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Wang XJ, Cornell PY, Belanger E, Thomas KS. Do end-of-life outcomes differ by assisted living memory-care designation? J Am Geriatr Soc 2024. [PMID: 38567799 DOI: 10.1111/jgs.18899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 02/12/2024] [Accepted: 03/04/2024] [Indexed: 04/24/2024]
Abstract
BACKGROUND Residential care/assisted living (RC/AL) is an increasingly common place of end-of-life care for persons with Alzheimer's disease and related dementia (ADRD), who have unique care needs as their health declines. Approximately 22% of RC/ALs provide specialized memory care (memory-care RC/AL). Understanding how end-of-life outcomes differ by memory care among residents with ADRD could facilitate aging/dying in place for this population. The objective of this paper is to examine if end-of-life outcomes (i.e., mortality, hospice use, and number of days receiving hospice in the last month of life) differ between residents with ADRD who moved to memory-care RC/AL, compared with residents with ADRD who moved to RC/AL without memory care (general RC/AL). METHODS Prospective cohort of 15,152 fee-for-service Medicare beneficiaries with ADRD who moved to large RC/AL (> = 25 beds) between 2016 and 2018. We used inverse probability treatment weighting to account for observable differences between memory-care and general RC/AL residents. Two-part models estimated the difference by memory care in the number of days receiving hospice care in the last months of life among RC/AL decedents. RESULTS The unadjusted mortality rates were 13.4% in general RC/AL and 15.8% in memory-care RC/AL with an adjusted difference of 1.3 percentage points higher mortality among memory-care RC/AL residents (p = 0.04). Hospice use was 8% and 10.6% among general and memory-care RC/AL residents, respectively, with an adjusted difference of 1.4 percentage points (p = 0.01) higher in memory care. Two-part models showed that decedents in memory-care RC/AL spent about 1.4 more days receiving hospice care in the last month of life (p = 0.02). CONCLUSION We find a higher mortality rate and higher rate of hospice use among memory-care RC/AL residents. These findings suggest that memory care may attract residents closer to the end of life and/or promote hospice use at the end of life.
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Affiliation(s)
- Xiao Joyce Wang
- Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Portia Y Cornell
- Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
- Centre for the Digital Transformation of Health/Centre for Health Policy, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Emmanuelle Belanger
- Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Kali S Thomas
- Center for Equity in Aging, Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
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Menchik DA, Giaquinta M. The words we die by. Soc Sci Med 2024; 340:116470. [PMID: 38091852 DOI: 10.1016/j.socscimed.2023.116470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 11/21/2023] [Accepted: 11/25/2023] [Indexed: 01/23/2024]
Abstract
Hospice is a venue organized to provide a "good death" for patients and family. Since many hospice patients are bedridden and often incoherent or unconscious, many of this venue's interactions take place between hospice professionals and patients' families. The families of patients desire definitive prognoses because knowing what to expect can help them decide how to act, but for professionals such knowledge is characterized by doubt. In light of their needs, how then do hospice professionals use language to achieve and maintain the family's buy-in? Drawing on eight months of observation in Hospice House Interdisciplinary Team (IDT) meetings, we analyze the verbal interactions between hospice professionals and patients' families, focusing in particular on registers of prognosis, to better understand how hospice professionals use language to manage family expectations. In order to accomplish this goal central to their occupational project, hospice professionals use future grammars, primarily comprising predictive and subjunctive verbs. Imperative verbs are rarely used. We refine the enactive perspective on authoritativeness by identifying some linguistic components that mediate authority's efficacy in a venue where emotion management is central to professional work. Paying attention to the uses of these linguistic registers helps us further understand some everyday ways that death is organized, and in general, may offer a richer understanding of death itself.
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Affiliation(s)
- Daniel A Menchik
- School of Sociology, 1145 E. South Campus Drive, University of Arizona, Tucson, AZ, 85721, USA.
| | - Maya Giaquinta
- Medical College of Wisconsin, Department of Pediatrics, Children's Corporate Center, 999 N. 92nd St., Milwaukee, WI, 53226, USA
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Wladkowski SP, Enguídanos S. Alzheimer's Disease and Related Dementias: Caregiver Perspectives on Hospice Re-Enrollment Following a Hospice Live Discharge. J Palliat Med 2023; 26:1374-1379. [PMID: 37155702 DOI: 10.1089/jpm.2023.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Background: The number of individuals dying of Alzheimer's disease and related dementias (ADRDs) is steadily increasing and they represent the largest group of hospice enrollees. In 2020, 15.4% of hospice patients across the United States were discharged alive from hospice care, with 5.6% decertified due to being "no longer terminally ill." A live discharge from hospice care can disrupt care continuity, increase hospitalizations and emergency room visits, and reduce the quality of life for patients and families. Furthermore, this discontinuity may impede re-enrollment into hospice services and receipt of community bereavement services. Objectives: The aim of this study is to explore the perspectives of caregivers of adults with ADRDs around hospice re-enrollment following a live discharge from hospice. Design: We conducted semistructured interviews of caregivers of adults with ADRDs who experienced a live discharge from hospice (n = 24). Thematic analysis was used to analyze data. Results: Three-quarters of participants (n = 16) would consider re-enrolling their loved one in hospice. However, some believed they would have to wait for a medical crisis (n = 6) to re-enroll, while others (n = 10) questioned the appropriateness of hospice for patients with ADRDs if they cannot remain in hospice care until death. Conclusions: A live discharge for ADRD patients impacts caregivers' decisions on whether they will choose to re-enroll a patient who has been discharged alive from hospice. Further research and support of caregivers through the discharge process are necessary to ensure that patients and their caregivers remain connected to hospice agencies postdischarge.
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Affiliation(s)
| | - Susan Enguídanos
- USC Leonard Davis School of Gerontology, Los Angeles, California, USA
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Cross SH, Kavalieratos D. Public Health and Palliative Care. Clin Geriatr Med 2023; 39:395-406. [PMID: 37385691 PMCID: PMC10571066 DOI: 10.1016/j.cger.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Meeting the needs of people at the end of life (EOL) is a public health (PH) concern, yet a PH approach has not been widely applied to EOL care. The design of hospice in the United States, with its focus on cost containment, has resulted in disparities in EOL care use and quality. Individuals with non-cancer diagnoses, minoritized individuals, individuals of lower socioeconomic status, and those who do not yet qualify for hospice are particularly disadvantaged by the existing hospice policy. New models of palliative care (both hospice and non-hospice) are needed to equitably address the burden of suffering from a serious illness.
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Affiliation(s)
- Sarah H Cross
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, 1518 Clifton Road Northeast, Atlanta, GA 30322, USA.
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, 1518 Clifton Road Northeast, Atlanta, GA 30322, USA
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Gianattasio KZ, Power MC, Lupu D, Prather C, Moghtaderi A. Medicare Hospice Policy Changes and Beneficiaries' Rate of Live Discharge and Length-of-Stay. J Pain Symptom Manage 2023; 65:162-172. [PMID: 36526252 PMCID: PMC9928899 DOI: 10.1016/j.jpainsymman.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/18/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022]
Abstract
CONTEXT The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act systemized audits of long hospice stays, and the 2016 two-tier payment system decreased daily reimbursement rates after 60 days of enrollment. Both aimed to reduce long stays. OBJECTIVES Examine how live discharge rates and length of stay changed in relation to the policies. METHODS We computed monthly hospice-level percent live discharges and length of stay using 2008-2019 Medicare hospice claims. We compared prepolicies trends and postpolicies trends overall, within Alzheimer's disease and related dementias (ADRD) patients, within lung cancer patients, and stratified by hospice ownership (for-profit vs. nonprofit/government-owned). RESULTS We included 10,539,912 and 10,453,025 episodes of care in the analytical samples for live discharge and length of stay analyses, respectively. Overall percent live discharges declined during the prepolicies period (-0.13 percentage-points per month, 95% CI: -0.14, -0.12), but exhibited no significant change during the postpolicies period. Trends were driven primarily by for-profits, with similar patterns within ADRD and lung cancer patients. Overall, mean length of stay increased over time, with greater rate of increase during the postpolicies period (0.41 days per month, 95% CI: 0.39, 0.42) compared to the prepolicies period (0.12 days per month, 95% CI: 0.10, 0.14). Length-of-stay increased faster among ADRD patients, but changed minimally for lung cancer patients. CONCLUSION Live discharge rates declined significantly during the prepolicies period, but plateaued after implementation of the policies, driven by changes in for-profits. However, the policies did not reduce length of stay, which increased at faster rates, suggesting that postpolicies excess live discharges were not restricted to long-stay patients.
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Affiliation(s)
- Kan Z Gianattasio
- Department of Health Policy and Management (K.Z.G., A.M.), George Washington University Milken Institute School of Public Health, Washington, DC; Department of Health Care Evaluation (K.Z.G.), NORC at the University of Chicago, Bethesda, Maryland.
| | - Melinda C Power
- Department of Epidemiology (M.C.P.), George Washington University Milken Institute School of Public Health, Washington, DC
| | - Dale Lupu
- George Washington University School of Nursing (D.L.), Washington, DC
| | - Christina Prather
- Division of Geriatrics and Palliative Medicine (C.P.), George Washington School of Medicine and Health Sciences, Washington, DC
| | - Ali Moghtaderi
- Department of Health Policy and Management (K.Z.G., A.M.), George Washington University Milken Institute School of Public Health, Washington, DC
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Patra L, Ghoshal A, Damani A, Salins N. Cancer palliative care referral: patients' and family caregivers' perspectives - a systematic review. BMJ Support Palliat Care 2022:spcare-2022-003990. [PMID: 36328397 DOI: 10.1136/spcare-2022-003990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Despite the evidence of palliative care benefits, referrals are infrequent and delayed. Patients and their caregivers are essential stakeholders in the referral process with valuable perspectives. This review systematically explored their perceived facilitators and barriers to palliative care referral. METHODS 4 subject-specific databases (PubMed, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and EMBASE), 3 multidisciplinary databases (SCOPUS, Web of Science and Cochrane database) and 11 journals from 1 January 1990 to 31 May 2022 were searched; and scored for their methodological rigour using Hawker's tool. Findings were synthesised using Popay's Narrative Synthesis method and interpreted using decision-making theory. RESULTS 4 themes were generated from 14 studies: (1) The timing of referral should be right and communication must be comprehensive. Delays in initiating serious illness conversations, prognostication, and decision-making hindered referral. In contrast, the presence of symptoms facilitated it. (2) Referral was equated to death, and as an inferior form of treatment, a rebranding might mitigate the stigma. (3) Referral made families feel emotional and devastated; explanation and team initiatives enabled the normalisation and positive coping. (4) Long-term holistic palliative care facilitated a positive care experience and a sense of reassurance and satisfaction, enabling a smooth transition from curative to comfort care. The late referral was associated with perceived inadequate symptom management, diminished quality of life and death and complicated bereavement issues. CONCLUSION Patients' and caregivers' predisposition to palliative care engagement was influenced by timely referral, comprehensive communication, perception and stigma about palliative care. Longitudinal association with the palliative care team mitigated negative perceptions and improved satisfaction and coping. PROSPERO REGISTRATION NUMBER CRD42018091481.
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Affiliation(s)
- Lipika Patra
- Bagchi-Karunashraya Palliative Care Centre, Bangalore Hospice Trust, Bhubaneswar, India
| | | | - Anuja Damani
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Wachterman MW, Corneau EE, O’Hare AM, Keating NL, Mor V. Association of Hospice Payer With Concurrent Receipt of Hospice and Dialysis Among US Veterans With End-stage Kidney Disease: A Retrospective Analysis of a National Cohort. JAMA HEALTH FORUM 2022; 3:e223708. [PMID: 36269338 PMCID: PMC9587478 DOI: 10.1001/jamahealthforum.2022.3708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Abstract
Importance For many patients with end-stage kidney disease (ESKD), the Medicare Hospice Benefit precludes concurrent receipt of hospice and dialysis services, forcing patients to choose between continuing dialysis or enrolling in hospice. Whether the more liberal hospice eligibility criteria of the Veterans Health Administration's (VA) are associated with improved access to concurrent dialysis and hospice care for patients with ESKD is not known. Objective To examine the frequency of concurrent hospice and dialysis care among US veterans by hospice payer and examine the payer for concurrent dialysis. Design, Setting, and Participants This was a retrospective cross-sectional study of all 70 577 VA enrollees in the US Renal Data System registry who initiated maintenance dialysis and died in 2007 to 2016. Data were analyzed from April 2021 to August 2022. Exposures Hospice payer, either Medicare, VA inpatient hospice, or VA-financed community-based hospice ("VA community care"). Primary hospice diagnosis-ESKD vs non-ESKD. Main Outcomes and Measures Concurrent receipt of hospice and dialysis services ("concurrent care"). Results There were 18 420 (26%) eligible veterans with ESKD who received hospice services (mean [SD] age, 75.4 [10.0] years; 17 457 [94.8%] men; 2997 [16.3%] Black, 15 162 [82.3%] White, and 261 (1.4%) individuals of other races). Most of the sample (n = 16 465; 89%) received hospice services under Medicare and 5231 (28%) continued to receive dialysis after hospice initiation. The adjusted proportion of veterans receiving concurrent care was higher for those enrolled in VA inpatient hospice or VA community care hospice than it was for those enrolled in Medicare hospice (57% and 41% vs 24%, respectively; both P < .001). Regardless of hospice payer, the majority (87%) of the dialysis treatments after hospice initiation were financed by the VA, including for Medicare beneficiaries who had a hospice diagnosis other than ESKD. Median hospice length of stay was 43 days for veterans who received concurrent dialysis vs 4 days for those who did not. Conclusions and Relevance In this retrospective cross-sectional study of US veterans with ESKD, a substantially higher proportion of veterans in VA-financed hospice received 1 or more dialysis treatments after hospice initiation than those enrolled in Medicare-financed hospice. Regardless of hospice payer, the VA financed most concurrent dialysis treatments. Hospice users who received concurrent dialysis care had substantially longer hospice lengths of stay than those who did not. These findings suggest that Medicare hospice policy may substantially restrict access to concurrent hospice and dialysis care among veterans with ESKD.
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Affiliation(s)
- Melissa W. Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Health Care System, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Emily E. Corneau
- Long Term Services and Supports Center of Innovation, Veterans Affairs Providence Health Care System, Providence, Rhode Island
| | - Ann M. O’Hare
- Department of Medicine and Kidney Research Institute, University of Washington, Seattle
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Nancy L. Keating
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Vincent Mor
- Long Term Services and Supports Center of Innovation, Veterans Affairs Providence Health Care System, Providence, Rhode Island
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
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8
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Ernecoff NC, Bell LF, Arnold RM, Shea CM, Switzer GE, Jhamb M, Schell JO, Kavalieratos D. Clinicians' Perceptions of Collaborative Palliative Care Delivery in Chronic Kidney Disease. J Pain Symptom Manage 2022; 64:168-177. [PMID: 35417752 PMCID: PMC9276626 DOI: 10.1016/j.jpainsymman.2022.04.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 11/20/2022]
Abstract
CONTEXT Guidelines recommend palliative care for patients with chronic kidney disease (CKD), who experience a high pain and symptom burden, and receive intensive treatments that often do not align with their values. A lack of scalable specialty palliative care services has prompted calls for attention to primary palliative care, delivered in primary care and nephrology settings. OBJECTIVES The objectives of this study were to 1) describe expectations for care to meet the palliative care needs of people living with CKD, and limitations to meeting those expectations in the current model, and 2) identify potential interventions to meet patients' palliative care needs. METHODS We conducted semi-structured interviews with clinicians from primary care, nephrology, and palliative care to assess 1) reasonable expectations for meeting palliative needs, 2) barriers to integrating primary palliative care, and 3) potential intervention points. RESULTS Clinicians discussed their expectations for high-quality communication (e.g., discussing disease understanding, assessing goals of care) and better integration of palliative care services. Clinicians expressed barriers to delivering that care, including poor inter-clinician communication. To address barriers, clinicians outlined potential intervention points, such as building collaborative models of care, and structural triggers to identify patients who may be appropriate for palliative care. CONCLUSION Interventions to address gaps in palliative care delivery for people living with CKD should incorporate systematic identification of patients with palliative care needs and structural mechanisms to meeting those needs via specialty and primary palliative care.
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Affiliation(s)
- Natalie C Ernecoff
- RAND Corporation (N.C.E.), Pittsburgh, Pennsylvania, USA; Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (N.C.E., L.F.B., R.M.A., J.O.S.), Pittsburgh, Pennsylvania, USA.
| | - Lindsay F Bell
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (N.C.E., L.F.B., R.M.A., J.O.S.), Pittsburgh, Pennsylvania, USA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (N.C.E., L.F.B., R.M.A., J.O.S.), Pittsburgh, Pennsylvania, USA
| | - Christopher M Shea
- Department of Health Policy and Management, University of North Carolina at Chapel Hill (C.M.S.), Chapel Hill, North Carolina, USA
| | - Galen E Switzer
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (G.E.S.), Pittsburgh, Pennsylvania, USA; Department of Psychiatry, University of Pittsburgh (G.E.S.), Pittsburgh, Pennsylvania, USA; Department of Clinical and Translational Science, University of Pittsburgh (G.E.S.), Pittsburgh, Pennsylvania, USA; Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System (G.E.S.), Pittsburgh, Pennsylvania, USA
| | - Manisha Jhamb
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh (M.J.), Pittsburgh, Pennsylvania, USA
| | - Jane O Schell
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh (N.C.E., L.F.B., R.M.A., J.O.S.), Pittsburgh, Pennsylvania, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine (D.K.), Atlanta, Georgia, USA
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Khayal IS, Brooks GA, Barnato AE. Development of dynamic health care delivery heatmaps for end-of-life cancer care: a cohort study. BMJ Open 2022; 12:e056328. [PMID: 35589364 PMCID: PMC9121487 DOI: 10.1136/bmjopen-2021-056328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 05/05/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Measures of variation in end-of-life (EOL) care intensity across hospitals are typically summarised using unidimensional measures. These measures do not capture the full dimensionality of complex clinical care trajectories over time that are needed to inform quality improvement efforts. The objective is to develop a novel visual map of EOL care trajectories that illustrates multidimensional utilisation over time. SETTING United States' National Cancer Institute or National Comprehensive Cancer Network (NCI/NCCN)-designated hospitals. PARTICIPANTS We identified Medicare claims for fee-for-service beneficiaries with poor prognosis cancers who died between April and December 2016 and received the preponderance of treatment in the last 6 months of life at an NCI/NCCN-designated hospital. DESIGN For each beneficiary, we transformed each Medicare claim into two elements to generate a two-dimensional individual-level heatmap. On the y-axis, each claim was classified into a categorical description of the service delivered by a healthcare resource. On the x-axis, the date for each claim was converted into the day number prior to death it occurred on. We then summed up individual-level heatmaps of patients attributed to each hospital to generate two-dimensional hospital-level heatmaps. We used four case studies to illustrate the feasibility of interpreting these heatmaps and to shed light on how they might be used to guide value-based, quality improvement initiatives. RESULTS We identified nine distinct EOL care delivery patterns from hospital-level heatmaps based on signal intensity and patterns for inpatient, outpatient and home-based hospice services. We illustrate that in most cases, heatmaps illustrating patterns of multidimensional healthcare utilisation over time provide more information about care trajectories and highlight more heterogeneity than current unidimensional measures. CONCLUSIONS This study illustrates the feasibility of representing multidimensional EOL utilisation over time as a heatmap. These heatmaps may provide potentially actionable insights into hospital-level care delivery patterns, and the approach may generalise to other serious illness populations.
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Affiliation(s)
- Inas S Khayal
- The Dartmouth Institute for Health Policy & Clinical Practice and Biomedical Data Science, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
- Department of Computer Science, Dartmouth College, Hanover, New Hampshire, USA
| | - Gabriel A Brooks
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
- Section of Medical Oncology, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
- Section of Palliative Care, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Hahn S, Ogle K. "Would you like me to take your hand?": Introduction to End of Life Doulas. OMEGA-JOURNAL OF DEATH AND DYING 2022:302228221097290. [PMID: 35477314 DOI: 10.1177/00302228221097290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
End-of-life (EOL) doulas are care providers and companions that offer spiritual, emotional, psychosocial, or psychological care to a person who is dying as well as their family and loved ones (Fukuzawa & Kondo, 2017). However, much like other options for EOL care (e.g., hospice, palliative care), their practice is often underutilized and misunderstood. There is limited research on EOL doulas, including who they are and what they do, leaving an opening for future studies to explore the topic (Krawczyk & Rush, 2020). As part of a larger investigation to gather information on EOL doulas, 12 in-depth, semi-structured interviews were conducted with certified doulas regarding their experiences. Three themes emerged from this project: motivations to become an EOL doula, roles of an EOL doula, and challenges of an EOL doula. In this article, only two themes, motivations to become an EOL doula and roles of an EOL doula are discussed.
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Affiliation(s)
- Sarah Hahn
- School of Social and Behavioral Sciences, 2986Mercy College, Dobbs Ferry, NY, USA
| | - Kimberly Ogle
- Grief Support Services and End of Life Preparation, Oxford, OH, USA
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11
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Mehanna EK, Catalano PJ, Cagney DN, Haas-Kogan DA, Alexander BM, Tulsky JA, Aizer AA. Hospice Utilization in Elderly Patients With Brain Metastases. J Natl Cancer Inst 2021; 112:1251-1258. [PMID: 32163145 DOI: 10.1093/jnci/djaa036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 02/20/2020] [Accepted: 03/04/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Brain metastases are associated with considerable morbidity and mortality. Integration of hospice at the end of life offers patients symptom relief and improves quality of life, particularly for elderly patients who are less able to tolerate brain-directed therapy. Population-level investigations of hospice utilization among elderly patients with brain metastases are limited. METHODS Using the Surveillance, Epidemiology and End Results-Medicare database for primary cancer sites that commonly metastasize to the brain, we identified 50 148 patients (aged 66 years and older) diagnosed with brain metastases between 2005 and 2016. We calculated the incidence, timing, and predictors of hospice enrollment using descriptive techniques and multivariable logistic regression. All statistical tests were 2-sided. RESULTS The incidence of hospice enrollment was 71.4% (95% confidence interval [CI] = 71.0 to 71.9; P < .001), a rate that increased over the study period (P < .001). The odds of enrollment for black (odds ratio [OR] = 0.76, 95% CI = 0.71 to 0.82; P < .001), Hispanic (OR = 0.80, 95% CI = 0.72 to 0.87; P < .001), and Asian patients (OR = 0.52, 95% CI = 0.48 to 0.57; P < .001) were substantially lower than white patients; men were less likely to be enrolled in hospice than women (OR = 0.78, 95% CI = 0.74 to 0.81; P < .001). Among patients enrolled in hospice, 32.6% (95% CI = 32.1 to 33.1; P < .001) were enrolled less than 7 days prior to death, a rate that was stable over the study period. CONCLUSIONS Hospice is used for a majority of elderly patients with brain metastases although a considerable percentage of patients die without hospice services. Many patients enroll in hospice late and, concerningly, statistically significant sociodemographic disparities exist in hospice utilization. Further investigations to facilitate targeted interventions addressing such disparities are warranted.
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Affiliation(s)
| | - Paul J Catalano
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA.,Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
| | - Daniel N Cagney
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA 02215, USA
| | - Daphne A Haas-Kogan
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA 02215, USA
| | - Brian M Alexander
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA 02215, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA 02215, USA
| | - Ayal A Aizer
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA 02215, USA
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de Avila V, Paik JM, de Avila L, Henry L, Mohess D, Roche-Green A, Younossi ZM. Hospice care utilisation among elderly patients who died with hepatocellular carcinoma in the United States. JHEP Rep 2021; 3:100236. [PMID: 33748729 PMCID: PMC7970151 DOI: 10.1016/j.jhepr.2021.100236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/08/2020] [Accepted: 12/28/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND & AIMS The benefits of hospice care in Medicare recipients with hepatocellular carcinoma (HCC) have not been fully evaluated, which we aimed to study. METHODS We used nationally representative samples of the Medicare beneficiaries in the USA (2011-2016) to assess the impact of hospice care on the outcomes of patients with HCC. Hospice care benefits on the survival time, length of stay (LOS), 30-day readmissions, and daily charges during the last year and month of life were assessed by logistic regression and generalised linear regression. RESULTS Among 2,230 Medicare beneficiaries with HCC (mean age, 74.9 years; non-Hispanic White 79.1%; male 66.6%), median survival from HCC diagnosis was 68 days; 556 (24.9%) received hospice services; median hospice LOS was 12 days (4-35 days). Hospice users increased from 20.1% to 31.1% over time, driven by enrolment ≤15 days (45.1-59.2%, respectively). In the last year of life, hospice users (vs. no hospice care) had longer median survival time (76.5 vs. 66 days), lower in-hospital mortality (1.1% vs. 25.5%) and lower median daily charges ($951 vs. $1,004) despite more inpatient admissions and higher comorbid diseases. Hospice enrolment was associated with 48.6% reduction in daily charges (95% CI: -54.9% to -41.5%). Longer hospice LOS was associated with lower rates of healthcare utilisation. Patients with chronic liver disease were less likely to enrol in hospice care (odds ratio = 0.18, 95% CI: 0.14-0.24). CONCLUSIONS Although hospice provides a significant decrease in healthcare utilisation and some benefit in survival, most care is given in the last 2 weeks of life. Efforts to encourage earlier use of hospice services must continue. LAY SUMMARY The purpose of hospice care is to provide comfort and lessen suffering at the end of life. Hospice care allows one to die outside the hospital environment which is the wish of most people. However, we found that among persons aged 65 years and older who were diagnosed with liver cancer (which has a poor prognosis), only 25% were enrolled in hospice care and the majority used a hospice only in the last weeks of life. This is a disheartening finding as liver cancer patients with longer hospice enrolment had lower costs and improved survival. We suggest that healthcare practitioners consider discussion of palliative and hospice care routinely with patients suffering from liver cancer.
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Affiliation(s)
- Victor de Avila
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - James M. Paik
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
- Center for Liver Disease and Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Leyla de Avila
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Linda Henry
- Center for Outcomes Research in Liver Diseases, Washington, DC, USA
| | - Denise Mohess
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Alva Roche-Green
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Zobair M. Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
- Center for Liver Disease and Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA
- Inova Medicine, Inova Health Systems, Falls Church, VA, USA
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Ko E, Fuentes D, Singh-Carlson S, Nedjat-Haiem F. Challenges and facilitators of hospice decision-making: a retrospective review of family caregivers of home hospice patients in a rural US-Mexico border region-a qualitative study. BMJ Open 2020; 10:e035634. [PMID: 32611740 PMCID: PMC7332198 DOI: 10.1136/bmjopen-2019-035634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Hospice care (HC) is seen as a comprehensive approach, that enhances quality of end-of-life (EOL) care, for terminally ill patients. Despite its positive aspects, HC enrolment is disproportionate for rural patients, who are less likely to use HC in comparison to their urban counterparts. The purpose of this study was to explore decision-making experiences, related to utilisation of HC programmes from a retrospective perspective, with family caregivers (FCGs) in a rural US-Mexico border region. DESIGN This qualitative study was conducted from May 2017 to January 2018 using semistructured face to face interviews with FCGs. Data were analysed using thematic analysis. SETTING The HC programme was situated at a local home health agency, located in rural Southern California, USA. PARTICIPANTS Twenty-eight informal FCGs of patients who were actively enrolled in the HC programme agreed to participate in the study. RESULTS Conversation about HC as an option was initiated by home healthcare staff (39.3%), followed by physicians (32.1%). Emerging themes related to challenges in utilisation of HC and decision-making included: (1) communication barriers; (2) lack of knowledge/misperception about HC; (3) emotional difficulties, including fear of losing their patient, doubt and uncertainty about the decision, denial and (4) patients are not ready for HC. Facilitators included: (1) patient's known EOL wishes; (2) FCG-physician EOL communication; (3) the patient's deteriorating health and (4) home as the place for death. CONCLUSIONS HC patients' FCGs in this rural region reported a lack of knowledge or misunderstanding of HC. It is recommended that healthcare providers need to actively engage family members in patient's EOL care planning. Optimal transition to an HC programme can be facilitated when FCGs are informed and have a clear understanding about patients' medical status along with information about HC.
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Affiliation(s)
- Eunjeong Ko
- Social Work, San Diego State University, San Diego, California, USA
| | - Dahlia Fuentes
- Social Work, San Diego State University, San Diego, California, USA
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Starr LT, Ulrich CM, Junker P, Huang L, O’Connor NR, Meghani SH. Patient Risk Factor Profiles Associated With the Timing of Goals-of-Care Consultation Before Death: A Classification and Regression Tree Analysis. Am J Hosp Palliat Care 2020; 37:767-778. [DOI: 10.1177/1049909120934292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Early palliative care consultation (“PCC”) to discuss goals-of-care benefits seriously ill patients. Risk factor profiles associated with the timing of conversations in hospitals, where late conversations most likely occur, are needed. Objective: To identify risk factor patient profiles associated with PCC timing before death. Methods: Secondary analysis of an observational study was conducted at an urban, academic medical center. Patients aged 18 years and older admitted to the medical center, who had PCC, and died July 1, 2014 to October 31, 2016, were included. Patients admitted for childbirth or rehabilitationand patients whose date of death was unknown were excluded. Classification and Regression Tree modeling was employed using demographic and clinical variables. Results: Of 1141 patients, 54% had PCC “close to death” (0-14 days before death); 26% had PCC 15 to 60 days before death; 21% had PCC >60 days before death (median 13 days before death). Variables associated with receiving PCC close to death included being Hispanic or “Other” race/ethnicity intensive care patients with extreme illness severity (85%), with age <46 or >75 increasing this probability (98%). Intensive care patients with extreme illness severity were also likely to receive PCC close to death (64%) as were 50% of intensive care patients with less than extreme illness severity. Conclusions: A majority of patients received PCC close to death. A complex set of variable interactions were associated with PCC timing. A systematic process for engaging patients with PCC earlier in the care continuum, and in intensive care regardless of illness severity, is needed.
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Affiliation(s)
- Lauren T. Starr
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Center for Bioethics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Connie M. Ulrich
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul Junker
- Program for Clinical Effectiveness and Quality Improvement, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Liming Huang
- BECCA Lab, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Nina R. O’Connor
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Salimah H. Meghani
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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15
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Currow DC, Agar MR, Phillips JL. Role of Hospice Care at the End of Life for People With Cancer. J Clin Oncol 2020; 38:937-943. [DOI: 10.1200/jco.18.02235] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Patient-defined factors that are important at the end of life include being physically independent for as long as possible, good symptom control, and spending quality time with friends and family. Hospice care adds to the quality of care and these patient-centered priorities for people with cancer and their families in the last weeks and days of life. Evidence from large observational studies demonstrate that hospice care can improve outcomes directly and support better and more appropriate health care use for people in the last stages of cancer. Team-based community hospice care has measurable benefits for patients, their family caregivers, and health services. In addition to improved symptom control for patients and a greater likelihood of time spent at home, caregiver outcomes are better when hospice care is accessed: informational needs are better met, and caregivers have an improved ability to move on with life after the patient’s death compared with people who did not have access to these services. Hospice care continues to evolve as its reach expands and the needs of patients continue to broaden. This is reflected in the transition from hospice being based on excellence in nursing to teams with a broad range of health professionals to meet the complex and changing needs of patients and their families. Additional integration of cancer services with hospice care will help to provide more seamless care for patients and supporting family caregivers during their caregiving and after the death of the patient.
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Affiliation(s)
- David C. Currow
- University of Technology Sydney, Ultimo, NSW, Australia
- University of Hull, Hull, United Kingdom
| | - Meera R. Agar
- University of Technology Sydney, Ultimo, NSW, Australia
- Liverpool Hospital, Liverpool, NSW, Australia
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16
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Elements of Palliative Care in the Last 6 Months of Life: Frequency, Predictors, and Timing. J Gen Intern Med 2020; 35:753-761. [PMID: 31650402 PMCID: PMC7080876 DOI: 10.1007/s11606-019-05349-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/28/2019] [Accepted: 09/10/2019] [Indexed: 10/25/2022]
Abstract
IMPORTANCE Persons living with serious illness often need skilled symptom management, communication, and spiritual support. Palliative care addresses these needs and may be delivered by either specialists or clinicians trained in other fields. It is important to understand core elements of palliative care to best provide patient-centered care. OBJECTIVE To describe frequency, predictors, and timing of core elements of palliative care during the last 6 months of life. DESIGN Retrospective chart review. SETTING Inpatient academic medical center. PARTICIPANTS Decedents with cancer, dementia, or chronic kidney disease (CKD) admitted during the 6 months preceding death. EXPOSURES We identified receipt and timing of core elements of palliative care: pain and symptom management, goals of care, spiritual care; and specialty palliative care utilization; hospital encounters; demographics; and comorbid diagnoses. We ran Poisson regression models to assess whether diagnosis or hospital encounters were associated with core elements of palliative care. RESULTS Among 402 decedents, the mean (SD) number of appropriately screened and treated symptoms was 2.9 (1.7)/10. Among 76.1% with documented goals of care, 58.0% had a primary goal of comfort; 55.0% had documented spiritual care. In multivariable models, compared with decedents with cancer, those with dementia or CKD were less likely to have pain and symptom management (respectively, 31% (incidence rate ratio [IRR], 0.69; 95% CI, 0.56-0.85) and 17% (IRR, 0.83; CI, 0.71-0.97)). There was a median of 3 days (IQR, 0-173) between transition to a goal of comfort and death, and a median of 12 days (IQR, 5-47) between hospice referral and death. CONCLUSIONS AND RELEVANCE Although a high proportion of patients received elements of palliative care, transitions to a goal of comfort or hospice happened very near death. Palliative care delivery can be improved by systematizing existing mechanisms, including prompts for earlier goals-of-care discussion, symptom screening, and spiritual care, and by building collaboration between primary and specialty palliative care services.
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Courtright KR, Jordan L, Murtaugh CM, Barrón Y, Deb P, Moore S, Bowles KH, Mikkelsen ME. Risk Factors for Long-term Mortality and Patterns of End-of-Life Care Among Medicare Sepsis Survivors Discharged to Home Health Care. JAMA Netw Open 2020; 3:e200038. [PMID: 32101307 PMCID: PMC7137683 DOI: 10.1001/jamanetworkopen.2020.0038] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Despite a growing recognition of the increased mortality risk among sepsis survivors, little is known about the patterns of end-of-life care among this population. OBJECTIVE To describe patterns of end-of-life care among a national sample of sepsis survivors and identify factors associated with long-term mortality risk and hospice use. DESIGN, SETTING, AND PARTICIPANTS This cohort study assessed sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care using national Medicare administrative, claims, and home health assessment data from 2013 to 2014. The initial and final primary analyses were conducted in July 2017 and from July to August 2019, respectively. EXPOSURES Sepsis hospital discharge and 1 or more home health assessments within 1 week. MAIN OUTCOMES AND MEASURES Outcomes were 1-year mortality among all sepsis survivors and hospitalization in the last 30 days of life, death in an acute care hospital, and hospice use among decedents. Multivariate logistic regression was used to identify factors associated with 1-year mortality and hospice use. RESULTS Among 87 581 sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care, 49 323 (56.3%) were aged 75 years or older, 69 499 (79.4%) were non-Hispanic white, and 48 472 (55.3%) were female. Among the total survivors, 24 423 (27.9%) people died within 1 year of discharge, with a median (interquartile range) survival time of 119 (51-220) days. Among these decedents, 16 684 (68.2%) were hospitalized in the last 30 days of life, 6560 (26.8%) died in an acute care hospital, and 12 573 (51.4%) were enrolled in hospice, with 5729 (45.6%) using hospice for 7 or fewer days. Several factors were associated with 1-year mortality, including a cancer diagnosis (odds ratio [OR], 3.66; 95% CI, 3.50-3.83; P < .001), multiple dependencies of activities of daily living or instrumental activities of daily living (OR, 2.80; 95% CI, 2.57-3.05; P < .001), and an overall poor health status (OR, 2.21; 95% CI, 2.01-2.44; P < .001) documented on home health assessment. Among the decedents, cancer was associated with hospice use (OR, 2.25; 95% CI, 2.11-2.41; P < .001), patients aged 85 years or older (OR, 1.49; 95% CI, 1.37-1.61; P < .001), and living in an assisted living setting (OR, 1.93; 95% CI, 1.69-2.19; P < .001). CONCLUSIONS AND RELEVANCE The findings of this study suggest that death within 1 year after sepsis discharge may be common among Medicare beneficiaries discharged to home health care. Although 1 in 2 decedents used hospice, aggressive care near the end of life and late hospice referral were common. Readily identifiable risk factors suggest opportunities to target efforts to improve palliative and end-of-life care among high-risk sepsis survivors.
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Affiliation(s)
- Katherine R. Courtright
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lizeyka Jordan
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York
| | | | - Yolanda Barrón
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York
| | - Partha Deb
- Department of Economics, Hunter College, The City University of New York (CUNY), New York
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Stanley Moore
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York
| | - Kathryn H. Bowles
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York
- Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania, Philadelphia
| | - Mark E. Mikkelsen
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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18
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Fu PK, Yang MC, Wang CY, Lin SP, Kuo CT, Hsu CY, Tung YC. Early Do-Not-Resuscitate Directives Decrease Invasive Procedures and Health Care Expenses During the Final Hospitalization of Life of COPD Patients. J Pain Symptom Manage 2019; 58:968-976. [PMID: 31404645 DOI: 10.1016/j.jpainsymman.2019.07.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 07/28/2019] [Accepted: 07/30/2019] [Indexed: 10/26/2022]
Abstract
CONTEXT Nearly 70% of do-not-resuscitate (DNR) directives for chronic obstructive pulmonary disease (COPD) patients are established during their terminal hospitalization. Whether patient use of end-of-life resources differs between early and late establishment of a DNR is unknown. OBJECTIVES The objective of this study was to compare end-of-life resource use between patients according to DNR directive status: no DNR, early DNR (EDNR) (established before terminal hospitalization), and late DNR (LDNR) (established during terminal hospitalization). METHODS Electronic health records from all COPD decedents in a teaching hospital in Taiwan were analyzed retrospectively with respect to medical resource use during the last year of life and medical expenditures during the last hospitalization. Multivariate linear regression analysis was used to determine independent predictors of cost. RESULTS Of the 361 COPD patients enrolled, 318 (88.1%) died with a DNR directive, 31.4% of which were EDNR. COPD decedents with EDNR were less likely to be admitted to intensive care units (12.0%, 55.5%, and 60.5% for EDNR, LDNR, and no DNR, respectively), had lower total medical expenditures, and were less likely to undergo invasive mechanical ventilator support during their terminal hospitalization. The average total medical cost during the last hospitalization was nearly twofold greater for LDNR than for EDNR decedents. Multivariate linear regression analysis revealed that nearly 60% of medical expenses incurred were significantly attributable to no EDNR, younger age, longer length of hospital stay, and more comorbidities. CONCLUSION Although 88% of COPD decedents died with a DNR directive, 70% of these directives were established late. LDNR results in lower quality of care and greater intensive care resource use in end-of-life COPD patients.
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Affiliation(s)
- Pin-Kuei Fu
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan; Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; College of Human Science and Social Innovation, Hungkuang University, Taichung, Taiwan; Science College, Tunghai University, Taichung, Taiwan
| | - Ming-Chin Yang
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
| | - Chen-Yu Wang
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Nursing, Hungkuang University, Taichung, Taiwan
| | - Shin-Pin Lin
- Computer & Communications Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chen-Tsung Kuo
- Computer & Communications Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chiann-Yi Hsu
- Biostatistics Task Force, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Chi Tung
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan.
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Abstract
This review proposes that the end of life is a uniquely contemporary life course stage. Epidemiologic, technological, and cultural shifts over the past two centuries have created a context in which dying has shifted from a sudden and unexpected event to a protracted, anticipated transition following an incurable chronic illness. The emergence of an end-of-life stage lasting for months or even years has heightened public interest in enhancing patient well-being, autonomy, and the receipt of medical care that accords with patient and family members' wishes. We describe key components of end-of-life well-being and highlight socioeconomic and race disparities therein, drawing on fundamental cause theory. We describe two practices that are critical to end-of-life well-being (advance care planning and hospice) and identify limitations that may undermine their effectiveness. We conclude with recommendations for future sociological research that could inform practices to enhance patient and family well-being at the end of life.
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Affiliation(s)
- Deborah Carr
- Department of Sociology, Boston University, Boston, Massachusetts 02215, USA
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20
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Cross SH, Kamal AH, Taylor DH, Warraich HJ. Hospice Use Among Patients with Heart Failure. Card Fail Rev 2019; 5:93-98. [PMID: 31179019 PMCID: PMC6545999 DOI: 10.15420/cfr.2019.2.2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/26/2019] [Indexed: 12/11/2022] Open
Abstract
Despite its many benefits, hospice care is underused for patients with heart failure. This paper discusses the factors contributing to this underuse and offers recommendations to optimise use for patients with heart failure and proposes metrics to optimise quality of hospice care for this patient group.
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Affiliation(s)
- Sarah H Cross
- Sanford School of Public Policy, Duke University Durham, NC, US
| | - Arif H Kamal
- Duke Cancer Institute Durham, NC, US.,Duke Fuqua School of Business, Duke University Durham, NC, US
| | - Donald H Taylor
- Sanford School of Public Policy, Duke University Durham, NC, US.,Margolis Center for Health Policy, Duke University Durham, NC, US.,Duke Clinical Research Institute Durham, NC, US
| | - Haider J Warraich
- Department of Medicine, Division of Cardiology, Duke University Medical Center Durham, NC, US
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Abstract
OBJECTIVES The current study sought to understand the differences hospice nurses perceived in caring for older adult patients who utilize hospice for longer and shorter periods, older adult patients' experience of hospice services, and if length of hospice stays influenced the patients' end-of-life experience. METHODS Interpretative Phenomenological Analysis was used to extract themes and subthemes from 10 interviews conducted with hospice nursing staff. RESULTS Four major themes were identified pertaining to nurses perspective on older adults' views of hospice and how length of hospice use impacts end-of-life care. CONCLUSION These themes suggest hospice nursing staff believe longer hospice stays are more positive and that older adults identify more positive aspects of hospice when using it for longer periods of time. Results suggest that nurses believe length of use directly impacts patient care and the experience of hospice services. CLINICAL IMPLICATIONS Participating nurses reported that older adults have a lack of information on hospice services. It was suggested that more information is needed and that providing such education may lead to longer hospice stays.
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Affiliation(s)
| | - Ernest Chavez
- a Department of Psychology, Colorado State University , Fort Collins , Colorado , USA
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22
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Kaufman BG, O'Brien EC, Stearns SC, Matsouaka RA, Holmes GM, Weinberger M, Schwamm LH, Smith EE, Fonarow GC, Xian Y, Taylor DH. Medicare Shared Savings ACOs and Hospice Care for Ischemic Stroke Patients. J Am Geriatr Soc 2019; 67:1402-1409. [DOI: 10.1111/jgs.15852] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/05/2019] [Accepted: 02/07/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Brystana G. Kaufman
- Department of Health Policy and ManagementThe University of North Carolina at Chapel Hill Chapel Hill North Carolina
- Duke Margolis Center for Health Policy Durham North Carolina
| | - Emily C. O'Brien
- Department of Population Health SciencesDuke University Durham North Carolina
| | - Sally C. Stearns
- Department of Health Policy and ManagementThe University of North Carolina at Chapel Hill Chapel Hill North Carolina
- The Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - Roland A. Matsouaka
- Duke Clinical Research Institute Durham North Carolina
- Department of Biostatistics and BioinformaticsDuke University Durham North Carolina
| | - G. Mark Holmes
- Department of Health Policy and ManagementThe University of North Carolina at Chapel Hill Chapel Hill North Carolina
- The Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - Morris Weinberger
- Department of Health Policy and ManagementThe University of North Carolina at Chapel Hill Chapel Hill North Carolina
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General HospitalHarvard Medical School Boston Massachusetts
| | - Eric E. Smith
- Department of Neurology, Cumming School of MedicineUniversity of Calgary Calgary Canada
| | - Gregg C. Fonarow
- Division of CardiologyDavid Geffen School of Medicine at UCLA Los Angeles California
| | - Ying Xian
- Duke Clinical Research Institute Durham North Carolina
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O’Connor NR. Hospice Among Hemodialysis Patients: Too Little, Too Late to Impact Care Delivery or Costs? Am J Kidney Dis 2018; 72:903-905. [DOI: 10.1053/j.ajkd.2018.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 06/15/2018] [Indexed: 11/11/2022]
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Ghesquiere A, Bagaajav A, Metzendorf M, Bookbinder M, Gardner DS. Hospice Bereavement Service Delivery to Family Members and Friends With Bereavement-Related Mental Health Symptoms. Am J Hosp Palliat Care 2018; 36:370-378. [PMID: 30428680 DOI: 10.1177/1049909118812025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES: A sizable minority of those who lose a loved one in hospice will experience symptoms of bereavement-related mental health disorders. Though hospices offer services to bereaved informal caregivers (family members or friends) of patients, little is known about services offered or interest in them. Therefore, we sought to assess services offered by hospice staff and interest expressed by bereaved informal caregivers with symptoms of depression, anxiety, or complicated grief (CG). METHODS: De-identified electronic bereavement care charts of 3561 informal caregivers who lost someone in a large urban metropolitan hospice from October 1, 2015, to June 30, 2016, were reviewed. RESULTS: Of bereaved informal caregivers in the sample, 9.4% (n = 333) were positive for symptoms of depression, anxiety, or CG. The symptom-positive family members/friends were more likely than other family members/friends to be offered mailings, one-to-one counseling, telephone calls, and reference material. However, interest in most services by symptom-positive caregivers was low, with only 6% interested in one-to-one counseling and 7% interested in outside referral. DISCUSSION: The findings suggest that hospices offer a range of services to family members or friends with symptoms of anxiety, depression, and CG, but that there can be a gap between what is offered and in the interest levels of the bereaved. Engagement with symptomatic family members and friends could be enhanced in future work.
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Affiliation(s)
- Angela Ghesquiere
- 1 Brookdale Center for Healthy Aging, Hunter College of the City University of New York, New York, NY, USA
| | - Ariunsanaa Bagaajav
- 2 Silberman School of Social Work, Hunter College of the City University of New York, New York, NY, USA
| | - Marguerite Metzendorf
- 3 Bereavement and Creative Art Services, MJHS Hospice and Palliative Care, New York, NY, USA
| | | | - Daniel S Gardner
- 2 Silberman School of Social Work, Hunter College of the City University of New York, New York, NY, USA
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McDermott CL, Bansal A, Ramsey SD, Lyman GH, Sullivan SD. Depression and Health Care Utilization at End of Life Among Older Adults With Advanced Non-Small-Cell Lung Cancer. J Pain Symptom Manage 2018; 56:699-708.e1. [PMID: 30121375 PMCID: PMC6226016 DOI: 10.1016/j.jpainsymman.2018.08.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/07/2018] [Accepted: 08/08/2018] [Indexed: 02/08/2023]
Abstract
CONTEXT Limited data exist regarding how depression diagnosed at different times relative to a cancer diagnosis may affect healthcare utilization at end of life (EOL). OBJECTIVES To assess the relationship between depression and health care utilization at EOL among older adults (ages >=67) diagnosed with advanced non-small cell lung cancer (NSCLC) from 2009 to 2011. METHODS Using the SEER-Medicare database, we fit multivariable logistic regression models to explore the association of depression with duration of hospice stay plus high-intensity care, for example inpatient admissions, in-hospital death, emergency department visits, and chemotherapy at EOL. We used a regression model to evaluate hospice enrollment, accounting for the competing risk of death. RESULTS Among 13,827 subjects, pre-cancer depression was associated with hospice enrollment (sub-hazard ratio 1.19, 95% confidence interval [CI] 1.11-1.28), 90 + hospice days (adjusted odds ratio [aOR] 1.29, 95% CI 1.06-1.58), and lower odds of most utilization; we found no association with EOL chemotherapy. Diagnosis-time depression was associated with hospice enrollment (SHR 1.16, 95% CI 1.05-1.29) but not high-intensity utilization. Post-diagnosis depression was associated with lower hospice enrollment (SHR 0.80, 95% CI 0.74-0.85) and higher odds of ICU admission (aOR 1.18, 95% CI 1.01-1.37). CONCLUSION EOL healthcare utilization varied by timing of depression diagnosis. Those with pre-cancer depression had lower odds of high-intensity healthcare, were more likely to utilize hospice, and have longer hospice stays. Regular depression screening and treatment may help patients optimize decision-making for EOL care. Additionally, hospice providers may need additional resources to attend to mental health needs in this population.
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Affiliation(s)
- Cara L McDermott
- Cambia Palliative Care Center of Excellence Department of Medicine, University of Washington, Seattle, Washington, USA; Hutchinson Institute for Cancer Outcomes Research Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.
| | - Aasthaa Bansal
- Hutchinson Institute for Cancer Outcomes Research Fred Hutchinson Cancer Research Center, Seattle, Washington, USA; Department of Pharmacy University of Washington, Seattle, Washington, USA
| | - Scott D Ramsey
- Hutchinson Institute for Cancer Outcomes Research Fred Hutchinson Cancer Research Center, Seattle, Washington, USA; Department of Pharmacy University of Washington, Seattle, Washington, USA
| | - Gary H Lyman
- Hutchinson Institute for Cancer Outcomes Research Fred Hutchinson Cancer Research Center, Seattle, Washington, USA; Department of Pharmacy University of Washington, Seattle, Washington, USA
| | - Sean D Sullivan
- Hutchinson Institute for Cancer Outcomes Research Fred Hutchinson Cancer Research Center, Seattle, Washington, USA; Department of Pharmacy University of Washington, Seattle, Washington, USA
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Wachterman MW, Hailpern SM, Keating NL, Kurella Tamura M, O'Hare AM. Association Between Hospice Length of Stay, Health Care Utilization, and Medicare Costs at the End of Life Among Patients Who Received Maintenance Hemodialysis. JAMA Intern Med 2018; 178:792-799. [PMID: 29710217 PMCID: PMC5988968 DOI: 10.1001/jamainternmed.2018.0256] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE Patients with end-stage renal disease are less likely to use hospice services than other patients with advanced chronic illness. Little is known about the timing of hospice referral in this population and its association with health care utilization and costs. OBJECTIVE To examine the association between hospice length of stay and health care utilization and costs at the end of life among Medicare beneficiaries who had received maintenance hemodialysis. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional observational study was conducted via the United States Renal Data System registry. Participants were all 770 191 hemodialysis patients in the registry who were enrolled in fee-for-service Medicare and died between January 1, 2000, and December 31, 2014. The dates of analysis were April 2016 to December 2017. MAIN OUTCOMES AND MEASURES Hospital admission, intensive care unit (ICU) admission, and receipt of an intensive procedure during the last month of life; death in the hospital; and costs to the Medicare program in the last week of life. RESULTS Among 770 191 patients, the mean (SD) age was 74.8 (11.0) years, and 53.7% were male. Twenty percent of cohort members were receiving hospice services when they died. Of these, 41.5% received hospice for 3 days or fewer. In adjusted analyses, compared with patients who did not receive hospice, those enrolled in hospice for 3 days or fewer were less likely to die in the hospital (13.5% vs 55.1%; P < .001) or to undergo an intensive procedure in the last month of life (17.7% vs 31.6%; P < .001) but had higher rates of hospitalization (83.6% vs 74.4%; P < .001) and ICU admission (54.0% vs 51.0%; P < .001) and similar Medicare costs in the last week of life ($10 756 vs $10 871; P = .08). Longer lengths of stay in hospice beyond 3 days were associated with progressively lower rates of utilization and costs, especially for those referred more than 15 days before death (35.1% hospitalized and 16.7% admitted to an ICU in the last month of life; the mean Medicare costs in the last week of life were $3221). CONCLUSIONS AND RELEVANCE Overall, 41.5% of hospice enrollees who had been treated with hemodialysis for their end-stage renal disease entered hospice within 3 days of death. Although less likely to die in the hospital and to receive an intensive procedure, these patients were more likely than those not enrolled in hospice to be hospitalized and admitted to the ICU, and they had similar Medicare costs. Without addressing barriers to more timely referral, greater use of hospice may not translate into meaningful changes in patterns of health care utilization, costs, and quality of care at the end of life in this population.
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Affiliation(s)
- Melissa W Wachterman
- Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts.,Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Susan M Hailpern
- Division of Nephrology, Kidney Research Institute, Department of Medicine, University of Washington, Seattle
| | - Nancy L Keating
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University, Palo Alto, California.,Geriatric Research and Education Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Ann M O'Hare
- Division of Nephrology, Kidney Research Institute, Department of Medicine, University of Washington, Seattle.,Hospital and Specialty Medical Service, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Kaufman BG, Klemish D, Kassner CT, Reiter JP, Li F, Harker M, O'Brien EC, Taylor DH, Bhavsar NA. Predicting Length of Hospice Stay: An Application of Quantile Regression. J Palliat Med 2018; 21:1131-1136. [PMID: 29762075 DOI: 10.1089/jpm.2018.0039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Use of the Medicare hospice benefit has been associated with high-quality care at the end of life, and hospice length of use in particular has been used as a proxy for appropriate timing of hospice enrollment. Quantile regression has been underutilized as an alternative tool to model distributional changes in hospice length of use and hospice payments outside of the mean. OBJECTIVE To test for heterogeneity in the relationship between patient characteristics and hospice outcomes across the distribution of hospice days. SETTING Medicare Beneficiary Summary File and survey data (2014) for hospice beneficiaries in North and South Carolina with common terminal diagnoses. MEASUREMENTS Distributional shifts associated with patient characteristics were evaluated at the 25th and 75th percentiles of hospice days and hospice payments using quantile regressions and compared to the mean shift estimated by ordinary least squares (OLS) regression. PRINCIPAL FINDINGS Significant (p < 0.001) heterogeneity in the marginal effects on hospice days and costs was observed, with patient characteristics associated with generally larger shifts in the 75th percentile than the 25th percentile. Mean effects estimated by OLS regression overestimate the magnitude of the median marginal effects for all patient characteristics except for race. Results for hospice payments in 2014 were similar. CONCLUSIONS Methodological decisions can have a meaningful impact in the evaluation of factors influencing hospice length of use or cost.
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Affiliation(s)
- Brystana G Kaufman
- 1 Department of Health Policy and Management, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina.,2 Department of Statistical Sciences, Duke University School of Medicine , Durham, North Carolina
| | - David Klemish
- 3 Department of Statistical Sciences, Duke University , Durham, North Carolina
| | | | - Jerome P Reiter
- 3 Department of Statistical Sciences, Duke University , Durham, North Carolina
| | - Fan Li
- 3 Department of Statistical Sciences, Duke University , Durham, North Carolina
| | - Matthew Harker
- 5 Margolis Center for Health Policy , Duke University, Durham, North Carolina
| | - Emily C O'Brien
- 2 Department of Statistical Sciences, Duke University School of Medicine , Durham, North Carolina
| | - Donald H Taylor
- 6 Sanford School of Public Policy , Duke University, Durham, North Carolina
| | - Nrupen A Bhavsar
- 2 Department of Statistical Sciences, Duke University School of Medicine , Durham, North Carolina
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Ross L, Neergaard MA, Petersen MA, Groenvold M. Measuring the quality of end-of-life care: Development, testing, and cultural validation of the Danish version of Views of Informal Carers' Evaluation of Services-Short Form. Palliat Med 2018; 32:804-814. [PMID: 29130380 DOI: 10.1177/0269216317740274] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The perspectives of patients and relatives are important in the improvement of the quality of health care. However, the quality of end-of-life care has not been systematically evaluated in Scandinavia. AIM To develop or adapt and subsequently validate a questionnaire assessing the quality of end-of-life care in Denmark. The questionnaire was intended for bereaved relatives in order to assess the quality of care in the last 3 months of the patient's life and the circumstances surrounding death. DESIGN AND DATA SOURCES Based on the literature and interviews with 15 bereaved relatives and 17 healthcare professionals, relevant topics to include in a questionnaire were identified. The topics were prioritized by 100 bereaved relatives and subsequently compared to existing questionnaires. The chosen questionnaire was tested by cognitive interviews with 36 bereaved relatives. RESULTS Most of the important topics were covered by the Views of Informal Carers' Evaluation of Services-Short Form, but not all Danish settings (e.g. home care by a palliative team) were covered. These settings were added to the Views of Informal Carers' Evaluation of Services-Short Form, and a few adaptations were made before a Danish version of the Views of Informal Carers' Evaluation of Services-Short Form was tested by cognitive interviews. This cultural validation showed that the slightly adapted Danish version was perceived as relevant, understandable, and acceptable. Furthermore, the cognitive interviews gave insight in the comprehension and interpretation of Views of Informal Carers' Evaluation of Services-Short Form items. CONCLUSION With a few adaptations, the British Views of Informal Carers' Evaluation of Services-Short Form was relevant in a Danish setting.
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Affiliation(s)
- Lone Ross
- 1 The Research Unit, Department of Palliative Medicine, Bispebjerg/Frederiksberg Hospital, University of Copenhagen, Copenhagen NV, Denmark
| | - Mette Asbjoern Neergaard
- 2 The Palliative Care Team, Department of Oncology, Aarhus University Hospital, Aarhus C, Denmark
| | - Morten Aagaard Petersen
- 1 The Research Unit, Department of Palliative Medicine, Bispebjerg/Frederiksberg Hospital, University of Copenhagen, Copenhagen NV, Denmark
| | - Mogens Groenvold
- 1 The Research Unit, Department of Palliative Medicine, Bispebjerg/Frederiksberg Hospital, University of Copenhagen, Copenhagen NV, Denmark.,3 Department of Health Services Research, Institute of Public Health, University of Copenhagen, Copenhagen K, Denmark
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Hutchinson RN, Lucas FL, Becker M, Wierman HR, Fairfield KM. Variations in Hospice Utilization and Length of Stay for Medicare Patients With Melanoma. J Pain Symptom Manage 2018; 55:1165-1172.e5. [PMID: 29247755 DOI: 10.1016/j.jpainsymman.2017.12.334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 12/01/2017] [Accepted: 12/01/2017] [Indexed: 11/30/2022]
Abstract
CONTEXT Timely hospice referral is an indicator of high-quality end-of-life care for cancer patients. Variations in patient characteristics associated with hospice utilization and length of stay have been demonstrated in studies of other malignancies but not melanoma. OBJECTIVES We sought to understand hospice utilization and patient characteristics associated with variability in use for the older melanoma population. METHODS We used the Surveillance, Epidemiology, and End Results-Medicare database to identify 13,393 melanoma patients aged 65+ years at time of diagnosis between 2000 and 2009, who died by 12/31/10. The primary outcome was enrollment in hospice with secondary outcome of hospice duration. Patient characteristics associated with variations in hospice enrollment were examined. RESULTS Among 13,393 patients who died with melanoma, 5298 (40%) received hospice care. Of these, 17% were enrolled in hospice for three days or less, while 13% had ≥90 days of hospice care. Despite improvements over time in the proportion of patients who received hospice and those who received at least 90 days of hospice care, late hospice enrollments did not change. Multivariable analysis revealed that patients of older age, with distant disease at time of diagnosis, and residing in rural areas or in census tracts with higher rates of high school completion were more likely to enroll in hospice. CONCLUSION Rates of hospice enrollment increased over time but remained under accepted quality benchmarks with variations evident in those who receive hospice services. Efforts to increase access to earlier hospice care for all patients dying with melanoma are essential.
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Affiliation(s)
- Rebecca N Hutchinson
- Division of Palliative Medicine, Maine Medical Center, Portland, Maine, USA; Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine, USA.
| | - F Lee Lucas
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine, USA
| | - Mary Becker
- Division of Palliative Medicine, Maine Medical Center, Portland, Maine, USA
| | - Heidi R Wierman
- Division of Geriatric Medicine, Maine Medical Center, Portland, Maine, USA
| | - Kathleen M Fairfield
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine, USA; Department of Medicine, Maine Medical Center, Portland, Maine, USA
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Cotogni P, Saini A, De Luca A. In-Hospital Palliative Care: Should We Need to Reconsider What Role Hospitals Should Have in Patients with End-Stage Disease or Advanced Cancer? J Clin Med 2018; 7:jcm7020018. [PMID: 29385757 PMCID: PMC5852434 DOI: 10.3390/jcm7020018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 01/08/2018] [Accepted: 01/13/2018] [Indexed: 12/25/2022] Open
Abstract
Traditionally, palliative care (PC) systems focused on the needs of advanced cancer patients, but most patients needing PC have end-stage organ diseases. Similarly, PC models focus on the needs of patients in hospices or at home; however, in most cases PC is provided in acute hospitals. Indeed, the symptom burden that these patients experience in the last year of life frequently forces them to seek care in emergency departments. The majority of them are admitted to the hospital and many die. This issue poses important concerns. Despite the efforts of attending healthcare professionals, in-hospital patients do not receive optimal care near the end-of-life. Also, evidence is emerging that delay in identifying patients needing PC have a detrimental impact on their quality of life (QoL). Therefore, there is an urgent need to identify, early and properly, these patients among those hospitalized. Several trials reported the efficacy of PC in improving the QoL in these patients. Each hospital should ensure that a multidisciplinary PC team is available to support attending physicians to achieve the best QoL for both PC patients and their families. This review discusses the role and the impact of in-hospital PC in patients with end-stage disease or advanced cancer.
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Affiliation(s)
- Paolo Cotogni
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, Molinette Hospital and University of Turin, C.so Bramante 88/90, 10126 Turin, Italy.
| | - Andrea Saini
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, Molinette Hospital and University of Turin, C.so Bramante 88/90, 10126 Turin, Italy.
| | - Anna De Luca
- Pain Management and Palliative Care, Department of Anesthesia and Intensive Care, Molinette Hospital and University of Turin, C.so Bramante 88/90, 10126 Turin, Italy.
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Aslakson RA, Dy SM, Wilson RF, Waldfogel J, Zhang A, Isenberg SR, Blair A, Sixon J, Lorenz KA, Robinson KA. Patient- and Caregiver-Reported Assessment Tools for Palliative Care: Summary of the 2017 Agency for Healthcare Research and Quality Technical Brief. J Pain Symptom Manage 2017; 54:961-972.e16. [PMID: 28818633 DOI: 10.1016/j.jpainsymman.2017.04.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 04/11/2017] [Accepted: 04/13/2017] [Indexed: 12/21/2022]
Abstract
CONTEXT Assessment tools are data collection instruments that are completed by or with patients or caregivers and which collect data at the individual patient or caregiver level. OBJECTIVES The objectives of this study are to 1) summarize palliative care assessment tools completed by or with patients or caregivers and 2) identify needs for future tool development and evaluation. METHODS We completed 1) a systematic review of systematic reviews; 2) a supplemental search of previous reviews and Web sites, and/or 3) a targeted search for primary articles when no tools existed in a domain. Paired investigators screened search results, assessed risk of bias, and abstracted data. We organized tools by domains from the National Consensus Project Clinical Practice Guidelines for Palliative Care and selected the most relevant, recent, and highest quality systematic review for each domain. RESULTS We included 10 systematic reviews and identified 152 tools (97 from systematic reviews and 55 from supplemental sources). Key gaps included no systematic review for pain and few tools assessing structural, cultural, spiritual, or ethical/legal domains, or patient-reported experience with end-of-life care. Psychometric information was available for many tools, but few studies evaluated responsiveness (sensitivity to change) and no studies compared tools. CONCLUSION Few to no tools address the spiritual, ethical, or cultural domains or patient-reported experience with end-of-life care. While some data exist on psychometric properties of tools, the responsiveness of different tools to change and/or comparisons between tools have not been evaluated. Future research should focus on developing or testing tools that address domains for which few tools exist, evaluating responsiveness, and comparing tools.
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Affiliation(s)
- Rebecca A Aslakson
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Department of Oncology, Palliative Care Program, Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA.
| | - Sydney M Dy
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Renee F Wilson
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Julie Waldfogel
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Allen Zhang
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Sarina R Isenberg
- Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Alex Blair
- Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Joshua Sixon
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Karl A Lorenz
- VA Palo Alto Health Care System, Palo Alto, California; Stanford School of Medicine, Department of Medicine, Palo Alto, California
| | - Karen A Robinson
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland, USA; Department of Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Anhang Price R, Elliott MN. Measuring Patient-Centeredness of Care for Seriously Ill Individuals: Challenges and Opportunities for Accountability Initiatives. J Palliat Med 2017; 21:S28-S35. [PMID: 29091531 DOI: 10.1089/jpm.2017.0452] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Patient- and family-centeredness of care is particularly important for individuals with serious illness. In this article, we describe methodological challenges of using measures of patient- and family-centeredness in accountability initiatives such as public reporting and pay for performance. We begin with background on measuring patient- and family-centered care using standardized surveys, describe evidence of the use of these measures for quality improvement, and highlight methodological challenges in the development and implementation of these measures for use in accountability. To ensure that patient- and family-centeredness is the cornerstone of public and private accountability initiatives designed to promote high-quality care to seriously ill patients, we recommend development of (1) a nationally endorsed survey instrument that assesses patient and family experiences of serious illness care across the full range of patient trajectories and care settings in which this care is provided; (2) administrative data infrastructure that allows for identification and outreach to the most knowledgeable respondents for the survey, regardless of the patient's setting of care; and (3) a broad toolkit of quality improvement approaches to ensure that as the emphasis on accountability grows, providers across settings have access to tools that can help them improve patient- and family-centeredness of care for the seriously ill.
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Identifying Advanced Illness Patients in the Emergency Department and Having Goals-of-Care Discussions to Assist with Early Hospice Referral. J Emerg Med 2017; 54:191-197. [PMID: 28988735 DOI: 10.1016/j.jemermed.2017.08.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 06/22/2017] [Accepted: 08/08/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The emergency department (ED) is often where patients with advanced illness (AI) present when faced with an acute deterioration in their disease. OBJECTIVES To investigate the effectiveness of our AI Management program in the ED on key outcomes. METHODS We conducted a pre-post study with a retrospective chart review with ED patients at an academic, tertiary care hospital in the New York metropolitan area. We assessed changes from baseline to intervention period on percent of patients identified in the ED with AI, percent who received an ED-led goals-of-care (GOC) discussion, and percent referred to hospice from the ED. We used the Fisher's exact test or the Mann-Whitney test to compare groups, as appropriate. RESULTS Our sample consisted of 82 patients (21 baseline and 61 intervention). Patients in the baseline period had a median age of 75 years, with 61.9% being female, whereas those in the intervention period had a median age of 83 years, with 67.2% being female. Patients in the intervention, compared with baseline, were significantly more likely to be identified as having AI in the ED (90.2% vs. 0.0%; p < 0.0001), to receive an ED-led GOC conversation (83.6% vs. 0.0%; p < 0.0001), and to be discharged to home hospice (39.3% vs. 0.0%; p < 0.0001). CONCLUSIONS The ED provides a critical opportunity to identify AI patients, have ED-led GOC discussions, and refer appropriate patients to hospice.
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Feasibility of the Korean-Advance Directives Among Community-Dwelling Elderly Persons. Holist Nurs Pract 2017; 31:234-242. [PMID: 28609408 DOI: 10.1097/hnp.0000000000000216] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
A newly developed Korean-Advance Directive (K-AD) consists of a value statement, treatment directives, and proxy appointment. It remains undetermined whether K-AD is applicable to community-dwelling persons (≥ aged 60 years). Using a descriptive study design, 275 elderly persons completed the K-AD (mean age = 77.28 ± 8.24 years). The most frequent value at the end of life was comfort dying, followed by no burden to family (23.6%). Among 4 K-AD treatment options, more than half had a preference for hospice care and had reluctance with aggressive treatment choices of cardiopulmonary resuscitation (76.4%), artificial ventilation (75.6%), and tube feeding (76.4%), with one-fifth having a desire for such options. All persons provided proxies, who were predominantly descendants (77.1%), followed by spouses (17.5%). For treatment preferences, men and those with no religion were more likely to receive life-sustaining treatments. These data support the K-AD as being applicable and acceptable among community-dwelling elderly persons; awareness of the K-AD in the community setting may facilitate future application when the need occurs.
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Sanjo M, Morita T, Miyashita M, Sato K, Kamibeppu K, Tsuneto S, Shima Y. Are Bereaved Family Members Satisfied With Information Provision About Palliative Care Units in Japan? Am J Hosp Palliat Care 2017; 35:275-283. [PMID: 28875733 DOI: 10.1177/1049909117729805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
This study clarified the evaluation of the information about palliative care units (PCUs) from the oncologists by the bereaved family members of Japanese patients with cancer at the time of their first referral. A multicenter questionnaire survey examining the amount, timing, and adequacy of information received about PCUs was conducted. Half of the respondents (N = 465, mean age = 60 years) were spouses. Findings showed that 55% of the respondents thought the amount of information was inadequate and 33% thought the timing of the information about PCU from the oncologist was inadequate. Greater perceived inadequacy of the amount of information was significantly associated with (1) obtaining information from other patients and/or family member who had no experience with PCUs and (2) not acquiring information about the availability of medical staff and medical treatments at PCUs. Greater perceived inadequacy of the timing of the information was significantly associated with acts by the oncologist and/or nurses, such as providing insufficient information or saying there is nothing more that can be done any longer; however, this was not significantly associated with the actual timing of the oncologists' information. Medical staff should understand what information families desire and provide enough detail for patients to imagine accurately what time spent in a PCU would be like. Moreover, practitioners should strive to improve methods of communication and engagement after the information provision, rather than prioritizing the timing of the information.
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Affiliation(s)
- Makiko Sanjo
- 1 Cancer/Advanced Adult Nursing, Department of Nursing, Graduate School of Medicine, Yokohama City University, Kanagawa, Tokyo, Japan.,2 Division of Health Science and Nursing, Department of Family Nursing, Division of Health Science and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Morita
- 3 Department of Palliative and Supportive Care, Palliative Care Team, and Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Mitsunori Miyashita
- 4 Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuki Sato
- 5 Department of Nursing, School of Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kiyoko Kamibeppu
- 2 Division of Health Science and Nursing, Department of Family Nursing, Division of Health Science and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoru Tsuneto
- 6 Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasuo Shima
- 7 Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
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Einstein DJ, DeSanto-Madeya S, Gregas M, Lynch J, McDermott DF, Buss MK. Improving End-of-Life Care: Palliative Care Embedded in an Oncology Clinic Specializing in Targeted and Immune-Based Therapies. J Oncol Pract 2017; 13:e729-e737. [DOI: 10.1200/jop.2016.020396] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose: Patients with advanced cancer benefit from early involvement of palliative care. The ideal method of palliative care integration remains to be determined, as does its effectiveness for patients treated with targeted and immune-based therapies. Materials and Methods: We studied the impact of an embedded palliative care team that saw patients in an academic oncology clinic specializing in targeted and immune-based therapies. Patients seen on a specific day accessed the embedded model, on the basis of automatic criteria; patients seen other days could be referred to a separate palliative care clinic (usual care). We abstracted data from the medical records of 114 patients who died during the 3 years after this model’s implementation. Results: Compared with usual care (n = 88), patients with access to the embedded model (n = 26) encountered palliative care as outpatients more often ( P = .003) and earlier (mean, 231 v 109 days before death; P < .001). Hospice enrollment rates were similar ( P = .303), but duration was doubled (mean, 57 v 25 days; P = .006), and enrollment > 7 days before death—a core Quality Oncology Practice Initiative metric—was higher in the embedded model (odds ratio, 5.60; P = .034). Place of death ( P = .505) and end-of-life chemotherapy (odds ratio, 0.361; P = .204) did not differ between the two arms. Conclusion: A model of embedded and automatically triggered palliative care among patients treated exclusively with targeted and immune-based therapies was associated with significant improvements in use and timing of palliative care and hospice, compared with usual practice.
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Affiliation(s)
- David J. Einstein
- Beth Israel Deaconess Medical Center; Boston College; and Massachusetts General Hospital, Boston, MA
| | - Susan DeSanto-Madeya
- Beth Israel Deaconess Medical Center; Boston College; and Massachusetts General Hospital, Boston, MA
| | - Matthew Gregas
- Beth Israel Deaconess Medical Center; Boston College; and Massachusetts General Hospital, Boston, MA
| | - Jessica Lynch
- Beth Israel Deaconess Medical Center; Boston College; and Massachusetts General Hospital, Boston, MA
| | - David F. McDermott
- Beth Israel Deaconess Medical Center; Boston College; and Massachusetts General Hospital, Boston, MA
| | - Mary K. Buss
- Beth Israel Deaconess Medical Center; Boston College; and Massachusetts General Hospital, Boston, MA
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El-Jawahri A, Traeger L, Shin JA, Knight H, Mirabeau-Beale K, Fishbein J, Vandusen HH, Jackson VA, Volandes AE, Temel JS. Qualitative Study of Patients' and Caregivers' Perceptions and Information Preferences About Hospice. J Palliat Med 2017; 20:759-766. [PMID: 28557586 DOI: 10.1089/jpm.2016.0104] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The goal of this study is to assess perceptions about hospice among patients with metastatic cancer and their caregivers (i.e., family and/or friends). DESIGN AND SETTING We conducted semi-structured interviews with 16 adult patients with a prognosis ≤12 months and 7 of their caregivers. The interviews focused on perceptions, knowledge, and information preferences about hospice. Two raters coded interviews independently (κ > 0.85). We used a framework approach for data analysis. RESULTS Participants showed variable gaps in understanding about hospice, including who would benefit from hospice care and the extent of services provided. They all perceived that hospice involves a psychological transition to accepting imminent death and often referred to hospice from a relatively cognitive distance, using hypothetical scenarios of others for whom hospice would be more relevant. Participants' attitudes about hospice reflected their concerns about suffering, loss of dignity, and death, as well as their perceived understanding of hospice services. These attitudes along with the psychological barriers to projecting a need for hospice and lack of knowledge were all perceived as important barriers to hospice utilization. All participants felt they needed more information about hospice, yet they were mixed regarding the optimal timing of this information. CONCLUSIONS Study participants had misunderstandings about hospice and perceived end-of-life (EOL) concerns such as fear of suffering, loss of dignity, and death, as well as lack of knowledge as the main barriers to hospice utilization. Interventions are needed to educate patients and their families about hospice and to address their EOL concerns.
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Affiliation(s)
- Areej El-Jawahri
- 1 Department of Hematology-Oncology, Massachusetts General Hospital , Boston, Massachusetts
- 2 Harvard Medical School , Boston, Massachusetts
| | - Lara Traeger
- 3 Department of Psychiatry, Massachusetts General Hospital , Boston, Massachusetts
| | - Jennifer A Shin
- 2 Harvard Medical School , Boston, Massachusetts
- 4 Department of Palliative Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Helen Knight
- 1 Department of Hematology-Oncology, Massachusetts General Hospital , Boston, Massachusetts
- 3 Department of Psychiatry, Massachusetts General Hospital , Boston, Massachusetts
| | - Kristina Mirabeau-Beale
- 2 Harvard Medical School , Boston, Massachusetts
- 5 Radiation Oncology, Massachusetts General Hospital , Boston, Massachusetts
- 6 General Internal Medicine, Massachusetts General Hospital , Boston, Massachusetts
| | - Joel Fishbein
- 1 Department of Hematology-Oncology, Massachusetts General Hospital , Boston, Massachusetts
- 3 Department of Psychiatry, Massachusetts General Hospital , Boston, Massachusetts
| | - Harry H Vandusen
- 1 Department of Hematology-Oncology, Massachusetts General Hospital , Boston, Massachusetts
- 3 Department of Psychiatry, Massachusetts General Hospital , Boston, Massachusetts
| | - Vicki A Jackson
- 2 Harvard Medical School , Boston, Massachusetts
- 4 Department of Palliative Care, Massachusetts General Hospital , Boston, Massachusetts
| | - Angelo E Volandes
- 2 Harvard Medical School , Boston, Massachusetts
- 5 Radiation Oncology, Massachusetts General Hospital , Boston, Massachusetts
- 6 General Internal Medicine, Massachusetts General Hospital , Boston, Massachusetts
| | - Jennifer S Temel
- 1 Department of Hematology-Oncology, Massachusetts General Hospital , Boston, Massachusetts
- 2 Harvard Medical School , Boston, Massachusetts
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Carpenter JG, McDarby M, Smith D, Johnson M, Thorpe J, Ersek M. Associations between Timing of Palliative Care Consults and Family Evaluation of Care for Veterans Who Die in a Hospice/Palliative Care Unit. J Palliat Med 2017; 20:745-751. [PMID: 28471732 DOI: 10.1089/jpm.2016.0477] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Palliative care consultations (PCC) improve end-of-life (EOL) care, although they may occur too late in an illness to effect the best outcomes. Evidence about the optimal timing of PCC is limited. OBJECTIVE To examine the associations between PCC timing and bereaved families' evaluation of care. METHODS A retrospective, cross-sectional analysis of data collected between October 2011 and September 2014 was conducted with 5,592 patients who died in a Veterans Affairs inpatient hospice/palliative care unit. The independent measure was the date of first documented PCC within 180 days of death. Outcomes came from the validated Bereaved Family Survey (BFS) and included one global and three subscale scores characterizing EOL care in the last month of life. RESULTS After adjustment for patient and facility characteristics, family members of veterans whose first PCC occurred 91-180 days before death were more likely to rate overall care as "excellent" compared with those whose PCC occurred 0-7 days before death, 67.9% versus 62.1%, respectively (adjusted odds ratio = 1.37; confidence interval [95% CI] 1.08-1.73). Mean scores on two of the three subscales also were significantly higher for veterans receiving PCC 31-90 days before the veteran's death compared with those who had their first PCC 0-7 days before death: Respectful Care and Communication, 13.6 versus 13.4, respectively (β = 0.26; 95% CI 0.11-0.41), and Emotional and Spiritual Support, 7.6 versus 7.4, respectively (β = 0.22; 95% CI 0.03-0.41). CONCLUSIONS Earlier PCC is associated with greater family satisfaction with care. Strategies that are aimed at conducting PCC earlier in life-limiting illness are needed.
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Affiliation(s)
- Joan G Carpenter
- 1 Corporal Michael J. Crescenz Veterans Affairs Medical Center , Philadelphia, Pennsylvania
| | - Meghan McDarby
- 1 Corporal Michael J. Crescenz Veterans Affairs Medical Center , Philadelphia, Pennsylvania
| | - Dawn Smith
- 1 Corporal Michael J. Crescenz Veterans Affairs Medical Center , Philadelphia, Pennsylvania
| | - Megan Johnson
- 1 Corporal Michael J. Crescenz Veterans Affairs Medical Center , Philadelphia, Pennsylvania
| | - Joshua Thorpe
- 2 Center for Health Equity Research and Promotion, Department of Veterans Affairs Medical Center , Pittsburgh, Pennsylvania.,3 Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy , Pittsburgh, Pennsylvania
| | - Mary Ersek
- 1 Corporal Michael J. Crescenz Veterans Affairs Medical Center , Philadelphia, Pennsylvania.,4 University of Pennsylvania School of Nursing , Philadelphia, Pennsylvania
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Nahapetyan L, Orpinas P, Glass A, Song X. Planning Ahead: Using the Theory of Planned Behavior to Predict Older Adults’ Intentions to Use Hospice if Faced With Terminal Illness. J Appl Gerontol 2017; 38:572-591. [DOI: 10.1177/0733464817690678] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Hospice is underutilized in the United States, and many patients enroll for short periods of times. The purpose of this cross-sectional study was to identify significant predictors of intentions to use hospice in community-dwelling older adults. The Theory of Planned Behavior informed the selection of predictors. Data were collected from 146 White older adults ( M age = 69.5; 69% females). Multiple linear regression analyses showed that higher hospice knowledge, normative beliefs that support hospice utilization, higher perceived control to use hospice, and preferences for end-of-life care that favor comfort and quality of life over living as long as possible were significant predictors of intentions to use hospice. In spite of being a sample of mostly highly educated older adults, almost half did not know about funding for hospice. These results provide better understanding of where to focus interventions to educate older adults about hospice, ideally in advance of a crisis.
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Affiliation(s)
| | | | - Anne Glass
- University of North Carolina Wilmington, USA
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Kumar P, Wright AA, Hatfield LA, Temel JS, Keating NL. Family Perspectives on Hospice Care Experiences of Patients with Cancer. J Clin Oncol 2016; 35:432-439. [PMID: 27992271 DOI: 10.1200/jco.2016.68.9257] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To determine whether hospice use by patients with cancer is associated with their families' perceptions of patients' symptoms, goal attainment, and quality of end-of-life (EOL) care. Methods We interviewed 2,307 families of deceased patients with advanced lung or colorectal cancer who were enrolled in the Cancer Care Outcomes Research and Surveillance study (a multiregional, prospective, observational study) and died by 2011. We used propensity-score matching to compare family-reported outcomes for patients who did and did not receive hospice care, including the presence and relief of common symptoms (ie, pain, dyspnea), concordance with patients' wishes for EOL care and place of death, and quality of EOL care. We also examined associations between hospice length of stay and these outcomes among hospice enrollees. Results In a propensity-score-matched sample of 1,970 individuals, families of patients enrolled in hospice reported more pain in their patient compared with those not enrolled in hospice. However, families of patients enrolled in hospice more often reported that patients received "just the right amount" of pain medicine (80% v 73%; adjusted difference, 7 percentage points; 95% confidence interval [CI], 1 to 12 percentage points) and help with dyspnea (78% v 70%; adjusted difference, 8 percentage points; 95% CI, 2 to 13 percentage points). Families of patients enrolled in hospice also more often reported that patients' EOL wishes were followed (80% v 74%; adjusted difference, 6 percentage points; 95% CI, 2 to 11 percentage points) and "excellent" quality EOL care (57% v 42%; adjusted difference, 15 percentage points; 95% CI, 11 to 20). Families of patients who received > 30 days of hospice care reported the highest quality EOL outcomes. Conclusion Hospice care is associated with better symptom relief, patient-goal attainment, and quality of EOL care. Encouraging earlier and increased hospice enrollment may improve EOL experiences for patients with cancer and their families.
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Affiliation(s)
- Pallavi Kumar
- Pallavi Kumar, University of Pennsylvania, Philadelphia, PA; Alexi A. Wright, Laura A. Hatfield, Jennifer S. Temel, and Nancy L. Keating, Harvard Medical School, and Nancy L. Keating, Brigham and Women's Hospital, Boston, MA
| | - Alexi A Wright
- Pallavi Kumar, University of Pennsylvania, Philadelphia, PA; Alexi A. Wright, Laura A. Hatfield, Jennifer S. Temel, and Nancy L. Keating, Harvard Medical School, and Nancy L. Keating, Brigham and Women's Hospital, Boston, MA
| | - Laura A Hatfield
- Pallavi Kumar, University of Pennsylvania, Philadelphia, PA; Alexi A. Wright, Laura A. Hatfield, Jennifer S. Temel, and Nancy L. Keating, Harvard Medical School, and Nancy L. Keating, Brigham and Women's Hospital, Boston, MA
| | - Jennifer S Temel
- Pallavi Kumar, University of Pennsylvania, Philadelphia, PA; Alexi A. Wright, Laura A. Hatfield, Jennifer S. Temel, and Nancy L. Keating, Harvard Medical School, and Nancy L. Keating, Brigham and Women's Hospital, Boston, MA
| | - Nancy L Keating
- Pallavi Kumar, University of Pennsylvania, Philadelphia, PA; Alexi A. Wright, Laura A. Hatfield, Jennifer S. Temel, and Nancy L. Keating, Harvard Medical School, and Nancy L. Keating, Brigham and Women's Hospital, Boston, MA
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Park EM, Deal AM, Yopp JM, Edwards T, Wilson DJ, Hanson LC, Rosenstein DL. End-of-life experiences of mothers with advanced cancer: perspectives of widowed fathers. BMJ Support Palliat Care 2016; 6:437-444. [PMID: 26685117 PMCID: PMC5293732 DOI: 10.1136/bmjspcare-2015-000976] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 10/12/2015] [Accepted: 11/25/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Despite the importance of parenting-related responsibilities for adult patients with terminal illnesses who have dependent children, little is known about the psychological concerns of dying parents and their families at the end of life (EOL). The aim of this study was to elicit widowed fathers' perspectives on how parental status may have influenced the EOL experiences of mothers with advanced cancer. SUBJECTS 344 men identified themselves through an open-access educational website as widowed fathers who had lost a spouse to cancer and were raising dependent children. METHODS Participants completed a web-based survey about their wife's EOL experience and cancer history, and their own depression (Center for Epidemiologic Studies Depression Scale, CES-D) and bereavement (Texas Revised Inventory of Grief, TRIG) symptoms. Descriptive statistics, Fisher's exact tests, and linear regression modelling were used to evaluate relationships between variables. RESULTS According to fathers, 38% of mothers had not said goodbye to their children before death and 26% were not at all 'at peace with dying.' Ninety per cent of widowed fathers reported that their spouse was worried about the strain on their children at the EOL. Fathers who reported clearer prognostic communication between wife and physician had lower CES-D and TRIG scores. CONCLUSIONS To improve EOL care for seriously ill patients and their families, we must understand the concerns of parents with dependent children. These data underscore the importance of parenting-related worries in this population and the need for additional clinical and research programmes devoted to addressing these issues.
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Affiliation(s)
- Eliza M Park
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC (USA)
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center Biostatistics Core Facility, University of North Carolina, Chapel Hill, NC (USA)
| | - Justin M Yopp
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC (USA)
| | - Teresa Edwards
- H. W. Odum Institute for Research in Social Science, University of North Carolina at Chapel Hill, Chapel Hill, NC (USA)
| | - Douglas J Wilson
- Lineberger Comprehensive Cancer Center Biostatistics Core Facility, University of North Carolina, Chapel Hill, NC (USA)
| | - Laura C Hanson
- Division of Geriatric Medicine and Palliative Care Program, Department of Medicine, University of North Carolina, Chapel Hill, NC (USA)
| | - Donald L Rosenstein
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC (USA)
- Department of Medicine, University of North Carolina, Chapel Hill, NC (USA)
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Willingness to use hospice care among caregivers of Latino patients in the United States–Mexico border region. Palliat Support Care 2016; 15:279-287. [PMID: 27609418 DOI: 10.1017/s1478951516000687] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTObjective:Hospice is an important method of promoting quality end-of-life (EoL) care, yet its utilization is relatively low in underserved populations. The unique characteristics of a border community—such as a lack of healthcare resources and cultural integration—impact EoL decision making. The aim of our study was to assess the willingness to use hospice care services and its predictors among family caregivers of Latino patients in the United States (U.S.)–Mexico border region of Southern California.Method:This study analyzes secondary data from a home health agency in the U.S.–Mexico border region. Quantitative data were collected via a face-to-face interview with 189 caregivers of patients enrolled in the agency. Bivariate tests and logistic regression were employed to address our study objectives.Results:The majority (83%) of family caregivers were willing to use hospice services for their loved ones. The factors impacting willingness to use hospice services included the primary language of the caregiver (OR = 6.30, CI95% = 1.68, 23.58); trust in doctors to make the right decisions (OR = 3.77, CI95% = 1.05, 13.57); and the belief that using hospice care means giving up on life (OR = 0.52, CI95% = 0.30; 0.88). Caregivers who trusted doctors to make the best decisions for their loved ones and English-speaking caregivers were more willing to utilize hospice services, while caregivers who held a strong belief that hospice care means giving up on life were less likely to consider using hospice care for their loved ones.Significance of results:The willingness of family caregivers to use hospice services for their loved ones is influenced by cultural perspectives about hospice care. As the importance of family involvement in EoL care planning has been highlighted, family caregivers' beliefs about hospice care services need to be addressed within their particular cultural context.
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Palmer WW, Yuen FK. The Impact of Hospice Patient Disease Type and Length of Stay on Caregiver Utilization of Grief Counseling: A 10-Year Retrospective Study. Am J Hosp Palliat Care 2016; 34:880-886. [DOI: 10.1177/1049909116662459] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This investigation explored the relationship between hospice patient disease type, length of stay (LOS) in hospice, and caregiver utilization of grief counseling in bereavement. A 10-year retrospective study was conducted utilizing data from caregivers associated with hospice patients who died between 2004 and 2014. A threshold of inclusion for disease type (≥1.00% of hospice admissions) resulted in a sample size of 3704 patients, comprising 19 different disease types and 348 associated caregivers who received counseling. Replicating a previous study, brain cancer, lung cancer, and renal failure were among the top 4 disease types associated with higher-than-average utilization of bereavement services among caregivers, regardless of the patient’s LOS. This finding may be related to factors such as the duration of the disease, the deterioration of the patient, the absence of symptom control, and secondary losses. LOS as a predictor of whether counseling will be utilized by hospice caregivers was unsupported by this study, as the percentage of caregivers receiving counseling closely paralleled the patient’s LOS across 4 cohorts (1-30 days, 31-60 days, 61-90 days, and 91+ days). However, among the caregivers who utilized counseling, the LOS was a statistically significant predictor of the number of counseling sessions utilized. For caregivers who utilized only 1 counseling session, the associated patient median LOS was 21.5 days. For caregivers who utilized 5 or more counseling sessions, the associated patient median LOS dropped to 12 days, suggesting an inverted relationship between hospice patient LOS and the duration of counseling in bereavement.
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Waldrop DP, Meeker MA, Kutner JS. Is It the Difference a Day Makes? Bereaved Caregivers' Perceptions of Short Hospice Enrollment. J Pain Symptom Manage 2016; 52:187-195.e1. [PMID: 27233144 PMCID: PMC4996677 DOI: 10.1016/j.jpainsymman.2016.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/17/2016] [Accepted: 04/06/2016] [Indexed: 11/30/2022]
Abstract
CONTEXT Hospice enrollment for less than one month has been considered too late by some caregivers and at the right time for others. Perceptions of the appropriate time for hospice enrollment in cancer are not well understood. OBJECTIVES The objectives of the study were to identify contributing factors of hospice utilization in cancer for ≤7 days, to describe and compare caregivers' perceptions of this as "too late" or at the "right time." METHODS Semistructured, in-depth, in-person interviews were conducted with a sample subgroup of 45 bereaved caregivers of people who died from cancer within seven days of hospice enrollment. Interviews were transcribed and entered into Atlas.ti for coding. Data were grouped by participants' perceptions of the enrollment as "right time" or "too late." RESULTS Overall, the mean length of enrollment was MLOE = 3.77 (SD = 1.8) days and ranged from three hours to seven days. The "right time" group (N = 25 [56%]) had a MLOE = 4.28 (SD = 1.7) days. The "too late" group (N = 20 [44%]) had a MLOE = 3.06 (SD = 1.03) days. The difference was statistically significant (P = 0.029). Precipitating factors included: late-stage diagnosis, continuing treatment, avoidance, inadequate preparation, and systems barriers. The "right time" experience was characterized by: perceived comfort, family needs were met, preparedness for death. The "too late" experience was characterized by perceived suffering, unprepared for death, and death was abrupt. CONCLUSION The findings suggest that one more day of hospice care may increase perceived comfort, symptom management, and decreased suffering and signal the need for rapid response protocols.
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Affiliation(s)
- Deborah P Waldrop
- University at Buffalo School of Social Work, Buffalo, New York, USA.
| | - Mary Ann Meeker
- University at Buffalo School of Nursing, Buffalo, New York, USA
| | - Jean S Kutner
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Tse CS, Ellman MS. Development, implementation and evaluation of a terminal and hospice care educational online module for preclinical students. BMJ Support Palliat Care 2016; 7:73-80. [DOI: 10.1136/bmjspcare-2015-000952] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 02/09/2016] [Accepted: 05/10/2016] [Indexed: 11/03/2022]
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Timing of referral to inpatient palliative care services for advanced cancer patients and earlier referral predictors in mainland China. Palliat Support Care 2015; 14:503-9. [PMID: 26481125 DOI: 10.1017/s1478951515001212] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Routine early integration of palliative care with advanced cancer management is not yet a part of standard practice in many countries, including mainland China. Whether patients in China suffering from advanced cancer are referred to palliative care services in a timely manner remains unclear. We sought to investigate the timing of palliative care referral of Chinese cancer patients at our center and its predictors. METHOD Retrospective medical data including demographic characteristics and referral information were collected for analysis. A total of 759 patients referred to our palliative care unit (PCU) from January of 2007 to December of 2013 were included in the final analysis. RESULTS The mean age of the 759 patients included in the study was 62.89 years (range 61.95-63.82). Some 369 patients (48.6%) were male and 559 (73.6%) Shanghainese (indigenous). Lung cancer (17.9%) was the most common diagnosis. The time interval since enrollment into the PCU until a patient's death (length of stay, LOS) was calculated. A longer LOS indicated earlier referral to inpatient PC services. The median LOS was 21 days (CI 95% = 19.79-22.21). Multivariate analysis showed that whether or not the patient was indigenous (p = 0.002) and younger than 65 (p = 0.031) were independent factors for a longer LOS. Such other characteristics as gender and primary cancer type bore no relationship to LOS. SIGNIFICANCE OF RESULTS Our findings demonstrate that Chinese cancer patients are referred relatively late in the course of their disease to inpatient palliative care services. To overcome the barriers to early integration of palliative care into a patient's treatment plan, accurate information about palliative care must be provided to both oncologists and patients via comprehensive and systematic educational programs.
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Kao YH, Chiang JK. Effect of hospice care on quality indicators of end-of-life care among patients with liver cancer: a national longitudinal population-based study in Taiwan 2000-2011. BMC Palliat Care 2015; 14:39. [PMID: 26286505 PMCID: PMC4545784 DOI: 10.1186/s12904-015-0036-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 08/11/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Quality of near end-of-life (EOL) care is typically evaluated using six accepted quality indicators (QIs). Research has yet to evaluate the quality of EOL care for liver cancer patients in Taiwan. We evaluated the effect of hospice care on the quality of EOL care for patients with advanced liver cancer. METHODS Using claims data obtained from the Taiwan National Health Insurance Research Database, we analyzed the QIs of EOL care for patients who died between 2000 and 2011. Logistic regression was performed to identify predictors for QIs of EOL care. RESULTS A total of 3092 adult patients died of liver cancer during the study period. The patients were divided into those who received hospice care for a period longer than 1 month (long-H group), shorter than 1 month (short-H group), and not at all (non-H group). There was no significant difference in survival probability among the three groups (p = 0.212). Compared with the non-H group, the long- and short-H groups exhibited a significantly lower risk of being admitted to an intensive care unit (ICU) (odds ratios [ORs] = 0.25 and 0.26, respectively, p < 0.001) and requiring cardiopulmonary resuscitation (CPR) during the final month of life (ORs = 0.21 and 0.09, respectively, p < 0.001). Compared with the non-H group, the short-H group had a higher risk of more than one emergency room (ER) visit, and more than one hospital admission (OR = 1.97, p = 0.003; and OR = 1.56, p = 0.001, respectively), but the long-H group did not differed significantly from the non-H group on these measures. CONCLUSIONS Patients with liver cancer who received hospice care were less likely to be admitted to ICUs or require CPR compared with those who received no hospice care. A longer duration of hospice care was associated with reduced risks of more than one ER visit and more than one hospital admission. We conclude that EOL cancer care in Taiwan might be improved by implementing policies encouraging early hospice referral programs.
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Affiliation(s)
- Yee-Hsin Kao
- Department of Family Medicine, Tainan Municipal Hospital, Tainan, Taiwan.
| | - Jui-Kun Chiang
- Department of Family Medicine, Buddhist Dalin Tzu Chi Hospital, 2 Minsheng Road, Dalin, Chiayi, Taiwan.
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MacKenzie MA, Meghani SH, Buck HG, Riegel B. Does Diagnosis Make a Difference? Comparing Hospice Care Satisfaction in Matched Cohorts of Heart Failure and Cancer Caregivers. J Palliat Med 2015; 18:1008-14. [PMID: 26275175 DOI: 10.1089/jpm.2015.0078] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Half of heart failure patients will die within five years of diagnosis, making them an ideal population for hospice to reach. Yet hospice originated in oncology, and problems have been noted with the enrollment of heart failure patients. Whether caregiver satisfaction, a key quality measure in hospice, differs between heart failure and cancer caregivers is unknown. OBJECTIVE We aimed to determine whether diagnosis makes a difference in satisfaction with hospice care in matched cohorts of heart failure caregivers and cancer caregivers. METHODS This was a national cohort study, using caregiver responses to the Family Evaluation of Hospice Care (FEHC) survey. Heart failure and cancer caregivers were matched via propensity scoring. The relationship between diagnosis and caregiver satisfaction was examined across the domains of symptom management, emotional support, caregiver teaching, coordination of care, and global satisfaction, both before and after matching via logistic regression. RESULTS One-to-one matching with calipers yielded 7730 matched pairs out of an original sample of 8175 heart failure caregivers and 24,972 cancer caregivers. Significant differences were found in caregiver teaching, emotional support, coordination of care, and global satisfaction prior to matching, but the effect sizes were small. All differences disappeared after matching. High rates of dissatisfaction with caregiver teaching (42%) and emotional support (30%) were found in both cohorts. CONCLUSIONS The diagnosis of heart failure, in and of itself, does not appear to make a difference in informal caregiver satisfaction with hospice care. Hospice provides high-quality care for patients, but improvements are needed in caring for the caregiver.
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Affiliation(s)
| | - Salimah H Meghani
- 2 School of Nursing, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Harleah G Buck
- 3 College of Nursing, The Pennsylvania State University , University Park, Pennsylvania
| | - Barbara Riegel
- 2 School of Nursing, University of Pennsylvania , Philadelphia, Pennsylvania
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Lendon JP, Ahluwalia SC, Walling AM, Lorenz KA, Oluwatola OA, Anhang Price R, Quigley D, Teno JM. Measuring Experience With End-of-Life Care: A Systematic Literature Review. J Pain Symptom Manage 2015; 49:904-15.e1-3. [PMID: 25543110 PMCID: PMC5063029 DOI: 10.1016/j.jpainsymman.2014.10.018] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 09/27/2014] [Accepted: 10/22/2014] [Indexed: 11/25/2022]
Abstract
CONTEXT Increasing interest in end-of-life care has resulted in many tools to measure the quality of care. An important outcome measure of end-of-life care is the family members' or caregivers' experiences of care. OBJECTIVES To evaluate the instruments currently in use to inform next steps for research and policy in this area. METHODS We conducted a systematic review of PubMed, PsycINFO, and PsycTESTS(®) for all English-language articles published after 1990 using instruments to measure adult patient, family, or informal caregiver experiences with end-of-life care. Survey items were abstracted and categorized into content areas identified through an iterative method using three independent reviewers. We also abstracted information from the most frequently used surveys about the identification of proxy respondents for after-death surveys, the timing and method of survey administration, and the health care setting being assessed. RESULTS We identified 88 articles containing 51 unique surveys with available content. We characterized 14 content areas variably present across the 51 surveys. Information and care planning, provider care, symptom management, and overall experience were the most frequent areas addressed. There was also considerable variation across the surveys in the identification of proxy respondents, the timing of survey administration, and in the health care settings and services being evaluated. CONCLUSION This review identified several comprehensive surveys aimed at measuring the experiences of end-of-life care, covering a variety of content areas and practical issues for survey administration. Future work should focus on standardizing surveys and administration methods so that experiences of care can be reliably measured and compared across care settings.
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Affiliation(s)
| | | | - Anne M Walling
- VA Greater Los Angeles, Los Angeles, California, USA; David Geffen School of Medicine at UCLA, Los Angeles, California, USA; RAND Corporation, Santa Monica, California, USA
| | - Karl A Lorenz
- VA Greater Los Angeles, Los Angeles, California, USA
| | | | | | | | - Joan M Teno
- Brown University, Providence, Rhode Island, USA
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