A population-based study on the specific locations of cancer deaths in Taiwan, 1997–2003

Hospital and Patient Characteristics Regarding the Place of Death of Hospitalized Impending Death Patients: A Multilevel Analysis

Objectives: To explore the influence of hospital and patient characteristics on deaths at home among inpatients facing impending death. Method: In this historical cohort study, 95,626 inpatients facing impending death from 362 hospitals in 2011 were recruited. The dependent variable was the place of death. The independent variables were the characteristics of the hospitals and the patients. A two-level hierarchical generalized linear model was used. Results: In total, 41.06% of subjects died at home. The hospital characteristics contributed to 29.25% of the total variation of the place of death. Private hospitals (odds ratio [OR] = 1.32, 95% confidence interval [CI] = 1.00–1.75), patients >65 years old (OR = 1.48, 95% CI. = 1.42–1.54), married (OR = 3.15, 95% CI. = 2.93–3.40) or widowed (OR = 3.39, 95% CI. = 3.12–3.67), from near-poor households (OR = 5.16, 95% CI. = 4.57–5.84), having diabetes mellitus (OR = 1.79, 95% CI. = 1.65–1.94), and living in a subcounty (OR = 2.27, 95% CI. = 2.16–2.38) were all risk factors for a death at home. Conclusion: Both hospital and patient characteristics have an effect of deaths at home among inpatients facing impending death. The value of the inpatient mortality rate as a major index of hospital accreditation should be interpreted intrinsically with the rate of deaths at home.

Factors associated with emergency services use in Taiwanese advanced cancer patients receiving palliative home care services during out-of-hours periods: a retrospective medical record study

Background

For patients receiving palliative home care, the need to visit the emergency department is considered to be an indicator of poor quality care. The situation can be particularly distressing when it occurs outside of normal hours of palliative home care service. The aim of this study was to investigate the factors for emergency department use during out-of-hours periods of palliative home care service among advanced cancer patients in Taiwan.

Methods

This case-control study was based on a retrospective medical chart review (January 2010 to December 2012) of advanced cancer patients who were receiving palliative home care in a community hospital in south Taiwan. The use of emergency medical services by these patients was dichotomized into either normal hours (8 a.m. to midnight, Monday to Friday, excluding public holidays) of palliative home care or outside normal hours. Logistic regression analyses were performed to evaluate factors associated with emergency services use during out-of-hours period of palliative home care.

Results: Of the 94 patients receiving palliative home care, 65 had used emergency services at least once during the 3-year study period. Of these 65 patients, 40% used emergency services during out-of-hours of palliative home care. Patients with distressing conditions (defined as the occurrence of any two conditions of dyspnea, change of consciousness, or gastrointestinal bleeding) were significantly more likely to use emergency services during out-of-hours of palliative home care.

Conclusions

Patients at risk of developing dyspnea, change of consciousness, or gastrointestinal bleeding should be provided with relevant information regarding these symptoms and signs.

Adult mortality in sub-saharan Africa, Zambia: Where do adults die?

Place of death remains an issue of growing interest and debate among scholars as an indicator of quality of end-of-life care in developed countries. In sub-Saharan Africa, however, variations in place of death may suggest inequalities in access to and the utilization of health care services that should be addressed by public health interventions. Limited research exists on factors associated with place of death in sub-Saharan Africa. The study examines factors associated with the place of death among Zambian adults aged 15–59 years using the 2010–2012 sample vital registration with verbal autopsy survey (SAVVY) data, descriptive statistics and multivariate logistic regression analysis. Results show that more than half of the adult deaths occurred in a health facility and two-fifths died at home. Higher educational attainment, urban versus rural residence, and being of female gender were significant predictors of the place of death. Improvement in educational attainment and investment in rural health facilities and the health care system as a whole may improve access and utilization of health services among adults.

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We examined factors associated with place of death among adults aged 15–59 in Zambia.

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Health facility remains the common place of death in Zambia followed by the deceased's home.

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High proportion of adults still dying at home indicates a lack of access to and the utilization of health care services.

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Educational attainment, sex, and urban-rural residence were strong predictors of the place of death.

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Variations in place of death by population background characteristics among adult decedents may suggest inequalities in access and utilization of health services.

Place of death in rural palliative care: A systematic review

BACKGROUND

There have been many studies on the actual and preferred place of care and death of palliative patients; however, most have been whole population surveys and/or urban focused. Data and preferences for terminally ill rural patients and their unofficial carers have not been systematically described.

AIM

To describe the actual place of death and preferred place of care and/or death in rural palliative care settings.

METHOD

A systematic mixed studies review using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

DATA SOURCE

PubMed, PsychINFO, Scopus and CINAHL databases were searched (September to December 2014); eligible quantitative and qualitative studies included preferred and/or actual place of death/care of rural, regional or remote residents; rural data that are clearly identifiable; death due to palliative condition (malignant and non-malignant) or survey of participants with current or hypothetical life-limiting illness.

RESULTS

A total of 25 studies described actual place of death; 12 preferred place of care or death (2 studies reported both); most deaths occurred in hospital with home as the preferred place of care/death; however qualitative studies suggest that preferences are not absolute; factors associated with place are not adequately described as rurality was an independent variable; significant heterogeneity (rural setting and participants), however, many areas had a greater chance of home death than in cities; rural data are embedded in population reports rather than from specific rural studies.

CONCLUSION

Home is the preferred place of rural death; however, more work is needed to explore influencing factors, absolute importance of preferences and experience of providing and receiving palliative care in rural hospitals which often function as substitute hospice.

The Changes of Ethical Dilemmas in Palliative Care. A Lesson Learned from Comparison Between 1998 and 2013 in Taiwan

The current ethical dilemmas met by healthcare professionals were never compared with those 15 years ago when the palliative care system was newly developing in Taiwan. The aim of the study was to investigate the ethical dilemmas met by palliative care physicians and nurses in 2013 and compare the results with the survey in 1998. This cross-sectional study surveyed 213 physicians and nurses recruited from 9 representative palliative care units across Taiwan in 2013. The compared survey in 1998 studied 102 physicians and nurses from the same palliative care units. All participants took a questionnaire to survey the "frequency" and "difficulty" of 20 frequently encountered ethical dilemmas, which were grouped into 4 domains by factor analysis. The "ethical dilemma" scores were calculated and then compared across 15 years by Student's t tests. A general linear model analysis was used to identify significant factors relating to a high average "ethical dilemma" score in each domain. All of the highest-ranking ethical dilemmas in 2013 were related to insufficient resources. Physicians with less clinical experience had a higher average "ethical dilemma" score in clinical management. Physicians with dissatisfaction in providing palliative care were associated a higher average "ethical dilemma" score in communication. Nurses reported higher "ethical dilemma" scores in all items of resource allocation in 2013. Further analysis confirmed that, in 2013, nurses had a higher average "ethical dilemma" score in resource allocation after adjustment for other relating factors. Palliative care nursing staff in Taiwan are more troubled by ethical dilemmas related to insufficient resources than they were 15 years ago. Training of decision making in nurses under the framework of ethical principles and community palliative care programs may improve the problems. To promote the dignity of terminal cancer patients, long-term fundraising plans are recommended for countries in which the palliative care system is in its early stages of development.

Patterns in place of cancer death in the State of Qatar: a population-based study

Background

International studies show that most people prefer to die at home; however, hospitals remain the most common place of death (PoD). This study aims to investigate the patterns in PoD and the associated factors, which are crucial for end-of-life cancer care enhancement.

Method

This retrospective, population-based study analyzed all registered cancer deaths in Qatar between January 1, 2006 and December 31, 2012 (n = 1,224). The main outcome measures were patient characteristics: age, gender, nationality, cancer diagnosis, year of death, and PoD. Time trends for age-standardized proportions of death in individual PoDs were evaluated using chi-square analysis. Odds ratio (OR) were determined for variables associated with the most preferred (acute palliative care unit [APCU] and hematology/oncology ward) versus least preferred (ICU and general medicine ward) PoDs in Qatar, stratified by nationality.

Results

The hematology/oncology ward was the most common PoD (32.4%; 95% CI 26.7–35.3%) followed by ICU (31.4%; 95% CI 28.7–34.3%), APCU (26.9%; 95% CI 24.3–29.6%), and general medicine ward (9.2%; 95% CI 7.6–11.1%). APCU trended upward (+0.057/year; p<0.001), while the hematology/oncology ward trended downward (−0.055/year; p<0.001). No statistically significant changes occurred in the other PoDs; home deaths remained low (0.4%; 95% Cl 0.38–0.42). Qataris who died from liver cancer (OR 0.23) and aged 65 or older (OR 0.64) were less likely to die in the APCU or hematology/oncology ward (p<0.05). Non-Qataris who died from pancreatic cancer (OR 3.12) and female (OR 2.05) were more likely to die in the APCU or hematology/oncology ward (p<0.05). Both Qataris and non-Qataris who died from hematologic malignancy (OR 0.18 and 0.41, respectively) were more likely to die in the ICU or general medicine ward (p<0.05).

Conclusion

A high percentage of cancer deaths in Qatar occur in hospital. As home was the preferred PoD for most people, effective home care and hospice programs are needed to improve end-of-life cancer care.

Factors affecting the place of death among hospice home care cancer patients in Taiwan

BACKGROUND

Some patients who receive hospice home care still end up dying in hospital. The significance of the variables possibly affecting the place of death in patients with terminal cancer who received hospice home care was examined.

METHODS

Retrospective study.

RESULTS

Four hundred and thirty-nine patients were enrolled in this study. In all, 60.8% of the patients died at home and 39.2% of the patients died in hospital. Multiple logistic regression analysis revealed that preferred place of death was the prior factor associated with home death, followed by average days of rehospitalization, education level, distance between home and hospital, and age.

CONCLUSIONS

For a better hospice care service, it is essential to inquire patients or their relatives on preferred place of death while concerning the influences of other factors.

Impact of availability of an inpatient hospice unit on the parent hospital's quality of palliative care for Taiwanese cancer decedents, 2001-2006

CONTEXT

Hospice care has increasingly been shown to affect quality of palliative care at both the individual and institutional levels. However, an institutional effect has only been addressed in single comprehensive cancer centers/selected community hospitals.

OBJECTIVES

To investigate the impact of an inpatient hospice unit on the parent hospital's quality of palliative care.

METHODS

This was a retrospective cohort study using administrative data from the entire population of 204,850 Taiwanese pediatric and adult cancer patients who died in 2001-2006. Outcome variables were adjusted by multivariate logistic regression for five groups of confounding variables: 1) patient demographics and disease characteristics, 2) primary hospital characteristics, 3) primary physician specialty, 4) health care resources at the hospital and regional levels, and 5) historical trend.

RESULTS

Taiwanese cancer patients who received primary care in a hospital with an inpatient hospice unit (whether or not they received hospice care) were significantly less likely to be intubated (adjusted odds ratio [AOR]: 0.71; 95% confidence interval [CI]: 0.58, 0.86) and use mechanical ventilation support (AOR: 0.70; 95% CI: 0.56, 0.87) in their last month of life. They also were more likely to use hospice care before death (AOR: 3.51; 95% CI: 1.57, 7.86). Furthermore, if they used hospice care, they tended to be referred earlier than cancer patients being cared for in a hospital without an inpatient hospice unit.

CONCLUSION

Integrating both acute care and palliative care approaches to caring for terminally ill cancer patients in the same hospital may influence the quality of palliative care throughout the hospital as evidenced by our findings that these patients have lower likelihood of being intubated with mechanical ventilation support in the last month of life, greater propensity to receive hospice care in the last year of life, and a trend toward earlier referral to hospice care. The generalizability of these results may be limited to patients who died of a noncancer cause and by the two groups not being exactly matched for patients' characteristics.

Propensity for home death among Taiwanese cancer decedents in 2001-2006, determined by services received at end of life

CONTEXT

The discrepancy between patients' preferred and actual place of death highlights the dilemma inherent in achieving their preferences for home death. Research on determinants of home death has been limited largely by focusing on individual-level factors and somewhat on health care resources at the primary hospital and regional levels.

OBJECTIVES

To investigate factors associated with home death, specifically, services received by cancer patients at the end of life (EOL).

METHODS

This was a retrospective cohort study using administrative data from 201,201 Taiwanese cancer decedents in the period 2001-2006.

RESULTS

Rates of home death decreased significantly over time (from 35.67% to 32.39%). Dying at home was associated with patient demographics (gender, age, and marital status) and disease characteristics (cancer type, metastatic status, postdiagnosis survival time, and comorbidity level). Taiwanese cancer patients were less likely to die at home if they received care from a medical oncologist and in hospitals or regions with abundant health care resources. Furthermore, Taiwanese cancer patients were less likely to die at home if they used life-sustaining treatments (intensive care unit care, cardiopulmonary resuscitation, intubation, and mechanical ventilation) in the last month of life. However, multiple emergency room visits in the last month of life and receiving hospice care increased Taiwanese cancer patients' propensity to die at home.

CONCLUSION

Despite the causal ambiguity in interpreting our research findings, they indicate that using life-sustaining treatments at EOL not only exacts a substantial toll from patients, family members, and society, but also decreases the likelihood of dying at home.

Destined to die in hospital? Systematic review and meta-analysis of place of death in haematological malignancy

Background

Haematological malignancies are a common, heterogeneous and complex group of diseases that are often associated with poor outcomes despite intensive treatment. Research surrounding end-of-life issues, and particularly place of death, is therefore of paramount importance, yet place of death has not been formally reviewed in these patients.

Methods

A systematic literature review and meta-analysis was undertaken using PubMed to identify all studies published between 1966 and 2010. Studies examining place of death in adult haematology patients, using routinely compiled morbidity and mortality data and providing results specific to this disease were included. 21 studies were identified with descriptive and/or risk-estimate data; 17 were included in a meta-analysis.

Results

Compared to other cancer deaths, haematology patients were more than twice as likely to die in hospital (Odds Ratio 2.25 [95% Confidence Intervals, 2.07-2.44]).

Conclusion

Home is generally considered the preferred place of death but haematology patients usually die in hospital. This has implications for patients who may not be dying where they wish, and also health commissioners who may be funding costly end-of-life care in inappropriate acute hospital settings. More research is needed about preferred place of care for haematology patients, reasons for hospital deaths, and how these can be avoided if home death is preferred.

Prevailing Ethical Dilemmas in Terminal Care for Patients With Cancer in Taiwan

Purpose

The study aimed to investigate prevailing ethical dilemmas in terminal care for patients with cancer nationwide and identify related factors after the enactment of the Natural Death Act in Taiwan.

Methods

This multicenter study surveyed 800 physicians and nursing staff of oncology wards and hospices through a set questionnaire. A total of 505 respondents (63.1%) who had taken care of patients with terminal cancer were analyzed.

Results

The most frequently encountered ethical dilemmas were truth-telling (mean ± SD = 1.30 ± 0.63; range [never, occasional, often], 0 to 2) and place of care (1.19 ± 0.69), both of which were related to communication issues. Dilemmas related to clinical management were artificial nutrition and hydration (1.04 ± 0.66) and use of antimicrobial agents (0.94 ± 0.70). Logistic regression analyses revealed that positive attitudes about the Natural Death Act was negatively related to the extent of ethical dilemmas (odds ratio, 0.426; 95% CI, 0.256 to 0.710].

Conclusion

The enactment of the Natural Death Act in Taiwan would contribute to improving the quality of end-of-life care, which suggests that this kind of law should be adopted in other countries. Educating cancer care professionals in building positive beliefs toward the act is strongly encouraged.

A longitudinal study of the role of patient-reported outcomes on survival prediction of palliative cancer inpatients in Taiwan

GOALS OF WORK

This study explores the significance of patient-reported outcomes for predicting length of survival of palliative cancer patients.

PATIENTS AND METHODS

Patients were recruited upon admission to the inpatient palliative care unit. Weekly assessment of 180 terminal cancer patients was carried out throughout their survival time using the Medical Outcome Study 36-Item Short-Form Health Survey, the Taiwanese version of the M.D. Anderson Symptom Inventory (MDASI-T), the Karnofsky Performance Status (KPS), the Brief Pain Inventory, and the Brief Fatigue Inventory. Generalized estimating equations (GEE) were utilized to analyze whether the patient-reported outcomes predicted survival time.

MAIN RESULTS

Of all patients, 64 had one assessment, 51 had two, 25 had three, and 40 had four or more assessments, up to a maximum of eight. The univariate analysis showed that gender (P < 0.01), KPS (P < 0.01), the physical component summary score (P = 0.02), the MDASI-T total score (P < 0.01), composite fatigue severity (P < 0.01), and composite pain severity (P < 0.01) were significantly associated with length of survival. The multivariate analysis showed that gender (P < 0.01), KPS (P < 0.01), and the MDASI-T total score (P = 0.01) were significant predictors of survival time.

CONCLUSIONS

This is the first study to explore the significance of patient-related outcomes for predicting length of survival of palliative cancer patients using the GEE method. This study confirms that overall symptom severity is a significant factor in assessing the length of survival of palliative cancer patients.

Trends in quality of end-of-life care for Taiwanese cancer patients who died in 2000-2006

BACKGROUND

Quality of end-of-life care received by cancer patients has never been explored in an entire Asian country for all ages and cancer groups.

PATIENTS AND METHODS

Retrospective cohort study to examine trends in quality of end-of-life care among a cohort of 242 530 Taiwanese cancer patients who died in 2000-2006.

RESULTS

In the last month of life, cancer care tended to become increasingly aggressive as shown by (i) intensive use of chemotherapy (15.45%-17.28%), (ii) frequent emergency room visits (15.69%-20.99%) and >14-day hospital stays (41.48%-46.20%), (iii) admissions to intensive care units (10.04%-12.41%), and (iv) hospital deaths (59.11%-65.40%). Use of cardiopulmonary resuscitation (13.09%-8.41%), intubation (26.01%-21.07%), and mechanical ventilation (27.46%-27.05%) decreased, whereas use of hospice services increased considerably (7.34%-16.83%). Among those receiving hospice services, rates of referrals to hospice services in the last 3 days of life decreased from 17.88% to 17.13% but remained steady after adjusting for selected covariates.

CONCLUSIONS

The quality of end-of-life care for Taiwanese cancer decedents was substantially inferior to that previously reported and to that recommended as benchmarks for not providing overly aggressive care near the end of life.