of deaths occurring in hospital ranged from 15.9% to 55.6% (35.4-43.1%), and the percentage of deaths associated with a stay in intensive care ranged from 8.4% to 36.8% (20.2-27.1%).

CONCLUSION

Striking variation exists in the utilisation of end of life care among US medical centres with strong national reputations for clinical care.

Tube feeding in advanced Alzheimer's disease: when language misleads

For much of the late 20th century, feeding tubes were often considered essential in the treatment of people with advanced Alzheimer's disease (AD) who developed swallowing or eating problems. Increasingly, the use of feeding tubes (i.e., percutaneous endoscopic gastrostomy or PEG tubes), has been challenged by empirical research, which has not supported the rationales provided for this intervention. The purpose of this commentary is to explain why healthcare providers, in light of empirical evidence, should refrain from using the terms "life-sustaining" or "life-prolonging" when discussing tube feeding with older adults, their family members, or other surrogate decision-makers.

Variations In The Longitudinal Efficiency Of Academic Medical Centers

Recent studies have revealed dramatic differences among academic medical centers (AMCs) in the quantity of care provided to their patients. The implications, however, depend upon whether the additional resources provided by some centers lead to better results. This study describes the content, quality, and outcomes of care across AMCs that differ by up to 60 percent in the overall intensity of medical services delivered to patients with serious chronic illnesses. Efforts to reduce costs will require attention to supply-sensitive services (the frequency of hospital stays, physician visits, specialist consultations, diagnostic tests, and minor procedures) and should include a focus on the longitudinal efficiency of hospitals and medical staffs.

End-of-life care and the effects of bereavement on family caregivers of persons with dementia

BACKGROUND

Although family caregiving has been intensively studied in the past decade, little attention has been paid to the impact of end-of-life care on caregivers who are family members of persons with dementia or to the caregivers' responses to the death of the patient.

METHODS

Using standardized assessment instruments and structured questions, we assessed the type and intensity of care provided by 217 family caregivers to persons with dementia during the year before the patient's death and assessed the caregivers' responses to the death.

RESULTS

Half the caregivers reported spending at least 46 hours per week assisting patients with activities of daily living and instrumental activities of daily living. More than half the caregivers reported that they felt they were "on duty" 24 hours a day, that the patient had frequent pain, and that they had had to end or reduce employment owing to the demands of caregiving. Caregivers exhibited high levels of depressive symptoms while providing care to the relative with dementia, but they showed remarkable resilience after the death. Within three months of the death, caregivers had clinically significant declines in the level of depressive symptoms, and within one year the levels of symptoms were substantially lower than levels reported while they were acting as caregivers. Seventy-two percent of caregivers reported that the death was a relief to them, and more than 90 percent reported belief that it was a relief to the patient.

CONCLUSIONS

End-of-life care for patients with dementia was extremely demanding of family caregivers. Intervention and support services were needed most before the patient's death. When death was preceded by a protracted and stressful period of caregiving, caregivers reported considerable relief at the death itself.

End-of-life care in the critically ill geriatric population

As the geriatric population in the United States increases and better management of chronic diseases improves survival, more elderly will become critically ill and potentially require treatment in an intensive care unit (ICU). Dan Callahan has written, "... we will live longer lives, be better sustained by medical care, in return for which our deaths in old age are more likely to be drawn out and wild." Although no health care provider hopes for a drawn out and wild death for elderly patients, many geriatric persons will succumb to disease and die after having chosen and received ICU care. Recent data suggest that, on average, 11% of Medicare recipients spend more that 7 days in the ICU within 6 months before death.

Hospitalization of Hospice Patients with Cancer

OBJECTIVES

To identify factors associated with hospitalization of elderly hospice patients with cancer and to describe their hospital experiences.

DESIGN

Retrospective analysis of the last year of life.

SETTING

Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database.

PARTICIPANTS

Medicare beneficiaries dying of lung or colorectal cancer between 1988 and 1998 who enrolled in hospice.

MEASUREMENTS

Hospitalization after hospice entry. For hospitalized patients, we describe admission diagnoses, aggressiveness of care, and in-hospital death.

RESULTS

Of the 23608 patients, 1423 (6.0%) were hospitalized after hospice enrollment. Hospitalization declined over time by 7.0% per year of hospice enrollment. Factors associated with higher hospitalization rates were younger age, male gender, black race/ethnicity, local cancer stage at diagnosis, and hospice enrollment within 4 months of cancer diagnosis. The most common reasons for hospital admission were lung cancer, metastatic disease, bone fracture, pneumonia, and volume depletion. Of the 1423 patients hospitalized, 34.6% received aggressive care and 35.8% died in the hospital.

CONCLUSION

The rates of hospitalization for elderly hospice patients with lung or colorectal cancer appear to be declining. However, patients who are hospitalized undergo aggressive care and often die in the hospital rather than at home. This aggressive care may be consistent with changes in patients' care preferences, but could also reflect the current culture of acute care hospitals, which focuses on curative treatment and is ill-equipped to provide palliative care.

CHOICES: Promoting Early Access to End-of-Life Care Through Home-Based Transition Management

CHOICES is a comprehensive home-based care coordination program designed to bridge the gap between home health and hospice for Medicare + Choice enrollees with advanced chronic illness in San Francisco's East Bay region. Key elements of the program include physician education, enrollment of patients with high disease burden who may not be terminally ill, co-management of care with the primary physician, and an advanced practice clinical team that provides comprehensive in-home assessments, a flexible mix of life-prolonging and palliative care that evolves with disease progression, focused education and advance planning, and caregiver support. During a 42-month demonstration, 208 patients were enrolled in the program. Eighty percent had a non-cancer diagnosis; 40% were people of color. After an 8-month follow-up, 44% of the study cohort had died in the program or after transfer to hospice, 51% had been discharged, and 5% remained active. Median length of stay for decedents was 260 days. Preliminary evidence supports the program's feasibility and acceptability to patients, families, physicians, and agency partners. However, the uncertain future of Medicare + Choice and of managed care may jeopardize the program's sustainability. Policymakers and taxpayers will need to determine how to care for the growing number of chronically ill elderly who wish to remain at home as illness advances. The care needs of these patients and their families may overwhelm a health system organized around hospital treatment of acute illness.

Next-of-Kin Perceptions of Physician Responsiveness to Symptoms of Hospitalized Patients Near Death

Many different medical providers visit critically ill patients during a hospitalization, and patients and family members may not feel any physician is truly in charge of care. This study explores whether perceiving that a physician was clearly in charge is associated with reports by surviving next of kin about the responsiveness of physicians to symptoms in hospitalized patients near the end of life. We conducted telephone interviews with surviving next of kin of adult patients (n = 1107) who died in one of five New York City teaching hospitals between April 1998 and June 1999 after a minimum 3-day inpatient stay. Next-of-kin ratings of whether physicians did "all they could" all or most of the time in response to patient pain, dyspnea, and affective distress (confusion, depression or emotional distress) were compared by whether the next of kin reported one or more physicians "clearly in charge" of care, adjusting for patient and next-of-kin characteristics. More than 80% of patients were reported to have experienced often serious pain, dyspnea, or affective distress. Physicians were rated as responsive to pain by 79.1% of respondents, to dyspnea by 84.9%, and to affective distress by 66.6%. Ratings of physician responsiveness to pain (p = 0.001) and affective distress (p = 0.001) were significantly lower among patients for whom no physician was seen as clearly in charge of care. This finding is consistent with the view that ensuring that a physician coordinates the care of seriously ill, hospitalized patients may improve symptom management. Further research is warranted to establish causality and identify optimal models of care.

Determinants of hospice home care use among terminally ill cancer patients

BACKGROUND

Despite the widespread availability of hospice services for more than two decades in the United States, currently many terminally ill cancer patients who may benefit from hospice care do not receive it.

PURPOSE

To identify determinants of the use of hospice home care services for terminally ill cancer patients during their final days of life.

METHODS

Secondary analysis of data from 127 terminally ill cancer patients who participated in a prospective and exploratory study aimed at identifying determinants of congruence between the preferred and actual place of death. Multivariate logistic regression analysis was conducted to identify determinants of hospice home care use.

RESULTS

Sixty-four (50.4%) out of the 127 participants had used hospice home care services before death. Important determinants of hospice home care use included: (a) longer length of survival (odds ratio [OR] 1.02; 95% confidence interval [CI]: 1.01-1.03); (b) perceived greater family ability to achieve preferred place of death (OR: 1.85; 95% CI: 1.30-2.62); (c) home as the realistic preferred place of death (OR: 5.58; 95% CI: 1.95-16.03); (d) being female (OR: 5.37; 95% CI: 1.81-15.95); (e) lower levels of functional dependency (OR: 0.94; 95% CI: 0.89-0.99); and (f) use of emergency care during the final days of life (OR: 4.03; 95% CI: 1.26-12.94).

CONCLUSIONS

The results of this study identified several groups of terminally ill cancer patients who were at a disadvantage to use hospice home care, including those without sufficient family resources but who required intensive nursing care. Providing nursing care that enables family care-taking at home may facilitate hospice home care use for patients.

Place of death of Houston area residents with cancer over a two-year period

The majority of cancer patients wish to die at home. Improved understanding of place of death and its relevant demographic predictors is important for the planning of palliative cancer care programs. The purpose of this study was to determine the place and predictors of site of death in cancer patients in a major U.S. metropolitan area. Death certificate data over two years were analyzed for Houston area residents with cancer who died in the Houston area. Information was obtained on factors that might be associated with the place where cancer patients die. For the purpose of this study, we looked at the following variables: primary site of cancer (hematological, breast, genitourinary, gastrointestinal, lung, and other); black, white, Hispanic, or Asian; age at death; marital status; sex; whether or not veteran of U.S. armed forces; levels of education; and area of residency within the Houston area. Univariate and multivariate analyses were performed. The majority of patients died in the hospital (51-52% both years), with the next most frequently occurring group dying at home (34-35% both years). Stepwise multivariate analysis resulted in a 6-variable logistic regression model. In this model, the odds of dying in hospital were increased by a factor of 2.7 if the patient had a hematological cancer (P<0.0001), a factor of 1.6 if the patient lived in Harris County (P<0.0001), and a factor of 1.5 if the patient was black (P<0.0001). Further characterization of factors associated with increased risk of hospital death rate is needed and systems should be developed to enable the majority of cancer patients to access palliative care services in the multiple settings in which they die.

Decisions for hospice care in patients with advanced cancer

OBJECTIVES

To identify factors that may influence the decision of whether to enter a hospice program or to continue with a traditional hospital approach in patients with advanced cancer and to understand their decision-making process.

DESIGN

Cross-sectional structured interview.

SETTING

One community-based hospice and three university-based teaching hospitals.

PARTICIPANTS

Two hundred thirty-four adult patients diagnosed with advanced lung, breast, prostate, or colon cancer with a life expectancy of less than 1 year: 173 hospice patients and 61 nonhospice patients receiving traditional hospital care.

MEASUREMENTS

Hospice and nonhospice patients' demographic, clinical, and other patient-related characteristics were compared. Multivariate analysis was then conducted to identify variables associated with the hospice care decision in a logistic regression model. Information sources regarding hospice care and people involved in the hospice decision were identified.

RESULTS

Patients receiving hospice care were significantly older (average age 69 vs 65 years, P =.009) and less educated (average 11.9 vs 12.9 years, P =.031) and had more people in their households (average 1.66 vs 1.16 persons, P =.019). Hospice patients had more comorbid conditions (1.30 vs 0.93, P =.035) and worse activities of daily living scores (7.01 vs 6.23, P =.030) than nonhospice patients. Hospice patients were more realistic about their disease course than their nonhospice counterparts. Patients' understanding of their prognoses affected their perceptions of the course of their disease. Hospice patients preferred quality of life to length of life. In the multivariate analysis, lower education level and greater number of people in the household were associated with the decision to enter hospice. A healthcare provider first told most of those who entered hospice about hospice. Families largely made the final decision to enter hospice (42%), followed by patients themselves (28%) and physicians (27%).

CONCLUSION

The decision to enter hospice is related to demographic, clinical, and other patient-related characteristics. This study suggests that the decision-making process for hospice care in patients with advanced cancer is multidimensional. The healthcare community may better meet the end-of-life care needs of advanced cancer patients through enhanced communication with patients and families, including providing accurate prognoses and better understanding of patients' preferences and values.

How does the timing of hospice referral influence hospice care in the last days of life?

OBJECTIVES

To determine factors associated with the type of hospice care received in the last days of life and, in particular, how the timing of referral influences the use of continuous hospice home care and inpatient hospice care.

DESIGN

Retrospective cohort study.

SETTING

Twenty-one hospice programs across seven states under the ownership of one hospice parent provider.

PARTICIPANTS

Hospice patients who were cared for and died between October 1, 1998, and September 30, 1999 (N = 28,747).

MEASUREMENTS

Patient sociodemographic and clinical data were merged with use data from the provider's centralized information system to examine the factors associated with the differing levels of hospice care in the last week of life. In the last days of life, patients were classified as having received routine hospice home care only, having received continuous hospice home care, or having died in an inpatient hospice bed.

RESULTS

Twenty-three percent of the patients received continuous hospice home care during the last week of life, and 34% died in an inpatient hospice bed. Patients with hospice stays of less than 7 days had a lower likelihood of receiving continuous hospice home care than those who had stays of more than 30 days (adjusted odds ratio (AOR) = 0.81, 95% confidence interval (CI) = 0.75-0.87). Patients with hospice stays of 14 days or less had a greater likelihood of dying in an inpatient hospice bed. Furthermore, patients with stays of less than 7 days who were referred from hospitals were six times likelier to die in an inpatient hospice bed than those who were referred from another source (AOR = 6.40, 95% CI = 5.74-7.14). Patients in nursing homes had a 93% lower likelihood of dying in an inpatient hospice bed than patients in the community without a live-in caregiver (AOR = 0.07, 95% CI = 0.03-0.19). Strong independent associations were observed between several other covariates and the study outcomes, particularly the covariates of which state hospice care was provided in and level of pain intensity.

CONCLUSION

Findings suggest that continuous hospice home care in the last week of life is less likely to occur when patients have short hospice stays. Also, the probability of dying in an inpatient hospice bed is substantially greater for patients referred from hospitals and referred closer to time of death. Further work to determine the appropriateness of use of the different levels of hospice care is needed.

When death is imminent: where terminally ill patients with cancer prefer to die and why

End-of-life care strives to honor terminally ill patients' preferences regarding the way of dying. Scholars defined one domain of quality of dying and death as dying at the place of one's choice. Despite efforts over more than two decades and more than 40 studies to investigate the influencing factors associated with the place of death for terminally ill patients with cancer, there is a notable lack of empirical data examining the reasons why terminally ill patients with cancer choose a specific setting as their preferred place of death. An exploratory and descriptive study was conducted to explore the preferences of terminally ill patients with cancer for the place of death, to identify the reasons for selecting a preferred place of death, and to examine the importance of dying at a place one prefers. A convenience sample of 180 terminally ill patients with cancer was recruited from four tertiary care hospitals and two home care programs in Connecticut. Nearly 90% of the subjects preferred to die at home. Quality of life, availability and ability of family caregivers, concerns of being a burden to others, long-standing relationships with healthcare providers, and quality of healthcare were the major considerations in decision making regarding the place of death. Terminally ill patients with cancer acknowledged dying at their preferred place of death as highly important. Effective nursing interventions need developing to facilitate death at a place that is in accord with dying patients' preferences.

Identifying potential indicators of the quality of end-of-life cancer care from administrative data

PURPOSE

To explore potential indicators of the quality of end-of-life services for cancer patients that could be monitored using existing administrative data.

METHODS

Quality indicators were identified and assessed by literature review for proposed indicators, focus groups with cancer patients and family members to assess candidate indicators and generate new ideas, and an expert panel ranking the meaningfulness and importance of each potential indicator using a modified Delphi approach.

RESULTS

There were three major concepts of poor quality of end-of-life cancer care that could be examined using currently-available administrative data (such as Medicare claims): institution of new anticancer therapies or continuation of ongoing treatments very near death; a high number of emergency room visits, inpatient hospital admissions, or intensive care unit days near the end of life; and a high proportion of patients never enrolled in hospice, only admitted in the last few days of life, or dying in an acute-care setting. Concepts such as access to psychosocial and other multidisciplinary services and pain and symptom control are important and may eventually be feasible, but they cannot currently be applied in most data systems. Indicators based on limiting the use of treatments with low probability of benefit or indicators based on economic efficiency were not acceptable to patients, family members, or physicians.

CONCLUSION

Several promising claims-based quality indicators were identified that, if found to be valid and reliable within data systems, could be useful in identifying health-care systems in need of improving end-of-life services.

Barriers to hospice care among older patients dying with lung and colorectal cancer

PURPOSE

To identify factors associated with hospice enrollment and length of stay in hospice among patients dying with lung or colorectal cancer.

METHODS

We used the Linked Medicare-Tumor Registry Database to conduct a retrospective analysis of the last year of life among Medicare beneficiaries diagnosed with lung or colorectal cancer at age > or = 66 years between January 1, 1973, and December 31, 1996, in the Surveillance, Epidemiology, and End Results Program who died between January 1, 1988, and December 31, 1998. Our outcomes of interest were time from cancer diagnosis to hospice enrollment and length of stay in hospice care. We used Cox proportional hazards regression to adjust for demographic and clinical information.

RESULTS

We studied elderly patients dying with lung cancer (n = 62,117) or colorectal cancer (n = 57,260). Overall, 27% of patients (n = 16,750) with lung cancer and 20% of patients (n = 11,332) with colorectal cancer received hospice care before death. Median length of stay for hospice patients with lung and colorectal cancer was 25 and 28 days, respectively. Overall, 20% of patients entered hospice within 1 week of death, whereas 6% entered more than 6 months before death. Factors associated with later hospice enrollment include being male; being of nonwhite, nonblack race; having fee-for-service insurance; and residing in a rural community. Many of these factors also were associated with shorter stays in hospice.

CONCLUSION

Although use of hospice care has increased dramatically over time, specific patient groups, including men, patients residing in rural communities, and patients with fee-for-service insurance continue to experience delays in hospice enrollment.

Factors associated with site of death: a national study of where people die

OBJECTIVES

Recent public attention has focused on quality of care for the dying. Where one dies is an important individual and public health concern.

MATERIALS AND METHODS

The 1993 National Mortality Followback Survey (NMFS) was used to estimate the proportion of deaths occurring at home, in a hospital, or in a nursing home. Sociodemographic variables, underlying cause of death, geographic region, hospice use, social support, health insurance, patients' physical limitations, and physical decline were considered as possible predictors of site of death. The relationship between these predictors and site death with multinomial logistic regression methods was analyzed.

RESULTS

Nearly 60% of deaths occurred in hospitals, and approximately 20% of deaths took place at home or in nursing homes. Decedents, who were black, less educated, and enrolled in an HMO were more likely to die in the hospital. After adjustment, functional decline in the last 5 months of life was an important predictor of dying at home (for loss of 3 or more ADLs [OR, 1.57; 95% CI, 1.11-2.21]). Having functional limitations 1 year before death, and experiencing functional decline in the last 5 months of life were both associated with dying in a nursing home.

CONCLUSIONS

Rapid physical decline during the last 5 months was associated with dying at home or in a nursing home, whereas earlier functional loss was associated with dying in a nursing home.

Physicians' interactions with health care teams and systems in the care of dying patients: perspectives of dying patients, family members, and health care professionals

This study investigated the specific physician skills required to interact with health care systems in order to provide high quality care at the end of life. We used focus groups of patients with terminal diseases, family members, nurses and social workers from hospice or acute care settings, and physicians. We performed content analysis based on grounded theory. Groups were interviewed. Two domains were found related to physician interactions with health care systems: 1) access and continuity, and 2) team communication and coordination. Components of these domains most frequently mentioned included taking as much time as needed with the patient, accessibility, and respect shown in working with health team members. This study highlights the need for both physicians and health care systems to improve accessibility for patients and families and increase coordination of efforts between health care team members when working with dying patients and their families.