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Wachterman MW, Sinha A, Leveille T, Waikar SS, Widera E, Romero K, Bokhour B. Nephrologists' perspectives and experiences with hospice among older adults with end-stage kidney disease. J Am Geriatr Soc 2024. [PMID: 38777614 DOI: 10.1111/jgs.18936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Hospice care leads to improved patient and family outcomes. Hospice use among older adults with end-stage kidney disease (ESKD) is markedly lower than among older adults with other serious illnesses, and the majority of those with ESKD who use hospice enroll in the last days of life. Here, our aim was to explore barriers to timely receipt of high-quality hospice care for older adults with ESKD. METHODS Utilizing a qualitative study design, we conducted a secondary analysis focused on hospice, a theme that we identified in our larger overarching study that involved semi-structured interviews with 20 nephrologists in the United States focused on treatment decision-making in older adults with advanced chronic kidney disease. We analyzed the interview transcripts using emergent thematic analysis to develop an understanding of barriers to high-quality hospice. RESULTS With a couple notable exceptions, nephrologists voiced general support for the concept of hospice, but few recalled patients of theirs who had received hospice. Nephrologists' interviews revealed two interrelated contributors to the lack of timely access to high-quality hospice care for seriously ill older adults with ESKD: (1) nephrologists view dialysis and hospice as mutually exclusive models of care; (2) nephrologists feel unsure who should manage hospice care for patients with ESKD. The first contributor was rooted in nephrologists' narrow vision of when to consider hospice (informed, in part, by policy barriers) and, in a couple of cases, strong discomfort with hospice. The second stemmed from nephrologists' belief that neither they nor hospice are adequately prepared to provide hospice care for ESKD. CONCLUSIONS Our findings suggest that, in addition to Medicare policy change, nephrologists need to receive more training in primary palliative care skills including in indications for hospice, initiating conversations about hospice with patients, and collaborating with hospice clinicians to care for these vulnerable patients.
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Affiliation(s)
- Melissa W Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Health Care System, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Sushrut S Waikar
- Section of Nephrology, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Eric Widera
- Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
- Division of Palliative Care, University of California San Francisco, San Francisco, California, USA
| | - Kai Romero
- Division of Palliative Care, University of California San Francisco, San Francisco, California, USA
- By the Bay Health, San Francisco, California, USA
| | - Barbara Bokhour
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
- Center for Healthcare Organization and Implementation of Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts, USA
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Ernecoff NC, Robinson MT, Motter EM, Bursic AE, Lagnese K, Taylor R, Lupu D, Schell JO. Concurrent Hospice and Dialysis Care: Considerations for Implementation. J Gen Intern Med 2024; 39:798-807. [PMID: 37962726 PMCID: PMC11043284 DOI: 10.1007/s11606-023-08504-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023]
Abstract
IMPORTANCE Hospice positively impacts care at the end of life for patients and their families. However, compared to the general Medicare population, patients on dialysis are half as likely to receive hospice. Concurrent hospice and dialysis care offers an opportunity to improve care for people living with end-stage kidney disease (ESKD). OBJECTIVE We sought to (1) develop a conceptual model of the Program and (2) identify key components, resources, and considerations for further implementation. DESIGN We conducted a template analysis of qualitative interviews and convened a community advisory panel (CAP) to get feedback on current concurrent care design and considerations for dissemination and implementation. PARTICIPANTS Thirty-nine patients with late-stage chronic kidney disease (CKD), family caregivers, bereaved family caregivers, hospice clinicians, nephrology clinicians, administrators, and policy experts participated in interviews. A purposive subset of 19 interviewees composed the CAP. MAIN MEASURES Qualitative feedback on concurrent care design refinements, implementation, and resources. KEY RESULTS Participants identified four themes that define an effective model of concurrent hospice and dialysis: it requires (1) timely goals-of-care conversations and (2) an interdisciplinary approach; (3) clear guidelines ensure smooth transitions for patients and families; and (4) hospice payment policy must support concurrent care. CAP participants provided feedback on the phases of an effective model of concurrent hospice and dialysis, and resources, including written and interactive educational materials, communication tools, workflow processes, and order sets. CONCLUSIONS We developed a conceptual model for concurrent hospice and dialysis care and a corresponding resource list. In addition to policy changes, clinical implementation and educational resources can facilitate scalable and equitable dissemination of concurrent care. Concurrent hospice and dialysis care must be systematically evaluated via a hybrid implementation-effectiveness trial that includes the resources outlined herein, based on our conceptual model of concurrent care delivery.
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Affiliation(s)
| | - Mayumi T Robinson
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Erica M Motter
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alexandra E Bursic
- Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Keith Lagnese
- Optum Home & Community Care, Landmark Health, Huntington Beach, CA, USA
| | | | - Dale Lupu
- School of Nursing, George Washington University, Washington, DC, USA
| | - Jane O Schell
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Division of Renal-Electrolyte, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Dialysis Clinic, Inc, Nashville, TN, USA
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Tate CE, Mami G, McNulty M, Rinehart DJ, Yasui R, Rondinelli N, Treem J, Fairclough D, Matlock DD. Evaluation of a Novel Hospice-Specific Patient Decision Aid. Am J Hosp Palliat Care 2024; 41:414-423. [PMID: 37477279 PMCID: PMC11083913 DOI: 10.1177/10499091231190776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
Abstract
Background: We tested a novel hospice-specific patient decision aid to determine whether the decision aid could improve hospice knowledge, opinions of hospice, and decision self-efficacy in making decisions about hospice. Methods: Two patient-level randomized studies were conducted using two different cohorts. Recruitment was completed from March 2019 through May 2020. Cohort #1 was recruited from an academic hospital and a safety-net hospital and Cohort #2 was recruited from community members. Participants were randomized to review a hospice-specific patient decision aid. The primary outcomes were change in hospice knowledge, hospice beliefs and attitudes, and decision self-efficacy Wilcoxon signed rank tests were used to evaluate differences on the primary outcomes between baseline and 1-month. Participants: Participants were at least 65 years of age. A total of 266 participants enrolled (131 in Cohort #1 and 135 in Cohort #2). Participants were randomized to the intervention group (n = 156) or control group (n = 109). The sample was 74% (n = 197) female, 58% (n = 156) African American and mean age was 74.9. Results: Improvements in hospice knowledge between baseline and 1-month were observed in both the intervention and the control groups with no differences between groups (.43 vs .275 points, P = .823). There were no observed differences between groups on Hospice Beliefs and Attitudes scale (3.29 vs 3.08, P = .076). In contrast, Decision Self-Efficacy improved in both groups and the effect of the intervention was significant (8.04 vs 2.90, P = -.027). Conclusions: The intervention demonstrated significant improvements in decision self-efficacy but not in hospice knowledge or hospice beliefs and attitudes.
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Affiliation(s)
- Channing E. Tate
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), School of Medicine, University of Colorado, Aurora, CO, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gwendolyn Mami
- President and CEO, Global Collaborations, LLC, Denver, CO, USA
- Advisory Team Chair, Zion Senior Center, Denver, CO, USA
| | - Monica McNulty
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), School of Medicine, University of Colorado, Aurora, CO, USA
| | - Deborah J. Rinehart
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, Denver, CO, USA
| | - Robin Yasui
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nicole Rondinelli
- Division of Palliative Care, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jonathan Treem
- Division of Palliative Care, University of Colorado School of Medicine, Aurora, CO, USA
| | - Diane Fairclough
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), School of Medicine, University of Colorado, Aurora, CO, USA
| | - Daniel D. Matlock
- Division of Geriatrics, University of Colorado School of Medicine, Aurora, CO, USA
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, CO, USA
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Jennerich AL. An Approach to Caring for Patients and Family of Patients Dying in the ICU. Chest 2024:S0012-3692(24)00153-3. [PMID: 38354905 DOI: 10.1016/j.chest.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/10/2024] [Accepted: 02/07/2024] [Indexed: 02/16/2024] Open
Abstract
TOPIC IMPORTANCE Death is common in the ICU and often occurs after a decision to withhold or withdraw life-sustaining therapies. Care of the dying is a core skill for ICU clinicians, requiring expert communication, primarily with family of critically ill patients. REVIEW FINDINGS Limited high-quality evidence supports specific practices related to the care of dying patients in the ICU; thus, many of the recommendations that exist are based on expert opinion. Value exists in sharing a practical approach to caring for patients during the dying process, including topics to be addressed with family members, rationales for recommended care, and strategies for implementing comfort measures only. Through dedicated preparation and planning, clinicians can help family members navigate this intense experience. SUMMARY After a decision had been made to discontinue life-sustaining therapies, family members need to be given a clear description of comfort measures only and provided with additional detail about what it entails, including therapies or interventions to be discontinued, monitoring during the dying process, and common features of the dying process. Order sets can be a valuable resource for ensuring that adequate analgesia and sedation are available and the care plan is enacted properly. To achieve a good death for patients, a collaborative effort among members of the care team is essential.
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Affiliation(s)
- Ann L Jennerich
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, and the Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA.
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Wachterman MW, Corneau EE, O’Hare AM, Keating NL, Mor V. Association of Hospice Payer With Concurrent Receipt of Hospice and Dialysis Among US Veterans With End-stage Kidney Disease: A Retrospective Analysis of a National Cohort. JAMA HEALTH FORUM 2022; 3:e223708. [PMID: 36269338 PMCID: PMC9587478 DOI: 10.1001/jamahealthforum.2022.3708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Abstract
Importance For many patients with end-stage kidney disease (ESKD), the Medicare Hospice Benefit precludes concurrent receipt of hospice and dialysis services, forcing patients to choose between continuing dialysis or enrolling in hospice. Whether the more liberal hospice eligibility criteria of the Veterans Health Administration's (VA) are associated with improved access to concurrent dialysis and hospice care for patients with ESKD is not known. Objective To examine the frequency of concurrent hospice and dialysis care among US veterans by hospice payer and examine the payer for concurrent dialysis. Design, Setting, and Participants This was a retrospective cross-sectional study of all 70 577 VA enrollees in the US Renal Data System registry who initiated maintenance dialysis and died in 2007 to 2016. Data were analyzed from April 2021 to August 2022. Exposures Hospice payer, either Medicare, VA inpatient hospice, or VA-financed community-based hospice ("VA community care"). Primary hospice diagnosis-ESKD vs non-ESKD. Main Outcomes and Measures Concurrent receipt of hospice and dialysis services ("concurrent care"). Results There were 18 420 (26%) eligible veterans with ESKD who received hospice services (mean [SD] age, 75.4 [10.0] years; 17 457 [94.8%] men; 2997 [16.3%] Black, 15 162 [82.3%] White, and 261 (1.4%) individuals of other races). Most of the sample (n = 16 465; 89%) received hospice services under Medicare and 5231 (28%) continued to receive dialysis after hospice initiation. The adjusted proportion of veterans receiving concurrent care was higher for those enrolled in VA inpatient hospice or VA community care hospice than it was for those enrolled in Medicare hospice (57% and 41% vs 24%, respectively; both P < .001). Regardless of hospice payer, the majority (87%) of the dialysis treatments after hospice initiation were financed by the VA, including for Medicare beneficiaries who had a hospice diagnosis other than ESKD. Median hospice length of stay was 43 days for veterans who received concurrent dialysis vs 4 days for those who did not. Conclusions and Relevance In this retrospective cross-sectional study of US veterans with ESKD, a substantially higher proportion of veterans in VA-financed hospice received 1 or more dialysis treatments after hospice initiation than those enrolled in Medicare-financed hospice. Regardless of hospice payer, the VA financed most concurrent dialysis treatments. Hospice users who received concurrent dialysis care had substantially longer hospice lengths of stay than those who did not. These findings suggest that Medicare hospice policy may substantially restrict access to concurrent hospice and dialysis care among veterans with ESKD.
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Affiliation(s)
- Melissa W. Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Health Care System, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Emily E. Corneau
- Long Term Services and Supports Center of Innovation, Veterans Affairs Providence Health Care System, Providence, Rhode Island
| | - Ann M. O’Hare
- Department of Medicine and Kidney Research Institute, University of Washington, Seattle
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Nancy L. Keating
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Vincent Mor
- Long Term Services and Supports Center of Innovation, Veterans Affairs Providence Health Care System, Providence, Rhode Island
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
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Ernecoff NC, Bursic AE, Motter EM, Lagnese K, Taylor R, Schell JO. Description and Outcomes of an Innovative Concurrent Hospice-Dialysis Program. J Am Soc Nephrol 2022; 33:1942-1950. [PMID: 35820784 PMCID: PMC9528329 DOI: 10.1681/asn.2022010064] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 06/21/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Compared with the general Medicare population, patients with ESKD have worse quality metrics for end-of-life care, including a higher percentage experiencing hospitalizations and in-hospital deaths and a lower percentage referred to hospice. We developed a Concurrent Hospice and Dialysis Program in which patients may receive palliative dialysis alongside hospice services. The Program aims to improve access to quality end-of-life care and, ultimately, improve the experiences of patients, caregivers, and clinicians. OBJECTIVES We sought to describe (1) the Program and (2) enrollment and utilization characteristics of Program participants. METHODS We conducted a quantitative description of demographics, patient characteristics, and utilization of Program enrollees. RESULTS Of 43 total enrollees, 44% received at least one dialysis treatment, whereas 56% received no dialysis. The median (range) hospice length of stay was 9 (1-76) days for all participants and 13 (4-76) days for those who received at least one dialysis treatment. The average number of dialysis treatments was 3.5 (range 1-9) for hemodialysis and 19.2 (range 3-65) for peritoneal dialysis. Sixty-five percent of enrollees died at home, 23% in inpatient hospice, and 12% in a nursing facility; no patients died in the hospital. CONCLUSIONS Our 3-year experience with the Program demonstrated that enrollees had a longer median hospice stay than the previously reported 5-day median for patients with ESKD. Most patients received no further dialysis treatments despite the option to continue dialysis. Our experience provides evidence to support future work testing the effectiveness of such clinical programs to improve patient and utilization outcomes.
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Affiliation(s)
| | - Alexandra E. Bursic
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Erica M. Motter
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | - Jane O. Schell
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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7
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Ho YY, Yung TSH, See YP, Koh M. Palliative dialysis in hospice: A paradox or promising answer? ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:384-385. [PMID: 35786762 DOI: 10.47102/annals-acadmedsg.2021475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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8
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Sullivan DR, Teno JM, Reinke LF. Evolution of Palliative Care in the Department of Veterans Affairs: Lessons from an Integrated Health Care Model. J Palliat Med 2021; 25:15-20. [PMID: 34665652 DOI: 10.1089/jpm.2021.0246] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Palliative care (PC) is beneficial, however, in many settings it is under-resourced and unable to consistently meet the needs of patients and their families. A lack of national health policy support for PC contributes to underutilization and the low value care experienced by many patients with serious illness at the end of life. Through a series of transformative health care structure and process improvements including developing robust initiatives and promoting institutional culture change, the Department of Veterans Affairs (VA) has significantly improved the quality of PC among veterans. VA's strategic simultaneous top-down and bottom-up approach to develop programs, policies, and initiatives provides important perspectives and deserves attention toward advancing PC in the broader U.S. health care system. Although opportunities for improvement exist, the comprehensive framework within VA should help inform the future of program development and serve as a model for integrated and accountable care organizations to emulate.
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Affiliation(s)
- Donald R Sullivan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University (OHSU), Portland, Oregon, USA.,Center to Improve Veteran Involvement in Care, Veterans Affairs Portland Healthcare System, Portland, Oregon, USA
| | - Joan M Teno
- Division of General Internal Medicine and Geriatrics, School of Medicine, OHSU, Portland, Oregon, USA
| | - Lynn F Reinke
- Department of Veterans Affairs, Puget Sound Health Care System, Health Services Research & Development, Seattle, Washington, USA.,Department of Biobehavioral Nursing and Health Systems, University of Washington, School of Medicine, Seattle, Washington, USA
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Orman ES, Johnson AW, Ghabril M, Sachs GA. Hospice care for end stage liver disease in the United States. Expert Rev Gastroenterol Hepatol 2021; 15:797-809. [PMID: 33599185 PMCID: PMC8282639 DOI: 10.1080/17474124.2021.1892487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Patients with end-stage liver disease (ESLD) have impaired physical, psychological, and social functions, which can diminish patient quality of life, burden family caregivers, and increase health-care utilization. For those with a life expectancy of less than six months, these impairments and their downstream effects can be addressed effectively through high-quality hospice care, delivered by multidisciplinary teams and focused on the physical, emotional, social, and spiritual wellbeing of patients and caregivers, with a goal of improving quality of life. AREAS COVERED In this review, we examine the evidence supporting hospice for ESLD, we compare this evidence to that supporting hospice more broadly, and we identify potential criteria that may be useful in determining hospice appropriateness. EXPERT OPINION Despite the potential for hospice to improve care for those at the end of life, it is underutilized for patients with ESLD. Increasing the appropriate utilization of hospice for ESLD requires a better understanding of patient eligibility, which can be based on predictors of high short-term mortality and liver transplant ineligibility. Such hospice criteria should be data-driven and should accommodate the uncertainty faced by patients and physicians.
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Affiliation(s)
- Eric S. Orman
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine,Corresponding author: Eric S. Orman, Address: Division of Gastroenterology & Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN 46202,
| | - Amy W. Johnson
- Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine
| | - Marwan Ghabril
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine
| | - Greg A. Sachs
- Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine,Indiana University Center for Aging Research, Regenstrief Institute, Inc
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10
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Feder SL, Tate J, Ersek M, Krishnan S, Chaudhry SI, Bastian LA, Rolnick J, Kutney-Lee A, Akgün KM. The Association Between Hospital End-of-Life Care Quality and the Care Received Among Patients With Heart Failure. J Pain Symptom Manage 2021; 61:713-722.e1. [PMID: 32931904 PMCID: PMC7952458 DOI: 10.1016/j.jpainsymman.2020.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/31/2020] [Accepted: 09/04/2020] [Indexed: 11/30/2022]
Abstract
CONTEXT Improving end-of-life care (EOLC) quality among heart failure patients is imperative. Data are limited as to the hospital processes of care that facilitate this goal. OBJECTIVES To determine associations between hospital-level EOLC quality ratings and the EOLC delivered to heart failure patients. METHODS Retrospective analysis of the Veterans Health Administration (VA) and the Bereaved Family Survey data of heart failure patients from 2013 to 2015 who died in 107 VA hospitals. We calculated hospital-level observed-to-expected casemix-adjusted ratios of family reported excellent EOLC, dividing hospitals into quintiles. Using logistic regression, we examined associations between quintiles and palliative care consultation, receipt of chaplain and bereavement services, inpatient hospice, and intensive care unit death. RESULTS Of 6256 patients, mean age was 77.4 (SD = 11.1), 98.3% were male, 75.7% were white, and 18.2% were black. Median hospital scores of "excellent" EOLC ranged from 41.3% (interquartile range 37.0%-44.8%) in the lowest quintile to 76.4% (interquartile range 72.9%-80.3%) in the highest quintile. Patients who died in hospitals in the highest quintile, relative to the lowest, were slightly although not significantly more likely to receive a palliative care consultation (adjusted proportions 57.6% vs. 51.2%; P = 0.32) but were more likely to receive chaplaincy (92.6% vs. 81.2%), bereavement (86.0% vs. 72.2%), and hospice (59.7% vs. 35.9%) and were less likely to die in the intensive care unit (15.9% vs. 31.0%; P < 0.05 for all). CONCLUSION Patients with heart failure who die in VA hospitals with higher overall EOLC quality receive more supportive EOLC. Research is needed that integrates care processes and develops scalable best practices in EOLC across health care systems.
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Affiliation(s)
- Shelli L Feder
- Yale University School of Nursing, West Haven, Connecticut, USA; VA Connecticut Healthcare System, West Haven, Connecticut, USA.
| | - Janet Tate
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Mary Ersek
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | - Lori A Bastian
- VA Connecticut Healthcare System, West Haven, Connecticut, USA; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Joshua Rolnick
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Ann Kutney-Lee
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Kathleen M Akgün
- VA Connecticut Healthcare System, West Haven, Connecticut, USA; Yale University School of Medicine, New Haven, Connecticut, USA
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11
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Beckwith HKS, Adwaney A, Appelbe M, Gaffney HT, Hill P, Moabi D, Prout VL, Salisbury E, Webster P, Tomlinson JAP, Brown EA. Perceptions of Illness Severity, Treatment Goals, and Life Expectancy: The ePISTLE Study. Kidney Int Rep 2021; 6:1558-1566. [PMID: 34169196 PMCID: PMC8207314 DOI: 10.1016/j.ekir.2021.02.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/08/2021] [Accepted: 02/15/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction A better understanding of factors influencing perceived life expectancy (PLE), interactions between patient prognostic beliefs, experiences of illness, and treatment behavior is urgently needed. Methods Case-notes at 3 hemodialysis units were screened: patients with ≥20% 1-year mortality risk were included. Patients and their health care professionals (HCPs) were invited to complete a structured interview or mixed-methods questionnaire. Four hundred eleven patient notes were screened. Seventy-seven eligible patients were approached and 51 were included. Results Patients predicted significantly higher life expectancies than HCPs (P < 0.0001). Documented cognitive impairment, gender, or increasing age did not affect 1- or 5-year PLE. PLE influenced priorities of care: one-fifth of patients who estimated themselves to have >95% 1-year survival preferred “care focusing on relieving pain and discomfort,” compared with nearly three-quarters of those reporting a ≤50% chance of 1-year survival. Twenty of 51 (39%) patients believed transplantation was an option for them, despite only 4 being waitlisted at the time of the interview. Patients who thought they were transplant candidates were significantly more confident they would be alive at 1 and 5 years and to want resuscitation attempted. Cognitive impairment had no effect on perceived transplant candidacy. A high symptom burden was present and underrecognized by HCPs. High symptom burden was associated with significantly lower PLE at both 1 and 5 years, increased anxiety/depression scores, and treatment choices more likely to prioritize relief of suffering. Conclusion There is a disparity between patient PLE and those of their HCPs. Severity of symptom burden and beliefs regarding PLE or transplant candidacy affect patient treatment preferences.
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Affiliation(s)
- Hannah K S Beckwith
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom.,Department of Renal Medicine, Imperial College London, London, United Kingdom
| | - Anamika Adwaney
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Maura Appelbe
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Helen T Gaffney
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Peter Hill
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Dihlabelo Moabi
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Virginia L Prout
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Emma Salisbury
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Phil Webster
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - James A P Tomlinson
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Edwina A Brown
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom.,Department of Renal Medicine, Imperial College London, London, United Kingdom
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O'Hare AM, Butler CR, Taylor JS, Wong SPY, Vig EK, Laundry RS, Wachterman MW, Hebert PL, Liu CF, Rios-Burrows N, Richards CA. Thematic Analysis of Hospice Mentions in the Health Records of Veterans with Advanced Kidney Disease. J Am Soc Nephrol 2020; 31:2667-2677. [PMID: 32764141 DOI: 10.1681/asn.2020040473] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 06/29/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Patients with advanced kidney disease are less likely than many patients with other types of serious illness to enroll in hospice. Little is known about real-world clinical decision-making related to hospice for members of this population. METHODS We used a text search tool to conduct a thematic analysis of documentation pertaining to hospice in the electronic medical record system of the Department of Veterans Affairs, for a national sample of 1000 patients with advanced kidney disease between 2004 and 2014 who were followed until October 8, 2019. RESULTS Three dominant themes emerged from our qualitative analysis of the electronic medical records of 340 cohort members with notes containing hospice mentions: (1) hospice and usual care as antithetical care models: clinicians appeared to perceive a sharp demarcation between services that could be provided under hospice versus usual care and were often uncertain about hospice eligibility criteria. This could shape decision-making about hospice and dialysis and made it hard to individualize care; (2) hospice as a last resort: patients often were referred to hospice late in the course of illness and did not so much choose hospice as accept these services after all treatment options had been exhausted; and (3) care complexity: patients' complex care needs at the time of hospice referral could complicate transitions to hospice, stretch the limits of home hospice, and promote continued reliance on the acute care system. CONCLUSIONS Our findings underscore the need to improve transitions to hospice for patients with advanced kidney disease as they approach the end of life.
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Affiliation(s)
- Ann M O'Hare
- Department of Medicine, University of Washington, Seattle, Washington .,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | | | - Janelle S Taylor
- Department of Anthropology, University of Toronto, Toronto, Ontario, Canada
| | - Susan P Y Wong
- Department of Medicine, University of Washington, Seattle, Washington.,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Elizabeth K Vig
- Department of Medicine, University of Washington, Seattle, Washington.,Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Ryan S Laundry
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Melissa W Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Health Care System, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Paul L Hebert
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, University of Washington, Seattle, Washington
| | - Chuan-Fen Liu
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, University of Washington, Seattle, Washington
| | - Nilka Rios-Burrows
- Chronic Kidney Disease Initiative, Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Claire A Richards
- Hospital and Specialty Medicine, Geriatrics and Extended Care and Seattle-Denver Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,School of Nursing, University of Washington, Seattle, Washington
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13
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Tate CE, Matlock DD. Stopping Dialysis, Good Deaths, and Social Justice. JAMA Netw Open 2019; 2:e1913110. [PMID: 31603480 PMCID: PMC8407520 DOI: 10.1001/jamanetworkopen.2019.13110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Channing E Tate
- Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora
| | - Daniel D Matlock
- Adult and Child Consortium for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver
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