Life sustaining treatment at end-of-life in Japan: Do the perspectives of the general public reflect those of the bereaved of patients who had died in hospitals?

What is the evidence that people with frailty have needs for palliative care at the end of life? A systematic review and narrative synthesis

BACKGROUND

The number of older people living and dying with frailty is rising, but our understanding of their end-of-life care needs is limited.

AIM

To synthesise evidence on the end-of-life care needs of people with frailty.

DESIGN

Systematic review of literature and narrative synthesis. Protocol registered prospectively with PROSPERO (CRD42016049506).

DATA SOURCES

Fourteen electronic databases (CINAHL, Cochrane, Embase, EThOS, Google, Medline, NDLTD, NHS Evidence, NICE, Open grey, Psychinfo, SCIE, SCOPUS and Web of Science) searched from inception to October 2017 and supplemented with bibliographic screening and reference chaining. Studies were included if they used an explicit definition or measure of frailty. Quality was assessed using the National Institute for Health tool for observational studies.

RESULTS

A total of 4,998 articles were retrieved. Twenty met the inclusion criteria, providing evidence from 92,448 individuals (18,698 with frailty) across seven countries. Thirteen different measures or definitions of frailty were used. People with frailty experience pain and emotional distress at levels similar to people with cancer and also report a range of physical and psychosocial needs, including weakness and anxiety. Functional support needs were high and were highest where people with frailty were cognitively impaired. Individuals with frailty often expressed a preference for reduced intervention, but these preferences were not always observed at critical phases of care.

CONCLUSION

People with frailty have varied physical and psychosocial needs at the end of life that may benefit from palliative care. Frailty services should be tailored to patient and family needs and preferences at the end of life.

Decreasing Use of Percutaneous Endoscopic Gastrostomy Tube Feeding in Japan

OBJECTIVES

To identify trends in percutaneous endoscopic gastrostomy (PEG) tube placement and intravenous hyperalimentation (IVH) in nonhospital settings (as a potential alternative to tube feeding for nutrition) and to summarize published reports concerning the decision-making process for PEG placement.

DESIGN

National survey and systematic review.

SETTING

Japan.

PARTICIPANTS

All Japanese people.

MEASUREMENTS

Data on numbers of individuals with a PEG tube and IVH were obtained from the website of the Japanese Ministry of Health, Labour, and Welfare and published reports concerning the decision-making process for PEG placement in Japan were summarized.

RESULTS

The number of PEG tube placements peaked in 2007 and has been decreasing since Japan experienced the Great East Japan Earthquake in 2011. A further decline was seen in 2015 after the Japanese Ministry of Health, Labour and Welfare revised the fee schedule in 2014. More than half of individuals who had tubes were aged 80 and older during the years observed. In contrast, the number of individuals receiving IVH was lowest in the same year as PEG tube placement peaked and has been increasing ever since. Four studies reported that the decision-making process included consideration of not only the underlying disease, but also the individual's age and social barriers and the physician's personal philosophy.

CONCLUSION

The number of PEG tube placements has been decreasing since its peak in 2007, and the number of individuals receiving IVH has been increasing. Many factors influence the decision-making process for PEG tube placement. Physicians in Japan may be realizing that there is little evidence to support the use of tube feeding in frail elderly adults.

Continuing or forgoing treatment at the end of life? Preferences of the general public and people with an advance directive

BACKGROUND

We studied preferences on continuing or forgoing different types of treatments at the end of life in two groups: the general public and people with an advance directive (AD). Furthermore, we studied factors associated with these preferences and whether people's preferences concurred with the content of their AD.

METHODS

A representative sample of the Dutch population (n=1402) and a cohort of people who own an AD, consisting of members of Right to Die-NL (NVVE, n=5661) and the Christian-orientated Nederlandse Patiënten Vereniging (NPV, n=1059), answered written questionnaires in 2005 or 2007. We used two hypothetical scenarios, about cancer and dementia, and asked questions about continuing or forgoing four medical treatments.

RESULTS

A majority of the Dutch public (62-87%) and NVVE members (88-99%) wanted to forgo the different treatments in both scenarios, while members of the NPV generally wanted to continue treatment (46-73%). In all three groups, in both scenarios, a substantial group (13-38%) had different preferences for the different treatments. People were more explicit in their preferences in case of dementia than in case of cancer. Being female, over 55 years of age, having had a higher education and having no (significant) religion increased the odds to refuse treatment. ADs that gave the direction to refuse treatment generally concurred with the preference of their owners (85-98% wanting to refuse treatments).

DISCUSSION

The fact that people with and without ADs have different preferences concerning different treatments and diseases stresses the importance of communication surrounding decision making at the end of life.

Good end-of-life care: perspectives of middle-aged and older Singaporeans

CONTEXT

Understanding preferences for end-of-life care is important for planning and improving services that provide such care. However, little is known about the perspective of Singaporeans regarding good end-of-life care.

OBJECTIVES

To identify the key components of good end-of-life care as perceived by middle-aged and older Singaporeans (≥50 years).

METHODS

Nine focus groups were conducted with a total of 63 participants. Preferences regarding end-of-life care were discussed. Thematic analysis was conducted on the transcribed results of the focus groups.

RESULTS

Eight components of good end-of-life care were identified: 1) have physical comfort at the end of life, 2) avoid inappropriate prolongation of the dying process, 3) maintain sensitivity toward religious and spiritual beliefs, 4) avoid burden on the family, 5) avoid expensive care, 6) be cared for by a trustworthy doctor, 7) maintain control over care decisions, and 8) achieve a sense of completion.

CONCLUSION

Eight components of good end-of-life care involving the person, family, and health services were identified among middle-aged and older Singaporeans. A focus on better management of pain, training of caregivers and doctors, shared decision making, and availability of affordable care may improve care at the end of life.

Predictors of dying at home for patients receiving nursing services in Japan: A retrospective study comparing cancer and non-cancer deaths

Background

The combined effects of the patient's and the family's preferences for death at home have in determining the actual site of death has not been fully investigated. We explored this issue on patients who had been receiving end-of-life care from Visiting Nurse Stations (VNS). In Japan, it has been the government's policy to promote end-of-life care at home by expanding the use of VNS services.

Methods

A retrospective national survey of a random sample of 2,000 out of the 5,224 VNS was made in January 2005. Questionnaires were mailed to VNS asking the respondents to fill in the questionnaire for each patient who had died either at home or at the hospital from July to December of 2004. Logistic regression analysis was respectively carried out to examine the factors related to dying at home for cancer and non-cancer patients.

Results

We obtained valid responses from 1,016 VNS (50.8%). The total number of patients who had died in the selected period was 4,175 (cancer: 1,664; non-cancer: 2,511). Compared to cancer patients, non-cancer patients were older and had more impairment in activities of daily living (ADL) and cognitive performance, and a longer duration of care. The factor having the greatest impact for dying at home was that of both the patient and the family expressing such preferences [cancer: OR (95% CI) = 57.00 (38.79-83.76); non-cancer: OR (95% CI) = 12.33 (9.51-15.99)]. The Odds ratio was greater compared with cases in which only the family had expressed such a preference and in which only the patient had expressed such a preference. ADL or cognitive impairment and the fact that their physician was based at a clinic, and not at a hospital, had modest effects on dying at home.

Conclusions

Dying at home was more likely when both the patient and the family had expressed such preferences, than when the patient alone or the family alone had done so, in both cancer and non-cancer patients. Health care professionals should try to elicit the patient's and family's preferences on where they would wish to die, following which they should then take appropriate measures to achieve this outcome.