Transferring home to die from critical care units: A scoping review of international practices

Characteristics, Outcomes and Factors for Place of Death in Patients Admitted to Community-Based Palliative Care Services in Shanghai China: A Multicenter Retrospective Cohort Study

Background

Community-based palliative care (CBPC) is only available in large cities in mainland China and little is known about who utilizes it.

Objectives

This study examined the characteristics, outcomes, and factors associated with place of death (PoD) among inpatient CBPC patients.

Design

This was a multicenter retrospective cohort study.

Settings/Subjects

All patients admitted to the inpatient CBPC unit in four community health centers in 2021 in Shanghai, China, were included.

Methods

Characteristics and outcome data were extracted from electronic health records and paper version notes between September 4 and December 29, 2022. PoD was followed up on May 12, 2023. Data were analyzed using descriptive analysis and categorized using two-step clustering. Decision tree analysis was used to identify factors associated with PoD.

Results

The cohort admitted in 2021 included 290 participants (Age: 75.7 ± 12.7 years; Male: n = 155, 53.4%) including two children, with a mortality rate of 59.0% and a median length of stay (LoS) of 14 days upon December 29, 2022. The primary diagnosis for 80.3% of participants was tumor. Two clusters were identified. Cluster 1 was smaller than Cluster 2 (n = 45, 15.5% vs. n = 245, 84.5%) and dominated by noncancer participants (n = 37, 82.2%), whereas Cluster 2 included 91.8% (n = 225) tumor patients. Greatest significant differences in age, sex, marital status, education level, awareness of diagnosis and/or prognosis, mortality, LoS, and costs were found between the clusters. In total, 265 deaths derived from the cohort upon May 12, 2023, occur in inpatient CBPC units (75.5%), at home (18.9%), and in hospital wards (5.7%), influenced largely by participants' marital status and age.

Conclusions

Establishing contextualized inpatient CBPC services in more places nationwide that are tailored to different characteristics between cancer patients (i.e., younger and shorter inpatient stay) and noncancer patients (i.e., older and longer stay) is essential to maintain that more dying patients remain in their community.

Trends and Changes in Intensive Care Use for Patients With Heart Failure in the Last Month of Life

A good death is a human right. Unfortunately, patients with chronic heart failure (CHF) in the terminal stage still receive inappropriate life-sustaining treatment before death. There is limited understanding of the status of intensive care unit (ICU) admission, mechanical ventilation (MV), cardiopulmonary resuscitation (CPR), and even extracorporeal membrane oxygenation (ECMO) for patients with CHF before death, as well as their use of hospice-related services. This study investigated the trends and trend changes in intensive procedures and hospice-related services for patients with CHF in the last month of life. This population-based retrospective observational study included 25 375 patients with CHF from the National Health Insurance research database in Taiwan and collected information on their intensive treatments during the last month of life. We computed intensive treatment utilization rates and analyzed the trends and trend changes via joinpoint regression. The average percentage of patients with CHF admitted to ICUs was 53.27% (n = 13 516). A total of 327 (1.29%) patients with CHF received ECMO. The percentages of patients receiving MV (54.3%'41.5%) and CPR (41.5%'17%) decreased over time. Conversely, the percentage of ECMO use (0.52%'1.78%) increased. However, only 222 (0.87%) patients with CHF received hospice care in the last month of life between 2001 and 2013. The rates of ICU admission and life-sustaining treatment among patients with CHF in the month before death remain high, and hospice-related services remain inadequate. This study highlights the need for research and training in providing palliative and hospice care for patients with CHF.

The decision-making process of transferring patients home to die from an intensive care unit in mainland China: A qualitative study of family members' experiences

OBJECTIVES

To map the decision-making process of family members involved in transferring a critically ill patient home to die from an intensive care unit in mainland China and to explore the experiences of those family members.

DESIGN

A constructivist qualitative study.

SETTING

One hospitals intensive care unit in Southeast China.

METHODS

Thirteen adult family members (of ten patients) who participated in decision-making related to transferring a relative home to die from the intensive care unit were purposively selected. Data were collected via interviews and analysed applying thematic analysis.

FINDINGS

A two-stage decision-making process was identified. Family decision-making was mediated by factors including: accepting the impending death and hope that the patient would not die; time pressures in which decisions had to be made, and the challenges of meeting cultural expectations of a home death. Transfer home was a family-centred decision constrained by a gender-based hierarchy restricting the involvement of different family members.

CONCLUSION

The stages and key factors in the decision-making process of family members when involved in transferring a patient home to die from an intensive care unit in China are rooted and informed by cultural expectations and limits in the current healthcare system regarding end-of-life care options. Understanding the climate in which family members must make decisions will facilitate supportive interventions to be implemented by healthcare professionals. Further empirical research is needed to explore family members' needs when the patient has been transferred and dies at home in mainland China.

IMPLICATIONS FOR CLINICAL PRACTICE

Healthcare professionals need to understand the challenges family members face when deciding to transfer a relative home to die from an intensive care unit. For example time pressures can limit the choices of family members so that to provide them with timely, ongoing, realistic updates for a greater involvement of family members in generating end of life care plans could be beneficial.¹.