Comparison of Palliative Care Delivery in the Last Year of Life Between Adults With Terminal Noncancer Illness or Cancer

A Nurse Practitioner-Driven Palliative and Supportive Care Service in Nursing Homes: Evaluation of a Quality Improvement Project

This article describes a quality improvement project implemented by a national postacute long-term care organization aimed at enhancing the provision of palliative care to nursing home residents. The project focused on improving advance care planning, end-of-life care, symptom management, and care of people living with serious illness. Both generalist and specialist palliative care training were provided to nurse practitioners in addition to implementing a system to identify residents most likely to benefit from a palliative approach to care. To evaluate the nurse practitioner experiences of the program, survey data were collected from nurse practitioners (N = 7) involved in the project at 5 months after implementation. Nurse practitioners reported the program was well received by nursing home staff, families, and residents. Most nurse practitioners felt more confident managing residents' symptoms and complex care needs; however, some reported needing additional resources for palliative care delivery. Most common symptoms that were managed included pain, delirium, and dyspnea; most common diagnoses cared for were dementia and chronic organ failure (eg, cardiac, lung, renal, and neurological diseases). In the next steps, the project will be expanded throughout the organization, and person- and family-centered outcomes will be evaluated.

Community Preferences for the Care of Older People at the End of Life: How Important is the Disease Context?

BACKGROUND

Population preferences for care at the end of life can inform palliative care policy and direction. Research investigating preferences for care at the end of life has focused predominantly on the context of advanced cancer, with relatively little attention to other life-limiting illnesses that are common causes of death.

OBJECTIVES

We aimed to investigate preferences for the care of older people at the end of life in three different disease contexts. The purpose was to understand if population preferences for care in the last 3 weeks of life would differ for patients dying from cancer, heart failure or dementia.

METHODS

Three discrete choice experiments were conducted in Australia with a general population sample using similar methods but different end-of-life disease contexts. Some attributes were common across the three experiments and others differed to accommodate the specific disease context. Each survey was completed by a different panel sample aged ≥45 years (cancer, n = 1548; dementia, n = 1549; heart failure, n = 1003). Analysis was by separate mixed logit models.

RESULTS

The most important attributes across all three surveys were costs to the patient and family, patient symptoms and informal carer stress. The probability of choosing an alternative was lowest (0.18-0.29) when any one of these attributes was at the least favourable level, holding other attributes constant across alternatives. The cancer survey explored symptoms more specifically and found patient anxiety with a higher relative importance score than the symptom attribute of pain. Dementia was the only context where most respondents preferred to not have a medical intervention to prolong life; the probability of choosing an alternative with a feeding tube was 0.40 (95% confidence interval 0.36-0.43).

CONCLUSIONS

This study suggests a need for affordable services that focus on improving patient and carer well-being irrespective of the location of care, and this message is consistent across different disease contexts, including cancer, heart failure and dementia. It also suggests some different considerations in the context of people dying from dementia where medical intervention to prolong life was less desirable.

A Comparison of Palliative Care Delivery between Ethnically Chinese and Non-Chinese Canadians in the Last Year of Life

BACKGROUND

Ethnically Chinese adults in Canada and the United States face multiple barriers in accessing equitable, culturally respectful care at the end-of-life. Palliative care (PC) is committed to supporting patients and families in achieving goal-concordant, high-quality serious illness care. Yet, current PC delivery may be culturally misaligned. Therefore, understanding ethnically Chinese patients' use of palliative care may uncover modifiable factors to sustained inequities at the end-of-life.

OBJECTIVE

To compare the use and delivery of PC in the last year of life between ethnically Chinese and non-Chinese adults.

DESIGN

Population-based cohort study.

PARTICIPANTS

All Ontario adults who died between January 1st, 2012, and October 31st, 2022, in Ontario, Canada.

EXPOSURES

Chinese ethnicity.

MAIN MEASURES

Elements of physician-delivered PC, including model of care (generalist; specialist; mixed), timing and location of initiation, and type of palliative care physician at initial consultation.

KEY RESULTS

The final study cohort included 527,700 non-Chinese (50.8% female, 77.9 ± 13.0 mean age, 13.0% rural residence) and 13,587 ethnically Chinese (50.8% female, 79.2 ± 13.6 mean age, 0.6% rural residence) adults. Chinese ethnicity was associated with higher likelihoods of using specialist (adjusted odds ratio [aOR] 1.53, 95%CI 1.46-1.60) and mixed (aOR 1.32, 95%CI 1.26-1.38) over generalist models of PC, compared to non-Chinese patients. Chinese ethnicity was also associated with a higher likelihood of PC initiation in the last 30 days of life (aOR 1.07, 95%CI 1.03-1.11), in the hospital setting (aOR 1.24, 95%CI 1.18-1.30), and by specialist PC physicians (aOR 1.33, 95%CI 1.28-1.38).

CONCLUSIONS

Chinese ethnicity was associated with a higher likelihood of mixed and specialist models of PC delivery in the last year of life compared to adults who were non-Chinese. These observed differences may be due to later initiation of PC in hospital settings, and potential differences in unmeasured needs that suggest opportunities to initiate early, community-based PC to support ethnically Chinese patients with serious illness.

End-Of-Life Symptoms and Symptom Management in Older Adults With Stroke Versus Cancer

Background: Little is known about the end-of-life (EOL) experience in older adults with stroke or how similar the EOL experience is in older adults with stroke when compared to those with cancer. Purpose: We utilized data from the National Health and Aging Trends Study (NHATS) to compare symptoms, symptom management, and overall rating of care in the last month of life between older adults diagnosed with stroke and those diagnosed with cancer. Methods: Logistic regression was used to examine the associations between diagnosis and symptom prevalence, symptom management, and overall care quality, adjusting for care intensity, place of death, and demographic covariates. Results: A total of 747 NHATS participants diagnosed with stroke or cancer were identified. Diagnosis of stroke was associated with whether the symptoms of pain (OR .46, 95% CI .26-.83), dyspnea (OR .32, 95% CI .17-.64), and emotional distress were documented (OR .57, 95% CI .33-.98). Diagnosis was not associated with pain management (OR .85, 95% CI .48-1.48), dyspnea management (OR .97, 95% CI .47-2.03), or emotional distress management (OR 1.02, 95% CI .53-1.97). Correlates of overall care quality included place of death and diagnosis, with patients with stroke more likely to report poorer care quality (OR 1.77, 95% CI 1.03-3.04) as well as those who died in the hospital (OR 2.18, 95% CI 1.26-3.77). Conclusions: Older adults with stroke are at risk for inadequate symptom assessment and documentation, as well as poorer symptom management and poorer overall care quality.

Palliative Care in Early Dementia

BACKGROUND

Palliative care is recommended for all people with dementia from diagnosis through end-of-life. However, palliative care needs and effective elements of palliative care are not well-defined for the earlier stages of dementia.

OBJECTIVE

To systematically map current research on palliative care early in the disease trajectory of dementia.

DESIGN

Scoping review of scientific literature.

DATA SOURCES

PubMed, CINAHL, EMBASE, Cochrane, PsycINFO, Web of Science.

REVIEW METHODS

We included studies published in English over the last decade (through March 2022) that focused on palliative care in early stages of dementia and targeted outcomes in palliative care domains. Two authors independently screened abstracts and full texts and scored the quality of included studies using tools by the Joanna Briggs Institute.

RESULTS

Among the 77 papers reviewed, few addressed early stages of dementia specifically. We found that: 1) While "early" palliative care was not well-defined in the literature, evidence indicated that palliative care needs were present at or before diagnosis and across the trajectory. Notable opportunities for palliative care arise at 'tipping points' (i.e., when symptoms, functional status, or caregiving needs change). 2) Palliative care needs in early dementia include advocacy for goal-aligned care in the future, reassurance against the threat of negligence and abandonment by caregivers, planning for future scenarios of care (practical, individual, and relational needs), and establishing of long-term relationships with providers entrusted for care later in disease. 3) Elements of effective palliative care in early dementia could include dementia-specific ACP and goals of care discussions, navigation for building a network of support, provision of tools and resources for family, tailored care and knowledge of the person, and well-prepared dementia-care providers. The scarcity of palliative care studies aimed at early disease indicates a gap in the evidence in dementia care.

CONCLUSION

The literature on palliative care in early dementia is sparse. Future studies should focus on assessment tools for optimizing timing of palliative care in early dementia, gaining better understanding of patient and family needs during early phases of disease, and providing training for providers and families in long-term relationships and communication around goals of care and future planning.

TEMPORARY REMOVAL: Opportunities to Improve End-of-Life Care Quality among Patients with Short Terminal Admissions

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Evaluating palliative care case conferences in primary care for patients with advanced non-malignant chronic conditions: a cluster-randomised controlled trial (KOPAL)

BACKGROUND

Patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and dementia are underrepresented in specialist palliative home care (SPHC). However, the complexity of their conditions requires collaboration between general practitioners (GPs) and SPHC teams and timely integration into SPHC to effectively meet their needs.

OBJECTIVE

To facilitate joint palliative care planning and the timely transfer of patients with advanced chronic non-malignant conditions to SPHC.

METHODS

A two-arm, unblinded, cluster-randomised controlled trial. 49 GP practices in northern Germany were randomised using web-based block randomisation. We included patients with advanced CHF, COPD and/or dementia. The KOPAL intervention consisted of a SPHC nurse-patient consultation followed by an interprofessional telephone case conference between SPHC team and GP. The primary outcome was the number of hospital admissions 48 weeks after baseline. Secondary analyses examined the effects on health-related quality of life and self-rated health status, as measured by the EuroQol 5D scale.

RESULTS

A total of 172 patients were included in the analyses. 80.4% of GP practices had worked with SHPC before, most of them exclusively for cancer patients. At baseline, patients reported a mean EQ-VAS of 48.4, a mean quality of life index (EQ-5D-5L) of 0.63 and an average of 0.80 hospital admissions in the previous year. The intervention did not significantly reduce hospital admissions (incidence rate ratio = 0.79, 95%CI: [0.49, 1.26], P = 0.31) or the number of days spent in hospital (incidence rate ratio = 0.65, 95%CI: [0.28, 1.49], P = 0.29). There was also no significant effect on quality of life (∆ = -0.02, 95%CI: [-0.09, 0.05], P = 0.53) or self-rated health (∆ = -2.48, 95%CI: [-9.95, 4.99], P = 0.51).

CONCLUSIONS

The study did not show the hypothesised effect on hospitalisations and health-related quality of life. Future research should focus on refining this approach, with particular emphasis on optimising the timing of case conferences and implementing discussed changes to treatment plans, to improve collaboration between GPs and SPHC teams.

Association between opioid use disorder and palliative care: a cohort study using linked health administrative data in Ontario, Canada

BACKGROUND

People with opioid use disorder (OUD) are at risk of premature death and can benefit from palliative care. We sought to compare palliative care provision for decedents with and without OUD.

METHODS

We conducted a cohort study using health administrative databases in Ontario, Canada, to identify people who died between July 1, 2015, and Dec. 31, 2021. The exposure was OUD, defined as having emergency department visits, hospital admissions, or pharmacologic treatments suggestive of OUD within 3 years of death. Our primary outcome was receipt of 1 or more palliative care services during the last 90 days before death. Secondary outcomes included setting, initiation, and intensity of palliative care. We conducted a secondary analysis excluding sudden deaths (e.g., opioid toxicity, injury).

RESULTS

Of 679 840 decedents, 11 200 (1.6%) had OUD. Compared with people without OUD, those with OUD died at a younger age and were more likely to live in neighbourhoods with high marginalization indices. We found people with OUD were less likely to receive palliative care at the end of their lives (adjusted relative risk [RR] 0.84, 95% confidence interval [CI] 0.82-0.86), but this difference did not exist after excluding people who died suddenly (adjusted RR 0.99, 95% CI 0.96-1.01). People with OUD were less likely to receive palliative care in clinics and their homes regardless of cause of death.

INTERPRETATION

Opioid use disorder can be a chronic, life-limiting illness, and people with OUD are less likely to receive palliative care in communities during the 90 days before death. Health care providers should receive training in palliative care and addiction medicine to support people with OUD.

The determinants of actual place of death among noncancer patients with end-stage chronic health conditions: a scoping review

A home is a preferred place of death by most people. Nurses play a key role in supporting end-of-life home care, yet less is known about the factors that determine home as a place of death. This scoping review describes the percentage of actual places of death and determines social factors related to home as the place of death among noncancer patients with end-stage chronic health conditions. Inclusion criteria included (1) noncancer chronic illness conditions, (2) outcomes of place of death, and (3) factors that determine home as a place of death. Sources of evidence included PubMed, CINAHL, and Web of Science databases, which were searched in May 2022, and additional searches from May 2022 to November 2023.The JBI scoping review guide (2020) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review extension were used. Twenty-eight studies were included in this analysis. The range of percentages is varied within the same place of death among the sample. Two major constructs that determine a home as a place of death were identified: preceding factors and social capital. The results suggest that the place of death among noncancer patients with end-stage chronic health conditions should be continued to be understood. Two constructs determined home as a place of death and are considered as a fundamental to increasing equal accessibility in the initiation of palliative care services to promote home death and meet end-of-life care goals.

Study protocol for the development and validation of a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia

BACKGROUND

Patients with dementia and their caregivers could benefit from advance care planning though may not be having these discussions in a timely manner or at all. A prognostic tool could serve as a prompt to healthcare providers to initiate advance care planning among patients and their caregivers, which could increase the receipt of care that is concordant with their goals. Existing prognostic tools have limitations. We seek to develop and validate a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia.

METHODS

The derivation cohort will include approximately 235,000 patients with dementia, who were admitted to hospital in Ontario from April 1st, 2009, to December 31st, 2017. Predictor variables will be fully prespecified based on a literature review of etiological studies and existing prognostic tools, and on subject-matter expertise; they will be categorized as follows: sociodemographic factors, comorbidities, previous interventions, functional status, nutritional status, admission information, previous health care utilization. Data-driven selection of predictors will be avoided. Continuous predictors will be modelled as restricted cubic splines. The outcome variable will be mortality within 1 year of admission, which will be modelled as a binary variable, such that a logistic regression model will be estimated. Predictor and outcome variables will be derived from linked population-level healthcare administrative databases. The validation cohort will comprise about 63,000 dementia patients, who were admitted to hospital in Ontario from January 1st, 2018, to March 31st, 2019. Model performance, measured by predictive accuracy, discrimination, and calibration, will be assessed using internal (temporal) validation. Calibration will be evaluated in the total validation cohort and in subgroups of importance to clinicians and policymakers. The final model will be based on the full cohort.

DISCUSSION

We seek to develop and validate a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. The model would be integrated into the electronic medical records of hospitals to automatically output 1-year mortality risk upon hospitalization. The tool could serve as a trigger for advance care planning and inform access to specialist palliative care services with prognosis-based eligibility criteria. Before implementation, the tool will require external validation and study of its potential impact on clinical decision-making and patient outcomes.

TRIAL REGISTRATION

NCT05371782.

Socioeconomic Status, Palliative Care, and Death at Home Among Patients With Cancer Before and During COVID-19

Importance

The COVID-19 pandemic had a profound impact on the delivery of cancer care, but less is known about its association with place of death and delivery of specialized palliative care (SPC) and potential disparities in these outcomes.

Objective

To evaluate the association of the COVID-19 pandemic with death at home and SPC delivery at the end of life and to examine whether disparities in socioeconomic status exist for these outcomes.

Design, Setting, and Participants

In this cohort study, an interrupted time series analysis was conducted using Ontario Cancer Registry data comprising adult patients aged 18 years or older who died with cancer between the pre-COVID-19 (March 16, 2015, to March 15, 2020) and COVID-19 (March 16, 2020, to March 15, 2021) periods. The data analysis was performed between March and November 2023.

Exposure

COVID-19-related hospital restrictions starting March 16, 2020.

Main Outcomes and Measures

Outcomes were death at home and SPC delivery at the end of life (last 30 days before death). Socioeconomic status was measured using Ontario Marginalization Index area-based material deprivation quintiles, with quintile 1 (Q1) indicating the least deprivation; Q3, intermediate deprivation; and Q5, the most deprivation. Segmented linear regression was used to estimate monthly trends in outcomes before, at the start of, and in the first year of the COVID-19 pandemic.

Results

Of 173 915 patients in the study cohort (mean [SD] age, 72.1 [12.5] years; males, 54.1% [95% CI, 53.8%-54.3%]), 83.7% (95% CI, 83.6%-83.9%) died in the pre-COVID-19 period and 16.3% (95% CI, 16.1%-16.4%) died in the COVID-19 period, 54.5% (95% CI, 54.2%-54.7%) died at home during the entire study period, and 57.8% (95% CI, 57.5%-58.0%) received SPC at the end of life. In March 2020, home deaths increased by 8.3% (95% CI, 7.4%-9.1%); however, this increase was less marked in Q5 (6.1%; 95% CI, 4.4%-7.8%) than in Q1 (11.4%; 95% CI, 9.6%-13.2%) and Q3 (10.0%; 95% CI, 9.0%-11.1%). There was a simultaneous decrease of 5.3% (95% CI, -6.3% to -4.4%) in the rate of SPC at the end of life, with no significant difference among quintiles. Patients who received SPC at the end of life (vs no SPC) were more likely to die at home before and during the pandemic. However, there was a larger immediate increase in home deaths among those who received no SPC at the end of life vs those who received SPC (Q1, 17.5% [95% CI, 15.2%-19.8%] vs 7.6% [95% CI, 5.4%-9.7%]; Q3, 12.7% [95% CI, 10.8%-14.5%] vs 9.0% [95% CI, 7.2%-10.7%]). For Q5, the increase in home deaths was significant only for patients who did not receive SPC (13.9% [95% CI, 11.9%-15.8%] vs 1.2% [95% CI, -1.0% to 3.5%]).

Conclusions and Relevance

These findings suggest that the COVID-19 pandemic was associated with amplified socioeconomic disparities in death at home and SPC delivery at the end of life. Future research should focus on the mechanisms of these disparities and on developing interventions to ensure equitable and consistent SPC access.

Specialist Palliative Care and Health Care Costs at the End of Life

BACKGROUND/AIMS

The use and costs of health care rise substantially in the months prior to death, and although the use of palliative care services may be expected to lead to less costly care, the evidence is mixed. We analysed the costs of care over the last year of life and the extent to which these are associated with the use and duration of specialist palliative care (SPC) for decedents who died from cancer or another life-limiting illness.

METHODS

The decedents were participants in a cohort study of older residents of the state of New South Wales, Australia. Using linked survey and administrative health data from 2007 to 2016, two cohorts were identified: n = 10,535 where the cause of death was cancer; and n = 11,179 where the cause of death was another life-limiting illness. Costs of various types were analysed with separate risk-adjusted linear regression models for the last 1, 3, 6, 9 and 12 months before death and for both cohorts. SPC was categorised according to time to death from first contact with the service as 1-7 days, 7-30 days, 30-180 days and more than 180 days.

RESULTS

SPC use was higher among the cancer cohort (30.0%) relative to the non-cancer cohort (4.8%). The mean costs over the final year of life were AU$55,037 (SD 45,059) for the cancer cohort and AU$35,318 (SD 41,948) for the non-cancer cohort. Earlier use of SPC was associated with higher costs over the last year of life but lower costs in the last 1 and 3 months for both cohorts. Initiating SPC use more than 180 days before death was associated with a mean difference relative to the no SPC group of AU$15,590 (95% CI 10,617 to 20,562) and AU$13,739 (95% CI 733 to 26,746) over the last year of life for those dying from cancer and another illness, respectively. The same differences over the last month of life were - AU$2810 (95% CI -  3945 to -  1676) and - AU$4345 (95% CI -  6625 to - 2066). Admitted hospital care was the major driver of costs, with longer SPC associated with lower rates of death in hospital for both cohorts.

CONCLUSION

Early initiation of SPC was associated with higher costs over the last year of life and lower costs over the last months of life. This was the case for both the cancer and non-cancer cohorts, and appeared to be largely attributed to reduced hospitalisation. Although further investigation is required, our results suggest that expanding the availability of SPC services to provide more equitable access could enable patients to spend more time at their usual place of residence, reduce pressure on inpatient services and facilitate death at home when that is preferred.

Trend Analysis of Palliative Care Utilization in Patients with Chronic Obstructive Pulmonary Disease During Hospitalization from 2007 to 2018 in Taiwan

Purpose

Palliative care utilization among hospitalized patients with advanced chronic obstructive pulmonary disease (COPD) in Taiwan remains low despite its costs making it eligible for reimbursement since 2009. Few studies have examined the trends of palliative care utilization. We analyzed the annual rate, associated factors, and timing of the inpatient palliative care utilization by hospitalized patients with COPD.

Patients and Methods

We conducted a cross-sectional observational study between 1 January 2007 and 31 December 2018. Population-based claims data were extracted from Taiwan's National Health Insurance Research Database to identify patients aged ≧40 years with COPD five years before the first instance of inpatient palliative care utilization.

Results

There were 24,502 patients with COPD receiving inpatient palliative care. Our results indicated that older age, concomitant chronic conditions-especially cancer-and severity of comorbidities were associated with a higher rate of palliative care utilization by hospitalized patients with chronic obstructive pulmonary disease. In our study, the proportion of hospitalized patients with COPD receiving inpatient palliative care and having a Charlson comorbidity index score of 1-2 was lower than that of patients with cancer and a Charlson comorbidity index score ≧3 during the 12-year study-observation period. In addition, approximately 50% of hospitalized patients with COPD received palliative care within 18 months after their initial admission for COPD during the study period. However, individuals with a CCI score of 1-2 exhibited a slower entry into palliative care, with nearly 50% initiating it within the first two years.

Conclusion

Inpatient palliative care utilization by hospitalized patients with advanced COPD remains low due to various causes. Our findings highlight that palliative care may be considered by professional care providers as routine care and as a way to manage problematic symptoms during hospitalization.

Association of patient sex with use of palliative care in Ontario, Canada: a population-based study

BACKGROUND

It is unclear whether there are sex-based differences in use of palliative care near the end of life. The objective of this study was to measure the association between sex and palliative care use.

METHODS

We performed a population-based retrospective cohort study of all patients aged 18 years or older in the last year of life who died in Ontario, Canada, between 2010 and 2018. The primary exposure was patient biologic sex (male or female). The primary outcome was receipt of physician-delivered palliative care; secondary outcomes were approach to in-hospital palliative care and sex concordance of the patient and referring physician. We used multivariable modified Poisson regression to measure the association between patient sex and palliative care receipt, as well as patient-physician sex concordance.

RESULTS

There were 706 722 patients (354 657 females [50.2%], median age 80 yr [interquartile range 69-87 yr]) in the study cohort, 377 498 (53.4%) of whom received physician-delivered palliative care. After adjustment for age and selected comorbidities, female sex was associated with a 9% relative increase (adjusted relative risk [RR] 1.09, 95% CI 1.08-1.10) in receipt of physician-delivered palliative care. Female patients were 16% more likely than male patients (adjusted RR 1.14, 95% CI 1.14-1.18) to have had their first hospital admission in their final year of life categorized as having a likely palliative intent. Female patients were 18% more likely than male patients (RR 1.18, 95% CI 1.17-1.19) to have had a female referring physician, and male patients were 20% more likely than female patients (adjusted RR 1.20, CI 1.19-1.21) to have had a male referring physician.

INTERPRETATION

After adjustment for age and comorbidities, male patients were slightly less likely than female patients to have received physician-delivered palliative care, and female patients were more likely than male patients to have had their first hospital admission in their final year of life categorized as having a likely palliative care intent. These results may reflect a between-sex difference in overall end-of-life care preferences or sex differences in decision-making influenced by patient-specific factors; further studies exploring how these factors affect end-of-life decision-making are required.

Impact of a financial incentive scheme for team-based palliative care in patients with heart failure in Japan: A nationwide database study

BACKGROUND

Palliative care provided to patients with heart failure (HF) are reported to be inadequate. Herein, we examined the impact of the recently introduced financial incentive scheme for team-based palliative care for patients with HF in acute care hospitals in Japan.

METHODS

Using a nationwide inpatient database, we identified patients aged ≥65 years with HF who had died between April 2015 and March 2021. Interrupted time-series analyses were used to compare practice patterns in end-of-life care (symptom management and invasive medical procedures within one week before death) before and after the financial incentive scheme issuance in April 2018.

RESULTS

Overall, 53,857 patients in 835 hospitals were eligible. The adoption of the financial incentive was 1.10 to 1.22% after the introduction. There were upward pre-trends in opioid use (+0.11% per month; 95% confidence interval [CI], 0.06 to 0.15) and antidepressant use (+0.06% per month; 95% CI, 0.04 to 0.09). Opioid use showed a downward slope change during the post-period (-0.07% change in trend; 95% CI, -0.13 to -0.01). Intensive care unit stay showed a downward pre-trend (-0.09% per month; 95% CI, -0.14 to -0.04) and upward slope changes during the post-period (+0.12% change in trend; 95% CI, 0.04 to 0.19). Invasive mechanical ventilation showed downward slope changes during the post-period (-0.11% change in trend; 95% CI, -0.18 to -0.04).

CONCLUSIONS

The financial incentive scheme for team-based palliative care was rarely adopted and not associated with changes in end-of-life care. Further multifaceted strategies to promote palliative care for HF are warranted.

End of life care of hospitalized patients with Parkinson disease: a retrospective analysis and brief review

Background

Towards the end of life (EOL), persons with parkinsonism (PwP) have complex needs and can present with unique palliative care (PC) challenges. There are no widely accepted guidelines to aid neurologists, hospitalists, or PC clinicians in managing the symptoms of PwP at EOL. We examined a population of PwP at EOL, aiming to describe trends of in-hospital management and utilization of PC services.

Methods

All PwP admitted to two hospitals during 2018 (N = 727) were examined retrospectively, assessing those who died in hospital or were discharged with hospice (EOL group, N = 35) and comparing them to the main cohort. Their demographics, clinical data, engagement of multidisciplinary and palliative services, code status changes, invasive care, frequency of admissions, and medication administration were assessed.

Results

Among the EOL group, 8 expired in hospital, and 27 were discharged to hospice. Forty-six percent of EOL patients received a PC consultation during their admission. The median interval from admission to death was 37 days. Seventy-seven percent had a full code status on admission. Compared to hospice patients, those who expired in hospital had higher rates of invasive procedures and intensive care unit transfers (41% vs. 75%, in both variables), and lower rates of PC involvement (52% vs. 25%). The transition of code status change for the EOL group from Full code to Do Not Resuscitate (DNR) occurred at a median 4-5 days from admission. For patients that passed in the hospital, the median days from transition of code status to death was 0(IQR 0-1). Levodopa dose deviations were frequent in both EOL and non-EOL group, but contraindicated medications were infrequently administered (11% in EOL group vs. 9% in non-EOL group).

Conclusion

Our data suggest a low utilization of PC services and delayed discussions of goals of care. More work is needed to raise awareness of inpatient teams managing PwP regarding the unique but common challenges facing PwP with advanced disease. A brief narrative review summarizing the suggested management of symptoms common to hospitalized PwP near EOL is provided.

Differences in trends in discharge location in a cohort of hospitalized patients with cancer and non-cancer diagnoses receiving specialist palliative care: A retrospective cohort study

BACKGROUND

Patients with and without cancer are frequently hospitalized, and have specialist palliative care needs. In-hospital mortality can serve as a quality indicator of acute care. Trends in acute care outcomes have not previously been evaluated in patients with confirmed specialist palliative care needs or between diagnostic groups.

AIM

To compare trends in discharge location between hospitalized patients with and without cancer who received specialist palliative care.

DESIGN

Retrospective cohort study. Association between diagnosis (cancer, non-cancer) and in-hospital mortality was assessed using multivariable logistic regression, controlling for demographic, clinical, and admission-specific information.

SETTING/PARTICIPANTS

Patients who received specialist palliative care at an academic tertiary hospital in Toronto, Canada from 2013 to 2019.

RESULTS

The cohort comprised 6846 patients, 5024 with and 1822 without cancer. A higher proportion of patients without cancer had a Palliative Performance Scale score <30%, anticipated prognosis of <1 month, and were referred for end-of-life care (all p < 0.001). The adjusted odds of dying in hospital was 1.24-times higher among patients without cancer (95% CI: 1.05-1.46; p = 0.011). Though the proportion of patients without cancer who died in hospital decreased by 8.4% from 2013 to 2019, this proportion (41.2%) remained substantially higher compared to patients with cancer (14.0%) in 2019.

CONCLUSIONS

Hospitalized patients without cancer were referred to specialist palliative care at a lower functional status, a poorer anticipated prognosis, and more likely for end-of-life care; and were more likely to die in hospital. Future studies are required to determine whether a proportion of hospital deaths in patients without cancer represent goal-discordant end-of-life care.

Physician continuity of care in the last year of life in community-dwelling adults: retrospective population-based study

OBJECTIVE

To describe the timing of involvement of various physician specialties over the last year of life across different levels of primary care physician continuity for differing causes of death.

METHODS

We conducted a retrospective cohort study of adults who died in Ontario, Canada, between 1 January 2013 and 31 December 2018, using linked population level health administrative data. Outcomes were median days between death and first and last outpatient palliative care specialist encounter, last outpatient encounter with other specialists and with the usual primary care physician. These were calculated by tertile of score on the Usual Provider Continuity Index, defined as the proportion of outpatient physician encounters with the patient's primary care physician.

RESULTS

Patients' (n=395 839) mean age at death was 76 years. With increasing category of usual primary care physician continuity, a larger proportion were palliative care generalists, palliative care specialist involvement decreased in duration and was concentrated closer to death, the primary care physician was involved closer to death, and other specialist physicians ceased involvement earlier. For patients with cancer, palliative care specialist involvement was longer than for other patients.

CONCLUSIONS

Compared with patients with lower continuity, those with higher usual provider continuity were more likely to have a primary care physician involved closer to death providing generalist palliative care.

Knowledge, goals, and misperceptions about palliative care in adults with chronic disease or cancer

OBJECTIVES

Limited evidence investigates how knowledge, misconceptions, and beliefs about palliative care vary across patients with cancerous versus non-cancerous chronic disease. We examined the knowledge of and misconceptions about palliative care among these groups.

METHODS

We used weighted data from the National Cancer Institute Health Information National Trends Survey 5 (Cycle 2) for nationally representative estimates and logistic regression to adjust for respondent characteristics. We identified respondents who reported having (1) cancer ([n = 585]; breast, lung, and colorectal), (2) chronic conditions ([n = 543]; heart failure, lung disease, or chronic obstructive pulmonary disorder), or (3) neither cancer nor other chronic conditions (n = 2,376).

RESULTS

Compared to cancer respondents, chronic condition respondents were more likely to report being Black or Hispanic, report a disability, and have lower socioeconomic status. In the sample, 65.6% of cancer respondents and 72.8% chronic conditions respondents reported they had never heard of palliative care. Chronic condition respondents were significantly (p < 0.05) less likely to report high palliative care knowledge than cancer respondents (9.1% vs. 16.6%, respectively). In adjusted analyses, cancer respondents had greater odds of high palliative care knowledge (odd ratio [OR] = 1.70; 95% confidence interval [CI] = 1.01, 2.86) compared to respondents with neither cancer nor chronic disease; chronic condition respondents did not have increased odds (OR = 0.96; CI = 0.59, 1.54).

SIGNIFICANCE OF RESULTS

Disparities in palliative care knowledge exist among people with non-cancerous chronic disease compared to cancer. Supportive educational efforts to boost knowledge about palliative care remains urgent and is critical for promoting equity, particularly for underserved people with chronic illnesses.

Functional Status Changes in Patients Receiving Palliative Care Consult During COVID-19 Pandemic

CONTEXT

Hospitalized patients with functional impairment have higher symptom burden and mortality. Little is known about how increased patient volume and acuity during the coronavirus disease 2019 (COVID-19) pandemic affected access to palliative care among patients with functional impairment.

OBJECTIVES

To examine changes in functional status and hospital outcomes among patients receiving inpatient palliative care consultation before, during and after the COVID-19 pandemic.

METHODS

We conducted a retrospective, multisite cohort study of all adult patients (≥ 18 years) admitted to four hospitals in New York City, USA, who received inpatient palliative care consultation between March 1, 2019 and February 28, 2022 with documented functional status at the time of consultation measured by Karnofsky Performance Status scale.

RESULTS

Among 13,180 eligible patients identified, patients' functional status at the time of consultation decreased as palliative care consult volume increased with the onset of the pandemic. Compared to pre-pandemic, there was a statistically significant trend of lower functional status (P < 0.001) and higher in-hospital mortality (P < 0.001) among patients with noncancer and non-COVID-19 diagnoses two years after the pandemic. In contrast, patients with cancer had a statistically significant trend of higher functional status (P < 0.001) and no significant changes in in-hospital mortality over time.

CONCLUSION

As the healthcare system was stressed with high demand and limited resources, palliative care consultation prioritized highest acuity patients by shifting towards those with lower functional status and higher in-hospital mortality. This shift disproportionately affected noncancer patients. Innovative approaches to ensure upstream palliative care consultation during increased resource constraints are needed.

Specialist Palliative Care Referral Practices Among Oncologists, Cardiologists, Respirologists: A Comparison of National Survey Studies

CONTEXT

Although patients with nonmalignant diseases have palliative care needs similar to those of cancer patients, they are less likely to receive specialist palliative care (SPC). Referral practices of oncologists, cardiologists, and respirologists could provide insight into reasons for this difference.

OBJECTIVES

We compared referral practices to SPC among cardiologists, respirologists, and oncologists, discerned from surveys (the Canadian Palliative Cardiology/Respirology/Oncology Surveys).

METHODS

Descriptive comparison of survey studies; multivariable linear regression analysis of association between specialty and referral frequency. Surveys for each specialty were disseminated to physicians across Canada in 2010 (oncologists) and 2018 (cardiologists, respirologists).

RESULTS

The combined response rate of the surveys was 60.9% (1568/2574): 603 oncologists, 534 cardiologists, and 431 respirologists. Perceived availability of SPC services was higher for cancer than for noncancer patients. Oncologists were more likely to make a referral to SPC for a symptomatic patient with a prognosis of

CONCLUSION

For cardiologists and respirologists in 2018, perceived availability of SPC services was poorer, timing of referral later, and frequency of referral lower than among oncologists in 2010. Further research is needed to identify reasons for differences in referral practices and to develop interventions to overcome them.

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Key Words

• Palliative care
• cancer
• chronic obstructive pulmonary disease
• health care disparity
• heart failure
• referral

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MESH Headings

• Humans
• Palliative Care
• Cardiologists
• Attitude of Health Personnel
• Practice Patterns, Physicians'
• Canada
• Neoplasms/therapy
• Referral and Consultation
• Oncologists

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Affiliation(s)

Michael Bonares Division of Palliative Medicine (M.B.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of Palliative Medicine (M.B., C.Z.), Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Lisa W Le Department of Biostatistics (L.W.L.), Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
Camilla Zimmermann Division of Palliative Medicine (M.B., C.Z.), Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Supportive Care (C.Z., K.W.), University Health Network, Toronto, Ontario, Canada
Kristen Wentlandt Department of Supportive Care (C.Z., K.W.), University Health Network, Toronto, Ontario, Canada; Division of Palliative Care (K.W.), Department of Community and Family Medicine, University of Toronto, Toronto, Ontario, Canada

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Real-world data on home end-of-life care for older adults with cancer: A retrospective claims data analysis

Background

Cancer incidence is expected to increase with population aging, making the availability of places for treating patients with terminal cancer a pressing issue. However, little is known about the actual state of home end-of-life care (HEC) in Japan.

Objective

The objective of this study was to examine the real-world state of HEC for older adults with cancer.

Methods

The Yokohama Original Medical Database was used to identify the cohort. Data of target patients was extracted based on three criteria: age ≥65 years, malignant neoplasm diagnosis, and having a specific billing code of HEC. Multivariable linear and logistic regression models were used to evaluate the association between age groups and HEC services or outcome indexes.

Results

Overall, 1323 people (554 and 769 aged < 80 and ≥ 80 years, respectively; men, 59.2%) had planned to receive HEC. The < 80 years group had more frequent emergent home visits than the ≥ 80-year group (P < 0.001), but the number of monthly home visits was similar between the two groups (P = 0.267). The rate of emergent admission was 5.9% in the ≥ 80-year group, which was higher than that in the < 80-year group (3.1%; P = 0.018). Conversely, the rates of central venous nutrition and opioid use were higher in the < 80-year group than those in the ≥ 80-year group.

Conclusions

This study reported patterns of use of HEC among older adults with cancer in the terminal stage. Our findings may provide the basis for providing HEC for older adults with cancer.

Predicting mortality in patients diagnosed with advanced dementia presenting at an acute care hospital: the PROgnostic Model for Advanced DEmentia (PRO-MADE)

BACKGROUND

Challenges in prognosticating patients diagnosed with advanced dementia (AD) hinders timely referrals to palliative care. We aim to develop and validate a prognostic model to predict one-year all-cause mortality (ACM) in patients with AD presenting at an acute care hospital.

METHODS

This retrospective cohort study utilised administrative and clinical data from Tan Tock Seng Hospital (TTSH). Patients admitted to TTSH between 1st July 2016 and 31st October 2017 and identified to have AD were included. The primary outcome was ACM within one-year of AD diagnosis. Multivariable logistic regression was used. The PROgnostic Model for Advanced Dementia (PRO-MADE) was internally validated using a bootstrap resampling of 1000 replications and externally validated on a more recent cohort of AD patients. The model was evaluated for overall predictive accuracy (Nagelkerke's R² and Brier score), discriminative [area-under-the-curve (AUC)], and calibration [calibration slope and calibration-in-the-large (CITL)] properties.

RESULTS

A total of 1,077 patients with a mean age of 85 (SD: 7.7) years old were included, and 318 (29.5%) patients died within one-year of AD diagnosis. Predictors of one-year ACM were age > 85 years (OR:1.87; 95%CI:1.36 to 2.56), male gender (OR:1.62; 95%CI:1.18 to 2.22), presence of pneumonia (OR:1.75; 95%CI:1.25 to 2.45), pressure ulcers (OR:2.60; 95%CI:1.57 to 4.31), dysphagia (OR:1.53; 95%CI:1.11 to 2.11), Charlson Comorbidity Index ≥ 8 (OR:1.39; 95%CI:1.01 to 1.90), functional dependency in ≥ 4 activities of daily living (OR: 1.82; 95%CI:1.32 to 2.53), abnormal urea (OR:2.16; 95%CI:1.58 to 2.95) and abnormal albumin (OR:3.68; 95%CI:2.07 to 6.54) values. Internal validation results for optimism-adjusted Nagelkerke's R², Brier score, AUC, calibration slope and CITL were 0.25 (95%CI:0.25 to 0.26), 0.17 (95%CI:0.17 to 0.17), 0.76 (95%CI:0.76 to 0.76), 0.95 (95% CI:0.95 to 0.96) and 0 (95%CI:-0.0001 to 0.001) respectively. When externally validated, the model demonstrated an AUC of 0.70 (95%CI:0.69 to 0.71), calibration slope of 0.64 (95%CI:0.63 to 0.66) and CITL of -0.27 (95%CI:-0.28 to -0.26).

CONCLUSION

The PRO-MADE attained good discrimination and calibration properties. Used synergistically with a clinician's judgement, this model can identify AD patients who are at high-risk of one-year ACM to facilitate timely referrals to palliative care.

Cancer Decedents' Hospital End-of-Life Care Documentation: A Retrospective Review of Patient Records

Objective: International standards of end-of-life care (EOLC) intend to guide the delivery of safe and high-quality EOLC. Adequately documented care is conducive to higher quality of care, but the extent to which EOLC standards are documented in hospital medical records is unknown. Assessing which EOLC standards are documented in patients' medical records can help identify areas that are performed well and areas where improvements are needed. This study assessed cancer decedents' EOLC documentation in hospital settings. Methods: Medical records of 240 cancer decedents were retrospectively evaluated. Data were collected across six Australian hospitals between 1/01/2019 and 31/12/2019. EOLC documentation related to Advance Care Planning (ACP), resuscitation planning, care of the dying person, and grief and bereavement care was reviewed. Chi-square tests assessed associations between EOLC documentation and patient characteristics, and hospital settings (specialist palliative care unit, sub-acute/rehabilitation care settings, acute care wards, and intensive care units). Results: Decedents' mean age was 75.3 years (SD 11.8), 52.0% (n = 125) were female, and 73.7% lived with other adults or carers. All patients (n = 240; 100%) had documentation for resuscitation planning, 97.6% (n = 235) for Care for the Dying Person, 40.0% for grief and bereavement care (n = 96), and 30.4% (n = 73) for ACP. Patients living with other adults or carers were less likely to have a documented ACP than those living alone or with dependents (OR 0.48; 95% CI 0.26-0.89). EOLC documentation was significantly greater in specialist palliative care settings than that in other hospital settings (P < .001). Conclusion: The process of dying is well documented among inpatients diagnosed with cancer. ACP and grief and bereavement support are not documented enough. Organizational endorsement of a clear practice framework and increased training could improve documentation of these aspects of EOLC.

Pain and Interventions in Stage IV Non-Small Cell Lung Cancer: A Province-Wide Analysis

Pain is a common symptom in stage IV non-small cell lung cancer (NSCLC). The objective of the study was to examine the use of interventions and factors associated with interventions for pain. A population-based cohort study in Ontario, Canada was conducted with patients diagnosed with stage IV NSCLC from January 2007 to September 2018. An Edmonton Symptom Assessment System (ESAS) score of ≥4 defined moderate-to-severe pain following diagnosis. The study cohort included 13,159 patients, of which 68.5% reported at least one moderate-to-severe pain score. Most patients were assessed by a palliative care team (85.4%), and the majority received radiation therapy (73.2%). The use of nerve block was rare (0.8%). For patients ≥65 years of age who had drug coverage, 59.6% received an opiate prescription. Patients with moderate-to-severe pain were more likely to receive palliative assessment or radiation therapy compared to patients with none or mild pain. Patients aged ≥70 years and with a greater comorbidity burden were associated with less likelihood to receive radiation therapy. Patients from rural/non-major urban residence and with a greater comorbidity burden were also less likely to receive palliative care assessment. Factors associated with interventions for pain are described to inform future symptom management in this population.

Palliative profile, one-year mortality and quality of life in older inpatients according to Be-PICT: a multicenter prospective cohort study

BACKGROUND

A palliative care approach (PCA), including advanced care planning (ACP), should be considered for patients with limited life expectancy. The Belgian Palliative Care Indicators Tool (Be-PICT) has been released to help identify patients who may benefit from such approach. This study aimed at measuring 1-year mortality and describe the quality of life in older inpatients, according to baseline Be-PICT results.

METHODS

Prospective multicentre cohort study in older patients (≥ 75 years) admitted at geriatrics and cardiology wards of four Belgian hospitals. The palliative profile was defined as a positive Be-PICT.1, defined by the presence of its three criteria, i.e. a negative physician's answer to the surprise question 'would you be surprised if this patient dies in the 6-12 next months?', ≥ 1 poor health indicator and ≥ 1 life-limiting condition.

RESULTS

Of the 379 patients (50% aged ≥85 years; 51% female), 52 (14%) presented a palliative profile and 83 (23%) died within 1 year. Be-PICT.1 showed the following characteristics to predict 1-year mortality: sensitivity 0.54, specificity 0.83, positive and negative predictive values 0.48 and 0.86, positive and negative likelihood ratios 3.22 and 0.55. The patients with a palliative profile were at higher mortality risk (hazard ratio 4.79 p < 0.001) and 1-year mortality rate (45%). Not using the SQ allowed to improve sensitivity to include a larger number of patients who may benefit from ACP and PCA.

CONCLUSIONS

Be-PICT.1 is a simple case-finding tool to identify older inpatients being at high mortality risk and candidates for ACP and PCA.

Quality of end-of-life care with non-malignant liver disease: Analysis of the VOICES National Survey of Bereaved People

BACKGROUND AND AIMS

Patients with liver disease struggle to access palliative care. We aimed to compare carers' perceptions of end-of-life care for decedents with non-malignant liver disease, malignant liver disease and other non-malignant diseases, and to identify associated factors in non-malignant liver disease.

METHODS

A retrospective analysis of individual-level data from the National Survey of Bereaved People 2011-2015.

RESULTS

More decedents with non-malignant liver disease died in hospital than other diseases (76.9% vs. 40.9% vs. 50.2%, p < .001), despite 89% wishing to die at home. Fewer decedents received home/hospice specialist palliative care compared with those with malignant liver disease (10.0% vs. 54.6%, p < .001). Carers of decedents with non-malignant liver disease were less likely to rate overall end-of-life care quality as outstanding/excellent (29.3% vs. 43.9% vs. 42.3%, p < .001). For this group, poorer care was associated with younger (65-74 vs. 18-64 years, OR [odds ratio] 1.39, p = .01), more socially deprived decedents (OR .78, p = .02), and better care with greater social support (OR 1.82, p < .001) and community specialist palliative care involvement (OR 1.80, p < .001). There was no association between outstanding/excellent rating and underlying cause of non-malignant liver disease (alcohol-related vs. non-alcohol-related, p = .92) or place of death (hospital vs. non-hospital, p = .476).

CONCLUSIONS

End-of-life care could be improved by integrating hepatology and community services, particularly specialist palliative care, and advance care planning to facilitate care and death (where desired) at home. However, death in hospital may be appropriate for those with non-malignant liver disease.

Palliative care for people with dementia

Dementia is the most common neurologic disease, affecting approximately 55 million people worldwide. Dementia is a terminal illness, although not always recognized as such. This chapter discusses the key issues in providing palliative care for people with living with dementia and their families. Common palliative care needs and symptoms are presented, including psychosocial, physical, emotional, and spiritual, and the need to actively anticipate and seek symptoms according to the dementia type and stage is emphasized. Families are hugely impacted by a dementia diagnosis, and throughout this chapter, they are considered in the unit of care, and also as a member of the care team. Multiple challenges particular to dementia palliative care are highlighted throughout, such as the lack of timely dementia diagnoses, difficulty with symptom prognostication, the person's inability to verbally express their symptoms and care preferences, and a low threshold for medication side effects. Finally, service models for dementia palliative care in community, residential, and acute hospital settings are discussed, along with the evidence for each. Overall, this chapter reinforces that the individual needs of the person living with dementia and their family must be considered to provide person-centered and comprehensive palliative care, enabling them to live well until death.

A systematic review defining non-beneficial and inappropriate end-of-life treatment in patients with non-cancer diagnoses: theoretical development for multi-stakeholder intervention design in acute care settings

Background

Non-beneficial treatment is closely tied to inappropriate treatment at the end-of-life. Understanding the interplay between how and why these situations arise in acute care settings according to the various stakeholders is pivotal to informing decision-making and best practice at end-of-life.

Aim

To define and understand determinants of  non-beneficial and inappropriate treatments for patients with a non-cancer diagnosis, in acute care settings at the end-of-life.

Design

Systematic review of peer-reviewed studies focusing on the above and conducted in upper-middle- and high-income countries. A narrative synthesis was undertaken, guided by Realist principles.

Data sources

Cochrane; PubMed; Scopus; Embase; CINAHL; and Web of Science.

Results

Sixty-six studies (32 qualitative, 28 quantitative, and 6 mixed-methods) were included after screening 4,754 papers. Non-beneficial treatment was largely defined as when the burden of treatment outweighs any benefit to the patient. Inappropriate treatment at the end-of-life was similar to this, but additionally accounted for patient and family preferences.

Contexts in which outcomes related to non-beneficial treatment and/or inappropriate treatment occurred were described as veiled by uncertainty, driven by organizational culture, and limited by profiles and characteristics of involved stakeholders. Mechanisms relating to ‘Motivation to Address Conflict & Seek Agreement’ helped to lessen uncertainty around decision-making. Establishing agreement was reliant on ‘Valuing Clear Communication and Sharing of Information’. Reaching consensus was dependent on ‘Choices around Timing & Documenting of end-of-life Decisions’.

Conclusion

A framework mapping determinants of non-beneficial and inappropriate end-of-life treatment is developed and proposed to be potentially transferable to diverse contexts. Future studies should test and update the framework as an implementation tool.

Trial registration

PROSPERO Protocol CRD42021214137.

Supporting the Heterogeneous and Evolving Treatment Preferences of Patients With Heart Failure Through Collaborative Home-Based Palliative Care

Background We characterized the treatment preferences, care setting, and end-of-life outcomes among patients with advanced heart failure supported by a collaborative home-based model of palliative care. Methods and results This decedent cohort study included 250 patients with advanced heart failure who received collaborative home-based palliative care for a median duration of 1.9 months of follow-up in Ontario, Canada, from April 2013 to July 2019. Patients were categorized into 1 of 4 groups according to their initial treatment preferences. Outcomes included location of death (out of hospital versus in hospital), changes in treatment preferences, and health service use. Among patients who initially prioritized quantity of life, 21 of 43 (48.8%) changed their treatment preferences during follow-up (mean 0.28 changes per month). The majority of these patients changed their preferences to avoid hospitalization and focus on comfort at home (19 of 24 changes, 79%). A total of 207 of 250 (82.8%) patients experienced an out-of-hospital death. Patients who initially prioritized quantity of life had decreased odds of out-of-hospital death (versus in-hospital death; adjusted odds ratio, 0.259 [95% CI, 0.097-0.693]) and more frequent hospitalizations (mean 0.45 hospitalizations per person-month) compared with patients who initially prioritized quality of life at home. Conclusions Our results yield a more detailed understanding of the interaction of advanced care planning and patient preferences. Shared decision making for personalized treatment is dynamic and can be enacted earlier than at the very end of life.

Prevalence and factors associated with demoralization in palliative care patients: A cross-sectional study from Hong Kong

OBJECTIVES

Although demoralization is common among palliative care patients, it has not yet been examined empirically in the Hong Kong Chinese context. This study aims to examine (1) the prevalence of demoralization among community-dwelling palliative care patients in Hong Kong; (2) the percentage of palliative care patients who are demoralized but not depressed and vice versa; and (3) the association of socio-demographic factors, particularly family support, with demoralization.

METHOD

A cross-sectional study targeting community-living palliative care patients in Hong Kong was conducted. A total of 54 patients were recruited by a local hospice and interviewed for completing a questionnaire which included measures of demoralization, depression, perceived family support, and demographic information.

RESULTS

The prevalence of demoralization was 64.8%. Although there was overlap between demoralization and depression (52.8% meeting the criteria of both), 7.5% of depressed patients were not demoralized, and 13.2% of demoralized patients were not depressed. Participants who were not single and had more depressive symptoms and less family support had a significantly higher demoralization level.

SIGNIFICANCE OF RESULTS

This is the first study which reports the prevalence of demoralization in Hong Kong. Demoralization was found common in community-living palliative care patients receiving medical social work services in Hong Kong. This study provides evidence of the importance of differentiating the constructs between demoralization and depression. It also provides an implication that those who are married, more depressed, and have the least family support could be the most vulnerable group at risk of demoralization. We recommend that early assessment of demoralization among palliative care patients be considered.

Equal receipt of specialized palliative care in breast and prostate cancer: a register study

PURPOSE

There are inequalities in cancer treatment. This study aimed to investigate whether receipt of specialized palliative care (SPC) is affected by typical female and male diagnoses (breast and prostate cancer), age, socioeconomic status (SES), comorbidities as measured by the Charlson Comorbidity Index (CCI), or living arrangements (home vs nursing home residence). Furthermore, we wanted to investigate if receipt of SPC affects the place of death, or correlated with emergency department visits, or hospital admissions.

METHODS

All breast and prostate cancer patients who died with verified distant metastases during 2015-2019 in the Stockholm Region were included (n = 2516). We used univariable and stepwise (forward) logistic multiple regression models.

RESULTS

Lower age, lower CCI score, and higher SES significantly predicted receipt of palliative care 3 months before death (p = .007-p < .0001). Patients with prostate cancer, a lower CCI score, receiving palliative care services, or living in a nursing home were admitted to a hospital or visited an emergency room less often during their last month of life (p = .01 to < .0001). Patients receiving palliative care services had a low likelihood of dying in an acute care hospital (p < .001). Those who died in a hospital were younger, had a lower CCI score, and had received less palliative care or nursing home services (p = .02- < .0001).

CONCLUSION

Age, comorbidities, and nursing home residence affected the likelihood of receiving SPC. However, the diagnosis of breast versus prostate cancer did not. Emergency room visits, hospital admissions, and hospital deaths are registered less often for patients with SPC.

Dying in hospital is worse for non-cancer patients. A regional cross-sectional survey of bereaved relatives' views

OBJECTIVE

The aim of the study is to examine differences in hospital care between patients with cancer and non-cancer conditions in their dying phase, perceived by bereaved relatives.

METHODS

A retrospective cross-sectional post-bereavement survey, with the total population of 351 deceased, 91 cancer patients and 46 non-cancer patients, who spent their last 2 days of life in hospital. A validated German version of the VOICES-questionnaire ('VOICES-LYOL-Cologne') was used.

RESULTS

There were substantial differences between the two groups in the rating of sufficient practical care such as pain relief or support to eat or drink (p = 0.005) and sufficient emotional care needs (p = 0.006) and in the quality of communication with healthcare professionals (p < 0.001), with non-cancer patients scoring lowest in all these dimensions.

CONCLUSION

In all surveyed dimensions on the quality of care in the dying phase, non-cancer patients' relatives rated the provided care worse than those of cancer patients. To compensate any differences in care in the dying phase between diagnosis groups, hospital care should be provided as needs-oriented and non-indication-specific.

Exploring Health Care Providers' Experiences of Providing Collaborative Palliative Care for Patients With Advanced Heart Failure At Home: A Qualitative Study

Background The HeartFull Collaborative is a regionally organized model of care which involves specialist palliative care and cardiology health care providers (HCPs) in a collaborative, home-based palliative care approach for patients with advanced heart failure (AHF). We evaluated HCP perspectives of barriers and facilitators to providing coordinated palliative care for patients with AHF at home. Methods and Results We conducted a qualitative study with 17 HCPs (11 palliative care and 6 cardiology) who were involved in the HeartFull Collaborative from April 2013 to March 2020. Individual, semi-structured interviews were held with each practitioner from November 2019 to March 2020. We used an interpretivist and inductive thematic analysis approach. We identified facilitators at 2 levels: (1) individual HCP level (on-going professional education to expand competency) and (2) interpersonal level (shared care between specialties, effective communication within the care team). Ongoing barriers were identified at 2 levels: (1) individual HCP level (e.g. apprehension of cardiology practitioners to introduce palliative care) and (2) system level (e.g. lack of availability of personal support worker hours). Conclusions Our results suggest that a collaborative shared model of care delivery between palliative care and cardiology improves knowledge exchange, collaboration and communication between specialties, and leads to more comprehensive patient care. Addressing ongoing barriers will help improve care delivery. Findings emphasize the acceptability of the program from a provider perspective, which is encouraging for future implementation. Further research is needed to improve prognostication, assess patient and caregiver perspectives regarding this model of care, and assess the economic feasibility and impact of this model of care.

Aggressiveness of care in the last days of life in the emergency department of a tertiary hospital in Korea

Background

High-quality end-of-life (EOL) care requires both comfort care and the maintenance of dignity. However, delivering EOL in the emergency department (ED) is often challenging. Therefore, we aimed to investigate characteristics of EOL care for dying patients in the ED.

Methods

We conducted a retrospective cohort study of patients who died of disease in the ED at a tertiary hospital in Korea between January 2018 and December 2020. We examined medical care within the last 24 h of life and advance care planning (ACP) status.

Results

Of all 222 disease-related mortalities, 140 (63.1%) were men, while 141 (63.5%) had cancer. The median age was 74 years. As for critical care, 61 (27.5%) patients received cardiopulmonary resuscitation, while 80 (36.0%) received mechanical ventilation. The absence of serious illness (p = 0.011) and the lack of an advance statement (p < 0.001) were both independently associated with the receipt of more critical care. Only 70 (31.5%) patients received comfort care through opioids. Younger patients (< 75 years) (p = 0.002) and those who completed life-sustaining treatment legal forms (p = 0.001) received more comfort care. While EOL discussions were initiated in 150 (67.6%) cases, the palliative care team was involved only in 29 (13.1%).

Conclusions

Patients in the ED underwent more aggressive care and less comfort care in a state of imminent death. To ensure better EOL care, physicians should minimize redundant evaluations and promptly introduce ACP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00988-3.

A scoping review of the evidence for community-based dementia palliative care services and their related service activities

Background

Palliative care is identified internationally as a priority for efficacious dementia care. Research into “effective models” of palliative care for people with dementia has been recommended by several European countries. To build an effective service-delivery model we must gain an understanding of existing models used in similar settings. The study aim is to identify core components of extant models of palliative care for people with dementia, and their families, who are living at home in the community.

Methods

A scoping review was employed. The search strategy was devised to identify all peer-reviewed research papers relating to the above aim. This process was iterative, and the search strategy was refined as evidence emerged and was reviewed. All types of study designs and both quantitative and qualitative studies of non-pharmacological interventions were considered for inclusion.

Results

The search identified 2,754 unique citations, of which 18 papers were deemed eligible for inclusion. Although a palliative care approach is recommended from early in the disease process, most evidence involves end-of-life care or advanced dementia and pertains to residential care. The majority of the research reviewed focused on the effects of advance care planning, and end-of-life care; specialist palliative care input, and/or generalist palliative care provided by dementia services to enable people to remain at home and to reduce costs of care. Community staff training in palliative care appeared to improve engagement with Specialist Palliative Care teams. Integration of dementia and palliative care services was found to improve care received for people with dementia and their carers.

Conclusions

While the evidence for integration of dementia and palliative care services is promising, further high-quality research is necessary particularly to identify the key components of palliative care for people living with dementia. This is imperative to enable people with dementia to inform their own care, to stay living at home for as long as possible, and, where appropriate, to die at home.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00922-7.

Palliative care for older people with dementia-we need a paradigm shift in our approach

Older people with dementia have multiple palliative care needs, with pain, agitation, dyspnoea, aspiration and pressure ulcers being common and persistent in advanced dementia. Anticipating the person's possible symptoms requires knowledge of the whole person, including the type of dementia, which is problematic when the dementia type is often not documented. A palliative care approach to dementia should look at symptoms across the four pillars of palliative care, but in reality, we tend to over-focus on physical and psychological symptoms, while spiritual and emotional needs can be overlooked, especially around the time of diagnosis, where such needs may be significant. Advance care planning (ACP) is a central tenet of good dementia palliative care, as the person may lose their ability to communicate and make complex decisions over time. Despite this, care planning is often approached too late, and with the person's family rather than with the person; much of the literature on ACP in dementia is based on proxy decision-making for people in residential care. Thus, we need a paradigm shift in how we approach dementia, beginning with timely diagnosis that includes the dementia type, and with services able to assess and meet emotional and spiritual needs especially around the time of diagnosis, and with timely ACP as an integral part of our overall approach.

The last year of life for patients dying from cancer vs. non-cancer causes: a retrospective cross-sectional survey of bereaved relatives

PURPOSE

To compare health care experiences of patients with cancer or non-cancer diseases in their last year of life.

METHODS

A cross-sectional post-bereavement survey was conducted using an adapted German version of the VOICES questionnaire (VOICES-LYOL-Cologne). Differences in the reported experiences were assessed using a two-sided Pearson's chi-square test and Mann-Whitney U test.

RESULTS

We collected data from 351 bereaved relatives. More than half of non-cancer patients were not informed that their disease could lead to death (p < 0.001). When this was communicated, in 46.7% of non-cancer and 64.5% of cancer patients, it was reported by the hospital doctor (p = 0.050). In all, 66.9% of non-cancer and 41.6% of cancer patients were not informed about death being imminent (p < 0.001). On average, non-cancer patients had significantly fewer transitions and hospital stays in their last year of life (p = 0.014; p = 0.008, respectively). Non-cancer patients were treated more often by general practitioners, and cancer patients were treated more often by specialists (p = 0.002; p = 0.002, respectively). A substantially lower proportion of non-cancer patients were treated by at least one member of or in the setting of general or specialized palliative care (p < 0.001).

CONCLUSIONS

Non-cancer patients experience disadvantages in communication regarding their care and in access to specialized palliative care in their last year of life compared to cancer patients. Regarding the assessment of palliative care needs and the lack of communication of an incurable disease, non-cancer patients are underserved. An early identification of patients requiring palliative care is a major public health concern and should be addressed irrespective of diagnosis.

TRIAL REGISTRATION

Prospectively registered by the German Clinical Trials Register (DRKS00011925, data of registration: 13.06.2017).

End-stage organ disease-Healthcare utilisation: Impact of palliative medicine

OBJECTIVES

Although patients living with end-stage organ disease (ESOD) suffer unmet needs from the physical and emotional burdens of living with chronic illness, they are less likely to receive palliative care.The aims of the study were to determine if palliative care referrals reduced healthcare utilisation and if impact on healthcare utilisation was dependent on the timing of the referral.

METHODS

Patients with ESOD who received palliative care support were matched with those who did not using coarsened exact matching and propensity score matching, and compared in this retrospective cohort study. Primary outcomes of interests were reduction in all-cause emergency department (ED) visits and costs, reduction in all-cause tertiary hospital admissions, length of hospital stay and inpatient hospital costs.

RESULTS

Patients with ESOD referred to palliative care experienced a reduction in the frequency of all cause ED visits and inpatient hospital admissions. Significant impact of a palliative care referral was at 3 months, rather than 1 month prior to death with a greater reduction in the frequency of ED visits, inpatient hospital admissions, length of stay and charges (p all <0.05). The most common ESOD referred to palliative care for 1110 matched patients was end-stage renal failure (57.7%), and least commonly for respiratory failure (7.6%).

CONCLUSION

Palliative care can reduce healthcare utilisation, with reduction greatest when the referral is timed earlier in the disease trajectory. Cost savings can be judiciously redirected to the development of palliative care resources for integrated support of patients and caregivers.

Association between high cost user status and end-of-life care in hospitalized patients: A national cohort study of patients who die in hospital

BACKGROUND

Studies comparing end-of-life care between patients who are high cost users of the healthcare system compared to those who are not are lacking.

AIM

The objective of this study was to describe and measure the association between high cost user status and several health services outcomes for all adults in Canada who died in acute care, compared to non-high cost users and those without prior healthcare use.

SETTINGS AND PARTICIPANTS

We used administrative data for all adults who died in hospital in Canada between 2011 and 2015 to measure the odds of admission to the intensive care unit (ICU), receipt of invasive interventions, major surgery, and receipt of palliative care during the hospitalization in which the patient died. High cost users were defined as those in the top 10% of acute healthcare costs in the year prior to a person's hospitalization in which they died.

RESULTS

Among 252,648 people who died in hospital, 25,264 were high cost users (10%), 112,506 were non-high cost users (44.5%) and 114,878 had no prior acute care use (45.5%). After adjustment for age and sex, high cost user status was associated with a 14% increased odds of receiving an invasive intervention, a 15% increased odds of having major surgery, and an 8% lower odds of receiving palliative care compared to non-high cost users, but opposite when compared to patients without prior healthcare use.

CONCLUSIONS

Many patients receive aggressive elements of end-of-life care during the hospitalization in which they die and a substantial number do not receive palliative care. Understanding how this care differs between those who were previously high- and non-high cost users may provide an opportunity to improve end of life care for whom better care planning and provision ought to be an equal priority.

Community palliative care services on addressing physical and psychosocial needs in people with advanced illness: a prospective cohort study

BACKGROUND

The integration of palliative care into primary health care has been advocated to improve its accessibility and the continuity of care. Recent studies on such an approach have mainly focused on health care cost and utilization. This study aims to evaluate the effects of a community interdisciplinary palliative care program on the symptom experience of patients with advanced disease.

METHODS

A prospective cohort study was conducted. The Integrated Palliative Care Outcome Scale was used for monthly assessment to monitor their condition. Wilcoxon signed-rank test was used to examine changes in symptom experience across time.

RESULTS

Forty-eight patients with a predominance of cancer diagnoses, enrolled in the program. They reported anxiety, hardly feeling at peace, and neither receiving information as wanted nor being able to share their feeling with family/friends as more overwhelming than physical symptoms. Improvements in emotional symptoms was statistically significant at 1-month follow up (p < 0.001). Improvements in communication/practical issues were also significant at the 1-month (p < 0.001) and 2-month (p = 0.005) follow-up. However, changes in symptom experiences in the subsequent months were not apparent.

CONCLUSIONS

This study reveals the overwhelming emotional, communication and information needs among patients with advanced diseases and provides empirical evidence of the community palliative care program in short term. Further work is needed to strengthen the medical-social partnership to support care in place albeit health deterioration.

Symptom trajectories of non-cancer patients in the last six months of life: Identifying needs in a population-based home care cohort

INTRODUCTION

The end-of-life symptom prevalence of non-cancer patients have been described mostly in hospital and institutional settings. This study aims to describe the average symptom trajectories among non-cancer patients who are community-dwelling and used home care services at the end of life.

MATERIALS AND METHODS

This is a retrospective, population-based cohort study of non-cancer patients who used home care services in the last 6 months of life in Ontario, Canada, between 2007 and 2014. We linked the Resident Assessment Instrument for Home Care (RAI-HC) (standardized home care assessment tool) and the Discharge Abstract Databases (for hospital deaths). Patients were grouped into four non-cancer disease groups: cardiovascular, neurological, respiratory, and renal (not mutually exclusive). Our outcomes were the average prevalence of these outcomes, each week, across the last 6 months of life: uncontrolled moderate-severe pain as per the Pain Scale, presence of shortness of breath, mild-severe cognitive impairment as per the Cognitive Performance Scale, and presence of caregiver distress. We conducted a multivariate logistic regression to identify factors associated with having each outcome respectively, in the last 6 months.

RESULTS

A total of 20,773 non-cancer patient were included in our study, which were analyzed by disease groups: cardiovascular (n = 12,923); neurological (n = 6,935); respiratory (n = 6,357); and renal (n = 3,062). Roughly 80% of patients were > 75 years and half were female. In the last 6 months of life, moderate to severe pain was frequent in the cardiovascular (57.2%), neurological (42.7%), renal (61.0%) and respiratory (58.3%) patients. Patients with renal disease had significantly higher odds for reporting uncontrolled moderate to severe pain (odds ratio [OR] = 1.21; 95% CI: 1.08 to 1.34) than those who did not. Patients with respiratory disease reported significantly higher odds for shortness of breath (5.37; 95% CI, 5.00 to 5.80) versus those who did not. Patients with neurological disease compared to those without were 9.65 times more likely to experience impaired cognitive performance and had 56% higher odds of caregiver distress (OR = 1.56; 95% CI: 1.43 to 1.71).

DISCUSSION

In our cohort of non-cancer patients dying in the community, pain, shortness of breath, impaired cognitive function and caregiver distress are important symptoms to manage near the end of life even in non-institutional settings.