Determinants of the place of death in the Brussels metropolitan region

Pediatric palliative care utilization by decedent children: A nationwide population-based study, 2002-2017

PURPOSE

This study aimed (1) to describe how trends in pediatric palliative care (PPC) utilization changed from 2002 to 2017, and (2) to examine factors predicting PPC utilization among decedent children in Taiwan.

DESIGN

This retrospective, correlational study retrieved 2002-2017 data from three national claims databases in Taiwan.

METHODS

Children aged 1 through 18 years who died between January 2002 and December 2017 were included. Pediatric palliative care utilization was defined as PPC enrollment and PPC duration, with enrollment described by frequency (n) and percentage (%) and duration described by mean and standard deviation (SD). Logistic regression was used to examine the associations of various demographic characteristics with PPC enrollment; generalized linear regression was used to examine associations of the demographic characteristics with PPC duration.

FINDINGS

Across the 16-year study period, PPC enrollment increased sharply (15.49 times), while PPC duration decreased smoothly (by 29.41%). Cause of death was a continuous predictor of both PPC enrollment and PPC duration. The children less likely to be enrolled in PPC services were those aged 1 to 6 years, boys, living in poverty, living in rural areas, and diagnosed with life-threatening noncancer diseases.

CONCLUSION

This study used nationwide databases to investigate PPC enrollment and PPC duration among a large sample of deceased children from 2002 to 2017. The findings not only delineate trends and predictors of PPC enrollment and PPC duration but also highlight great progress in PPC as well as the areas still understudied and underserved. This information could help the pediatric healthcare system achieve the core value of family-centered care for children with life-threatening diseases and their families.

CLINICAL RELEVANCE

Pediatric palliative care should be widely and continuously implemented in routine pediatric clinical practice to enhance quality of life for children and their families at the end of life.

Home hospitalization for palliative cancer care: factors associated with unplanned hospital admissions and death in hospital

Background

Home hospitalization at the end of life can sometimes be perturbed by unplanned hospital admissions (UHAs, defined as any admission that is not part of a preplanned care procedure), which increase the likelihood of death in hospital. The objectives were to describe the occurrence and causes of UHAs in cancer patients receiving end-of-life care at home, and to identify factors associated with UHAs and death in hospital.

Methods

A retrospective, single-center study (performed at a regional cancer center in the city of Lille, northern France) of advanced cancer patients discharged to home hospitalization between January 2014 and December 2017. We estimated the incidence of UHA over time using Kaplan-Meier method and Kalbfleish and Prentice method. We investigated factors associated with the risk UHA in cause-specific Cox models. We evaluated factors associated with death in hospital in logistic regressions.

Results

One hundred and forty-two patients were included in the study. Eighty-two patients (57.7 %) experienced one or more UHAs, a high proportion of which occurred within 1 month after discharge to home. Most UHAs were related to physical symptoms and were initiated by the patient’s family physician. A post-discharge palliative care consultation was associated with a significantly lower incidence of UHAs. Sixty-five patients (47.8 % of the deaths) died in hospital. In a multivariate analysis, living alone and the presence of one or more children at home were associated with death in hospital.

Conclusions

More than 40 % of cancer patients receiving end of life home hospitalization were not readmitted to hospital, reflecting the effectiveness of this type of palliative care setting. However, over half of the UHAs were due to an acute intercurrent event. Our results suggest that more efforts should be focused on anticipating these events at home – primarily via better upstream coordination between hospital physicians and family physicians.

Care homes as hospices for the prevalent form of dying: An analysis of long-term care provision towards the end of life in England

In the UK and the Westernised countries, most people die aged 80+ from disabling, chronic and degenerative diseases, having spent several years in poor health. There is thus continuity between long-term care (LTC) and end of life care (EOLC) in old age, but this continuity is poorly understood within policy and almost nothing is known about what determines the modality and intensity of LTC provision in old age towards the end of life. Drawing on multinomial logistic regression analysis of the English Longitudinal Study of Ageing (ELSA), this paper evaluates how health and socio-demographic factors affect the relative probability of receiving care through one of five long-term care arrangements (LTCAs) from the time of need at age ≥50 to death; and assesses the consequences this has for the English LTC and EOLC policy and planning. The study reveals that hospices provide end-of-life LTC for cancer diagnoses and adults aged 50-64, while care homes provide open-ended and end-of-life LTC for non-cancer diagnoses, dementia, severe disability, and adults aged 80+. Further, the informal, formal, mixed and care home LTCAs reflect increasing levels of disability and ill-health, and decreasing levels of family support, with differences concerning education and gender. Finally, dementia and Parkinson's disease are the single strongest determinants of high formal LTC provision, and overall high care needs determine high formal LTC provision. Within the English context, the consequences of this are that: 1) Continued reliance on informal family care is not sustainable; 2) To provide free formal LTC to old adults with high care needs is appropriate; and 3) Hospices do not cater for the prevalent form of dying in old age while care homes do, being the de facto hospices for severely disabled, very old (80+) adults with dementia. Yet this is not represented in English EOLC policy and research.

Residents in a Remote Island Having Family Members in Distant Areas Showed Higher Preference for Place of End-of-Life Care: The Ajishima Study

INTRODUCTION

To investigate the proportion of those having preferred place for end-of-life care among residents in a remote island and its association with family composition.

METHODS

Cross-sectional questionnaire survey was conducted in Ajishima, an island 23 km away from the coast of Ishinomaki City, northeast of Japan. Between October 2017 and February 2018, the questionnaire was distributed to 288 eligible residents and 113 valid responses were analyzed. Primary outcome was whether the subjects had preferred place for end-of-life care. The explanatory variable was family composition defined as whether having family members inside or outside the island [none (In-/Out-), only inside the island (In+/Out-), only outside the island (In-/Out+), and both inside and outside (In+/Out+)]. Poisson regression analysis was used to calculate the prevalence ratios (PRs) and 95% confidence intervals (CIs) of showing preferred place in each group.

RESULTS

The proportion of those having preferred place for end-of-life care was 72.6% in total. This rate significantly differed across family composition groups: 67.6%, 40.0%, and 82.9% for In+/Out+, In+/Out-, and In-/Out+ groups, respectively. The PR (95%CI) of having preferred place was 0.66 (0.33, 1.36) and 1.26 (1.01, 1.56) for In+/Out- and In-/Out+ groups, respectively, compared with In+/Out+ group.

CONCLUSIONS

This study showed that significantly higher preference for place of end-of-life care was seen among residents who had family members only outside the island compared with those who had families both inside and outside. Health care professionals should consider family compositions when initiating end-of-life discussion to residents in remote areas.

What socio-economic factors determine place of death for people with life-limiting illness? A systematic review and appraisal of methodological rigour

BACKGROUND

Socio-economic factors play important roles in place of death. However, up-to-date knowledge on socio-economic determinants for place of death is warranted including analysis of collinearity between socio-economic determinants.

AIM

To examine associations between socio-economic determinants (social class, deprivation level in area of residence, income, education, occupation, urbanisation) and place of death among adult patients with life-limiting illnesses. Furthermore, to describe how these factors are operationalised and examined for collinearity.

DESIGN

A systematic review was performed (PROSPERO, record: CRD42018091218) and quality was assessed using the Newcastle-Ottawa Scale.

DATA SOURCES

A comprehensive search of PubMed, Embase, CINAHL, Scopus and PsycINFO was conducted for studies published from 1 January 2008 until the date of the search (23 March 2018) in English or Scandinavian languages.

RESULTS

Of the 1599 unique citations identified, 34 studies were eligible. Dying at home was to a high degree associated with better financial situation and living in rural areas. Furthermore, hospital death was associated with a high level of deprivation in the area of residence and being employed. Regarding educational level, we found mixed and inconclusive results.

CONCLUSION

Inequalities concerning place of death were found, and attention towards socio-economic inequality concerning place of death is necessary, especially in patients with a poor financial status, patients living in deprived and metropolitan areas and patients who are employed. Furthermore, we found a low degree of assessment for collinearity and adjustment of socio-economic variables. These issues should be considered in planning of future studies of socio-economic determinants for place of death.

The Impact of Socioeconomic Status on Place of Death Among Patients Receiving Home Palliative Care in Toronto, Canada: A Retrospective Cohort Study

BACKGROUND

Socioeconomic disparities in home death have been noted in the literature. Home-based palliative care increases access to home death and has been suggested as a means to decrease these disparities.

AIM

Our study examines the association between socioeconomic status and other demographic factors on place of death in a population receiving home palliative care in Toronto, Canada.

DESIGN

This is a retrospective chart review of patients who died between August 2013 and August 2015 when admitted to a home-based palliative care service. Multivariate multinomial regression examined the relationship between the place of death (home, palliative care unit [PCU], or acute care) with age, gender, primary diagnosis, and income quintile. Bivariate logistic regression was fitted to calculate the odds ratio (OR) and probability of preference for home death.

SETTING/PARTICIPANTS

Patients receiving home-based palliative care services from the Latner Centre for Palliative Care in Toronto, Canada.

RESULTS

A total of 2066 patients were included in multivariate analysis. Patients in the lowest income quintile had increased odds of dying in acute care (OR = 2.41, P < .001) or dying in PCU (OR = 1.64, P = .008) than patients in highest income quintile. Patients in the next lowest income quintiles 2 and 3 were also more likely to die in acute care. The rate of preference for home death was significantly lower in the lowest income quintile (OR = 0.47, P = .0047).

CONCLUSIONS

Patients in lower income quintiles are less likely to die at home, despite receiving home-based palliative care, although they may also be less likely to prefer home death.

Socioeconomic position and use of healthcare in the last year of life: A systematic review and meta-analysis

BACKGROUND

Low socioeconomic position (SEP) is recognized as a risk factor for worse health outcomes. How socioeconomic factors influence end-of-life care, and the magnitude of their effect, is not understood. This review aimed to synthesise and quantify the associations between measures of SEP and use of healthcare in the last year of life.

METHODS AND FINDINGS

MEDLINE, EMBASE, PsycINFO, CINAHL, and ASSIA databases were searched without language restrictions from inception to 1 February 2019. We included empirical observational studies from high-income countries reporting an association between SEP (e.g., income, education, occupation, private medical insurance status, housing tenure, housing quality, or area-based deprivation) and place of death, plus use of acute care, specialist and nonspecialist end-of-life care, advance care planning, and quality of care in the last year of life. Methodological quality was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS). The overall strength and direction of associations was summarised, and where sufficient comparable data were available, adjusted odds ratios (ORs) were pooled and dose-response meta-regression performed. A total of 209 studies were included (mean NOS quality score of 4.8); 112 high- to medium-quality observational studies were used in the meta-synthesis and meta-analysis (53.5% from North America, 31.0% from Europe, 8.5% from Australia, and 7.0% from Asia). Compared to people living in the least deprived neighbourhoods, people living in the most deprived neighbourhoods were more likely to die in hospital versus home (OR 1.30, 95% CI 1.23-1.38, p < 0.001), to receive acute hospital-based care in the last 3 months of life (OR 1.16, 95% CI 1.08-1.25, p < 0.001), and to not receive specialist palliative care (OR 1.13, 95% CI 1.07-1.19, p < 0.001). For every quintile increase in area deprivation, hospital versus home death was more likely (OR 1.07, 95% CI 1.05-1.08, p < 0.001), and not receiving specialist palliative care was more likely (OR 1.03, 95% CI 1.02-1.05, p < 0.001). Compared to the most educated (qualifications or years of education completed), the least educated people were more likely to not receive specialist palliative care (OR 1.26, 95% CI 1.07-1.49, p = 0.005). The observational nature of the studies included and the focus on high-income countries limit the conclusions of this review.

CONCLUSIONS

In high-income countries, low SEP is a risk factor for hospital death as well as other indicators of potentially poor-quality end-of-life care, with evidence of a dose response indicating that inequality persists across the social stratum. These findings should stimulate widespread efforts to reduce socioeconomic inequality towards the end of life.

The interaction of socioeconomic status with place of death: a qualitative analysis of physician experiences

Background

Home is a preferred place of death for many people; however, access to a home death may not be equitable. The impact of socioeconomic status on one’s ability to die at home has been documented, yet there remains little literature exploring mechanisms that contribute to this disparity. By exploring the experiences and insights of physicians who provide end-of-life care in the home, this study aims to identify the factors perceived to influence patients’ likelihood of home death and describe the mechanisms by which they interact with socioeconomic status.

Methods

In this exploratory qualitative study, we conducted interviews with 9 physicians who provide home-based care at a specialized palliative care centre. Participants were asked about their experiences caring for patients at the end of life, focusing on factors believed to impact likelihood of home death with an emphasis on socioeconomic status, and opportunities for intervention. We relied on participants’ perceptions of SES, rather than objective measures. We used an inductive content analysis to identify and describe factors that physicians perceive to influence a patient’s likelihood of dying at home.

Results

Factors identified by physicians were organized into three categories: patient characteristics, physical environment and support network. Patient preference for home death was seen as a necessary factor. If this was established, participants suggested that having a strong support network to supplement professional care was critical to achieving home death. Finally, safe and sustainable housing were also felt to improve likelihood of home death. Higher SES was perceived to increase the likelihood of a desired home death by affording access to more resources within each of the categories. This included better health and health care understanding, a higher capacity for advocacy, a more stable home environment, and more caregiver support.

Conclusions

SES was not perceived to be an isolated factor impacting likelihood of home death, but rather a means to address shortfalls in the three identified categories. Identifying the factors that influence ability is the first step in ensuring home death is accessible to all patients who desire it, regardless of socioeconomic status.

Factors promoting resident deaths at aged care facilities in Japan: a review

Due to an increasingly ageing population, the Japanese government has promoted elderly deaths in aged care facilities. However, existing facilities were not designed to provide resident end-of-life care and the proportion of aged care facility deaths is currently less than 10%. Consequently, the present review evaluated the factors that promote aged care facility resident deaths in Japan from individual- and facility-level perspectives to exploring factors associated with increased resident deaths. To achieve this, MEDLINE, CINAHL, Web of Science and Ichushi databases were searched on 23 January 2016. Influential factors were reviewed for two healthcare services (insourcing and outsourcing facilities) as well as external healthcare agencies operating outside facilities. Of the original 2324 studies retrieved, 42 were included in analysis. Of these studies, five focused on insourcing, two on outsourcing, seven on external agencies and observed facility/agency-level factors. The other 28 studies identified individual-level factors related to death in aged care facilities. The present review found that at both facility and individual levels, in-facility resident deaths were associated with healthcare service provision, confirmation of resident/family end-of-life care preference and staff education. Additionally, while outsourcing facilities did not require employment of physicians/nursing staff to accommodate resident death, these facilities required visits by physicians and nursing staff from external healthcare agencies as well as residents' healthcare input. This review also found few studies examining outsourcing facilities. The number of healthcare outsourcing facilities is rapidly increasing as a result of the Japanese government's new tax incentives. Consequently, there may be an increase in elderly deaths in outsourcing healthcare facilities. Accordingly, it is necessary to identify the factors associated with residents' deaths at outsourcing facilities.

Increasing Trend in Hospital Deaths Consistent among Older Decedents in Korea: A Population-based Study Using Death Registration Database, 2001-2014

Background

With improvement in hospice palliative care services and long-term care, Republic of Korea (hereafter South Korea) has recorded significant changes in places of death (e.g., hospital, home), especially among older adults. Over the last few decades, the most common places of death in South Korea were hospitals. However, Koreans, especially older adults, reportedly prefer to receive terminal care and eventually die at home. This study was conducted to investigate trends in places of death among older Korean adults and factors associated therewith.

Methods

Data were obtained from the Korean Death Registration Database maintained by the National Statistical Office. Decedents who died after the age of 65 years from 2001 to 2014 were included in the analysis. For descriptive analysis, proportions of places of death were analyzed and were used to plot graphs for visualizing trends during 13-year period. Logistic regression model was used to evaluate factors associated with places of death (hospital versus home).

Results

Two million three hundred fifty eight thousand two hundred eleven older adult decedents were included in final analysis. Hospitals were the most common places of death (57.82%), followed by homes (32.12%). Dying at social welfare facilities was rare (2.61%). A gradual increase in hospital deaths (31.38% in 2001 to 75.30% in 2014) and a subsequent decrease in home deaths (60.44% to 15.95% over the same period) were noted. Hospital deaths were more likely for younger patients (ORs 1.28, 95% CI 1.27-1.29), females (ORs 1.28, 95% CI 1.27-1.29), and single/divorced or widowed individuals (ORs 1.77, 1.49 and 1.03 respectively). A higher education level and living in urban areas were strongly associated with a higher likelihood of dying in a hospital.

Conclusion

Over the study period, there was a consistent increasing trend in hospital deaths in South Korea. Trends in place of death and factors associated therewith should be more intensely investigated and monitored. Resources and facilities should be increased to fulfill end-of-life care preferences and the needs of an increasingly older population in South Korea.

Socioeconomic Differences and Trends in the Place of Death among Elderly People in China

China is facing a dramatic aging of its population. Little is known about the factors that influence the place of death and the trends in the place of death for elderly people in China. The purposes of this study were: (1) to examine the impact of the socioeconomic status (SES) on place of death for elderly Chinese residents; and (2) to assess temporal trends in the place of death over the last 15 years. Data were derived from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) (1998–2012). Place-of-death as an outcome was dichotomized into either death at home or death outside the home. Logistic regression analyses were used to examine the impact of SES on place of death. The results showed that, of the 23,098 deaths during the study period, 87.78% occurred at home. The overall trend in home death has increased since 2005. SES was shown to be an important factor affecting place of death. The elderly with higher SES were more likely to die where health resources were concentrated, i.e., in a hospital or other type of institution. Our finding suggests that the trend towards a greater emphasis on death at home may call for the development of more supportive home care programs in China. Our finding also suggests that the socioeconomic differences in the place of death may be related to the availability of or access to health care services.

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

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

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

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

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

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

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

Predictors of Place of Death for Those in Receipt of Home-Based Palliative Care Services in Ontario, Canada

Many cancer patients die in institutional settings despite their preference to die at home. A longitudinal, prospective cohort study was conducted to comprehensively assess the determinants of home death for patients receiving home-based palliative care. Data collected from biweekly telephone interviews with caregivers (n = 302) and program databases were entered into a multivariate logistic model. Patients with high nursing costs (odds ratio [OR]: 4.3; confidence interval [CI]: 1.8-10.2) and patients with high personal support worker costs (OR: 2.3; CI: 1.1-4.5) were more likely to die at home than those with low costs. Patients who lived alone were less likely to die at home than those who cohabitated (OR: 0.4; CI: 0.2-0.8), and those with a high propensity for a home-death preference were more likely to die at home than those with a low propensity (OR: 5.8; CI: 1.1-31.3). An understanding of the predictors of place of death may contribute to the development of effective interventions that support home death.

A population-level study of place of death and associated factors in Sweden

Aims: The aims of this study were to examine, on a population level, where people die in Sweden, and to investigate associations between place of death and underlying cause of death, socioeconomic and environmental characteristics, with a particular interest in people dying from life-limiting conditions typically in need of palliative care. Methods: This population-level study is based on death certificate data for all deceased individuals in Sweden in 2012, with a registered place of death ( n=83,712). Multivariable logistic regression was performed to investigate associations between place of death and individual, socioeconomic and environmental characteristics. Results: The results show that, in 2012, 42.1% of all deaths occurred in hospitals, 17.8% occurred at home and 38.1% in nursing home facilities. Individuals dying of conditions indicative of potential palliative care needs were less likely to die in hospital than those dying of other conditions (OR = 0.73; 95% CI = 0.70–0.77). Living at home in urban areas was associated with higher likelihood of dying in hospital or in a nursing home (OR = 1.04 and 1.09 respectively). Educational attainment and marital status were found to be somewhat associated with the place of death. Conclusions: The majority of deaths in Sweden occur in institutional settings, with comparatively larger proportions of nursing home deaths than most countries. Associations between place of death and other variables point to inequalities in availability and/or utilization of health services at the end of life.

Moving to and dying in a nursing home depends not only on health - an analysis of socio-demographic determinants of place of death in Switzerland

Background

In developed countries generally about 7 out of 10 deaths occur in institutions such as acute care hospitals or nursing homes. However, less is known about the influence of non-medical determinants of place of death. This study examines the influence of socio-demographic and regional factors on place of death in Switzerland.

Data and Methods

We linked individual data from hospitals and nursing homes with census and mortality records of the Swiss general population. We differentiated between those who died in a hospital after a length of stay ≤2 days or ≥3 days, those who died in nursing homes, and those who died at home. In gender-specific multinomial logistic regression models we analysed N = 85,129 individuals, born before 1942 (i.e., ≥65 years old) and deceased in 2007 or 2008.

Results

Almost 70% of all men and 80% of all women died in a hospital or nursing home. Regional density of nursing home beds, being single, divorced or widowed, or living in a single-person household were predictive of death in an institution, especially among women. Conversely, homeownership, high educational level and having children were associated with dying at home.

Conclusion

Place of death substantially depends on socio-demographic determinants such as household characteristics and living conditions as well as on regional factors. Individuals with a lower socio-economic position, living alone or having no children are more prone to die in a nursing home. Health policy should empower these vulnerable groups to choose their place of death in accordance to needs and wishes.

The support needs of terminally ill people living alone at home: a narrative review

Context: The number of terminally ill people who live alone at home and without a caregiver is growing and exerting pressure on the stretched resources of home-based palliative care services. Objectives: We aimed to highlight the unmet support needs of terminally ill people who live alone at home and have no primary caregiver and identify specific models of care that have been used to address these gaps. Methods: We conducted a narrative review of empirical research published in peer-reviewed journals in English using a systematic approach, searching databases 2002-2013. This review identified 547 abstracts as being potentially relevant. Of these, 95 were retrieved and assessed, with 37 studies finally reviewed. Results: Majority of the studies highlighted the reduced likelihood of this group to be cared for and die at home and the experiences of more psychosocial distress and more hospital admissions than people with a primary caregiver. Few studies reported on the development of models of care but showed that the challenges faced by this group may be mitigated by interventions tailored to meet their specific needs. Conclusion: This is the first review to highlight the growing challenges facing community palliative care services in supporting the increasing number of people living alone who require care. There is a need for more studies to examine the effectiveness of informal support networks and suitable models of care and to provide directions that will inform service planning for this growing and challenging group.

Dying at home--is it better: a narrative appraisal of the state of the science

BACKGROUND

Achieving home care and home death is increasingly used as an outcome measure of palliative care services.

AIM

To appraise the state of the science on dying at home.

METHODS

Appraisal and narrative review developed from a plenary presentation at the European Association for Palliative Care (EAPC) 2012 meeting examining the research on variations and trends in place of death, factors associated with dying in the preferred place, presenting evidence on outcomes for those dying at home and suggesting future research questions.

RESULTS

Meeting patients' preferences and creating home-like environments has been a major concern for hospice and palliative care since its inception. During the 20(th) century, in many countries, hospital deaths increased and home deaths reduced. Despite the fact that this trend has been halted or reversed in some countries (notably the United States, Canada and, more recently, the United Kingdom) in the last 5-20 years, a home death is still a distant reality for the majority, even though evidence shows it is the most commonly preferred place to die. Epidemiological studies identified factors associated with home death, including affluence, patients' preferences, provision of home care and extended family support. Evidence about the benefits of home care is conflicting, but recent data suggest that holistic well-being may be greater at home.

IMPLICATIONS

We call for further analyses of variations in place of care and place of death and robust studies on how patients and families formulate and change preferences over time. Regular monitoring of outcomes, quality and costs of palliative home care is urged.

Determinants of place of death: a population-based retrospective cohort study

Background

As Canada’s population ages, the location of end of life care (whether at home, extended care facility or hospital) may change depending on the location of death. We carried out a study to identify determinants of the place of death.

Methods

Data on deaths in British Columbia between 2004 and 2008 were obtained from the Vital Statistics Agency. Place of death was categorized into home, extended care facility, hospital or other. Logistic regression analyses were used to estimate the effects of age, sex, marital status, residence, place of birth and cause of death on place of death using adjusted odds ratios and 95% confidence intervals (95% CI).

Results

Of the 153,111 deaths in the study, 16.5% occurred at home, 29.0% in extended care, 51.0% in hospital and 3.5% occurred elsewhere. Male deaths were less likely to occur in extended care as compared with female deaths (odds ratio 0.73, 95% CI 0.71–0.75). Age (odds ratio 3.31, 95% CI 3.19–3.45 for those for ≥90 vs 70–79 years), marital status (odds ratio 1.42, 95% CI 1.38–1.47 widowed vs married), residence (odds ratio 0.80, 95% CI 0.76–0.83 rural vs Vancouver), place of birth (odds ratio 0.80, 95% CI 0.75–0.86 China vs Canada) and cause of death (odds ratio 3.91, 95% CI 3.69–4.13 dementia vs cancer) were also associated with death in extended care.

Conclusions

Information on determinants of place of death can inform public health policy regarding care at the end of life and make resource allocation more efficient.

Association of hospice patients' income and care level with place of death

IMPORTANCE

Terminally ill patients with lower incomes are less likely to die at home, even with hospice care.

OBJECTIVES

To examine the relationship between income and transfer from home before death and the interaction between income and level of hospice care as a predictor of transfer from home in patients admitted to routine home hospice care.

DESIGN

We matched zip codes to US census tracts to generate median annual household incomes and divided the measure into $10,000 increments (≤$20,000 to >$50,000). We abstracted data from the central administrative and clinical database of a hospice care provider. We analyzed the relationship between income and transfer from home before death using logistic regression adjusted for demographics, diagnosis, region, and length of stay. Level of hospice care was examined as any continuous care vs none. Unlike routine care, which includes periodic visits by hospice, continuous care is a higher level of care used for short periods of crisis to keep a patient at home and includes hospice services in the home at least 8 hours in a 24-hour period.

SETTING

A for-profit hospice provider, VITAS Healthcare, operating 26 programs in 8 states.

PARTICIPANTS

Hospice patients admitted to routine care in a private residence from January 1, 1999, through December 31, 2003.

MAIN OUTCOME MEASURE

Transfer from hospice care in a private residence to hospice care in a site outside the home before death.

RESULTS

Of the 61,063 enrollees admitted to routine care in a private residence, 13,804 (22.61%) transferred from home to another location (ie, inpatient hospice unit or nursing home) with hospice care before death. Patients who transferred had a lower mean median household income ($42,585 vs $46,777; P < .001) and were less likely to have received any continuous care (49.38% vs 30.61%; P < .001). The median number of days of continuous care was 4. For patients who did not receive continuous care, the odds of transfer from home before death increased with decreasing median annual household incomes (odds ratio range, 1.26-1.76). For patients who received continuous care, income was not a predictor of transfer from home.

CONCLUSIONS AND RELEVANCE

Patients with limited resources may be less likely to die at home, especially if they are not able to access needed support beyond what is available with routine hospice care.

Place of death and health care utilization for people in the last 6 months of life in Switzerland: a retrospective analysis using administrative data

Background

There is a growing interest in examining the current state of care and identifying opportunities for improving care and reducing costs at the end of life. The aim of this study is to examine patterns of health care use at the end of life and place of death and to describe the basic characteristics of the decedents in the last six months of their life.

Methods

The empirical analysis is based on data from 58,732 Swiss residents who died between 2007 and 2011. All decedents had mandatory health insurance with Helsana Group, the largest health insurer in Switzerland. Descriptive statistical techniques were used to provide a general profile of the study population and determinants of the outcome for place of death were analyzed with an econometric approach.

Results

There were substantial and significant differences in health care utilization in the last six months of life between places of death. The mean numbers of consultations with a general practitioner or a specialist physician as well as the number of different medications and the number of hospital days was consistently highest for the decedents who died in a hospital. We found death occurred in Switzerland most frequently in hospitals (38.4% of all cases) followed by nursing homes (35.1%) and dying at home (26.6%). The econometric analysis indicated that the place of death is significantly associated with age, sex, region and multiple chronic conditions.

Conclusions

The importance of nursing homes and patients’ own homes as place of death will continue to grow in the future. Knowing the determinants of place of death and patterns of health care utilization of decedents can help decision makers on the allocation of these needed health care services in Switzerland.

A national study of chaplaincy services and end-of-life outcomes

BACKGROUND

Medicine has long acknowledged the role of chaplains in healthcare, but there is little research on the relationship between chaplaincy care and health outcomes. The present study examines the association between chaplaincy services and end-of-life care service choices.

METHODS

HealthCare Chaplaincy purchased the AHA survey database from the American Hospital Association. The Dartmouth Atlas of Health Care database was provided to HealthCare Chaplaincy by The Dartmouth Institute for Health Policy & Clinical Practice, with the permission of Dartmouth Atlas Co-Principal Investigator Elliot S. Fisher, M.D., M.P.H. The Dartmouth Atlas of Health Care is available interactively on-line at http://www.dartmouthatlas.org/. Patient data are aggregated at the hospital level in the Dartmouth Atlas of Health Care. IRB approval was not sought for the project because the data are available to the public through one means or another, and neither database contains data about individual patients, i.e. all the variables are measures of hospital characteristics. We combined and analyzed data from the American Hospital Association's Annual Survey and outcome data from The Dartmouth Atlas of Health Care in a cross-sectional study of 3,585 hospitals. Two outcomes were examined: the percent of patients who (1) died in the hospital, and (2) were enrolled in hospice. Ordinary least squares regression was used to measure the association between the provision of chaplaincy services and each of the outcomes, controlling for six factors associated with hospital death rates.

RESULTS AND DISCUSSION

The analyses found significantly lower rates of hospital deaths (β = .04, p < .05) and higher rates of hospice enrollment (β = .06, p < .001) for patients cared for in hospitals that provided chaplaincy services compared to hospitals that did not.

CONCLUSIONS

The findings suggest that chaplaincy services may play a role in increasing hospice enrollment. This may be attributable to chaplains' assistance to patients and families in making decisions about care at the end-of-life, perhaps by aligning their values and wishes with actual treatment plans. Additional research is warranted.

Place of death related to demographic factors for hospice patients in Wellington, Aotearoa New Zealand

BACKGROUND

Because socioeconomic and cultural factors contribute to where one dies, it is important to document place of death determinants in diverse societies.

AIM

The purpose of this study was to describe where persons in an Aotearoa New Zealand hospice die, and to identify factors that are associated with place of death.

DESIGN

A retrospective chart review was conducted.

SETTING/PARTICIPANTS

Data were extracted from the charts of all patients receiving services from one hospice (i.e. secondary care) for whom death occurred during 2006-2008; 1268 cases for whom place of death was recorded comprise this sample.

RESULTS

For close to half (47%), death occurred in the hospice inpatient unit, whereas 29% died at home, 8% died in an acute hospital setting, and 17% died in an aged/residential care facility. Bivariate analyses showed that persons who die in an aged/residential care facility are more likely to be aged 65 or older, unmarried, have a non-cancer diagnosis, and are likely poorer. Asians, those aged less than 65, those with cancer, and those admitted initially to hospice for respite care tended to die in the hospice inpatient unit. Multinominal logistic regression indicated that dying at home was only predicted by being from a Pacific Island.

CONCLUSIONS

Age, economics, diagnosis, ethnicity, marital status, and whether one enters a hospice service for (at least in part) respite were all associated to a certain extent with where one dies. These findings contribute to the growing evidence linking various factors, especially ethnic groups, with place of death.

[Where do people die?: On the question of dying in institutions]

There is a great discrepancy in society between the number of people that prefer to die within their home and the number of cases where this wish actually becomes reality. The most frequent place of dying in Western societies is not the home but an institution, such as a hospital or nursing home. But what is the actual distribution of places of dying? Can we identify social patterns of dying related to the various places of dying? The article provides a theoretical and empirical overview of place of dying as a social phenomenon. Contemporary discourse on the institutionalization of dying is subjected to critical scrutiny in light of the state of the art of research.

The use of palliative care services associated with better dying circumstances. Results from an epidemiological population-based study in the brussels metropolitan region

CONTEXT

There is some consensus that a "good death" is one which occurs at home, in the presence of loved ones, and is free of distress. Involvement of palliative care services is assumed to improve these circumstances.

OBJECTIVES

This population-based study describes characteristics of the end of life of patients dying in Brussels and examines their associations with the involvement of palliative care services.

METHODS

In 2007, an anonymous large-scale mortality follow-back survey was conducted in Brussels by mailing questionnaires regarding end-of-life care and characteristics to the attending physicians of a representative sample of 1961 deaths.

RESULTS

Response rate was 41% (n=701). Of all deaths, 59% were nonsudden. Of these, 12% took place at home. For 27%, the attending physician was informed about the patient's preferred place of death. When the preference to die at home was known, 66% died at home. At the moment of death, in 47% of nonsudden deaths, loved ones were present. In a quarter of deaths, palliative care services were involved. Involvement with palliative care services was more likely for cancer patients than noncancer patients and was associated with the attending physicians more often being informed about the preferred place of death, with patients more often dying at home, with loved ones more often being present, and with a better feeling of well-being on the last day.

CONCLUSION

Overall, circumstances at the very end of life are suboptimal in Brussels. This study provides a case for stronger involvement of palliative care as a focal point for policies to improve end-of-life circumstances in a metropolitan area such as Brussels.

Dying in the margins: understanding palliative care and socioeconomic deprivation in the developed world

CONTEXT

Individuals from low socioeconomic (SE) groups have less resources and poorer health outcomes. Understanding the nature of access to appropriate end-of-life care services for this group is important.

OBJECTIVES

To evaluate the literature in the developed world for barriers to access for low SE groups.

METHODS

Electronic databases searched in the review included MEDLINE (1996-2010), CINAHL (1996-2010), PsychINFO (2000-2010), Cochrane Library (2010), and EMBASE (1996-2010). Publications were searched for key terms "socioeconomic disadvantage," "socioeconomic," "poverty," "poor" paired with "end-of-life care," "palliative care," "dying," and "terminal Illness." Articles were analyzed using existing descriptions for dimensions of access to health services, which include availability, affordability, acceptability, and geographical access.

RESULTS

A total of 67 articles were identified for the literature review. Literature describing end-of-life care and low SE status was limited. Findings from the review were summarized under the headings for dimensions of access.

CONCLUSION

Low SE groups experience barriers to access in palliative care services. Identification and evaluation of interventions aimed at reducing this disparity is required.

Factors influencing place of death in Germany

CONTEXT

Knowledge about factors influencing the place of death may be very useful for the planning of public health strategies to improve the situation of terminally ill patients.

OBJECTIVES

The aim of our study was to determine where people died in the German federal state of Rhineland-Palatinate in 2008. We further wanted to detect which factors had an influence on the place of death.

METHODS

Our cross-sectional survey was based on a random sample of 5000 inhabitants of Rhineland-Palatinate who had died between May 25, 2008 and August 24, 2008. Relatives of these randomly drawn deceased persons were interviewed by means of a written survey.

RESULTS

After removing duplicates, 4967 questionnaires were sent out. In total, 3832 questionnaires were delivered and 1378 completed, leading to a response rate of 36.0%. Of this group, 38.2% of the deceased died at home, 39.3% in a hospital, 13.4% in a nursing home, 7.5% in a palliative care facility, and 1.6% elsewhere. Suffering from cancer (adjusted odds ratio [AOR]: 1.30; 95% confidence interval [CI]: 1.01-1.68), social support (AOR being married: 1.33; 95% CI: 1.04-1.70; AOR having a nonworking relative: 1.71; 95% CI: 1.28-2.29), a high care level (AOR Care Level II: 2.79; 95% CI: 2.06-3.79, AOR Care Level III: 4.96; 95% CI: 3.40-7.24), and living in a rural municipality (AOR: 1.36; 95% CI: 1.01-1.84) were major factors favoring home death compared with institutional death.

CONCLUSION

Compared with other European countries, home death is still a frequent event in the federal state of Rhineland-Palatinate. Regional health policy should consider the actual distribution of place of death and corresponding predicting factors when establishing specialized palliative care home services as designed by recent German health legislation.

Study of recent and future trends in place of death in Belgium using death certificate data: a shift from hospitals to care homes

Background

Since most patients prefer out-of-hospital death, place of death can be considered an indicator of end-of-life care quality. The study of trends in place of death is necessary to examine causes of shifts, to evaluate efforts to alter place of death and develop future policies. This study aims to examine past trends and future projections of place of death.

Methods

Analysis of death certificates (decedents aged ≥ 1 year) in Belgium (Flanders and Brussels Capital region) 1998-2007. Trends in place of death were adjusted for cause of death, sociodemographic characteristics, environmental factors, numbers of hospital beds, and residential and skilled nursing beds in care homes. Future trends were based on age- and sex-specific mortality prognoses.

Results

Hospital deaths decreased from 55.1% to 51.7% and care home deaths rose from 18.3% to 22.6%. The percentage of home deaths remained stable. The odds of dying in a care home versus hospital increased steadily and was 1.65 (95%CI:1.53-1.78) in 2007 compared to 1998. This increase could be attributed to the replacement of residential beds by skilled nursing beds. Continuation of these trends would result in the more than doubling of deaths in care homes and a decrease in deaths at home and in hospital by 2040.

Conclusions

Additional end-of-life care resources in care homes largely explain the decrease in hospital deaths. Care homes will become the main locus of end-of-life care in the future. Governments should provide sufficient skilled nursing resources in care homes to fulfil the end-of-life care preferences and needs of patients.

Palliative inpatients in general hospitals: a one day observational study in Belgium

BACKGROUND

Hospital care plays a major role at the end-of-life. But little is known about the overall size and characteristics of the palliative inpatient population. The aim of our study was to analyse these aspects.

METHODS

We conducted a one-day observational study in 14 randomly selected Belgian hospitals. Patients who met the definition of palliative patients were identified as palliative. Then, information about their socio-demographic characteristics, diagnoses, prognosis, and care plan were recorded and analysed.

RESULTS

There were 2639 in-patients on the day of the study; 9.4% of them were identified as "palliative". The mean age of the group was 72 years. The primary diagnosis was cancer in 51% of patients and the estimated life expectancy was shorter than 3 months in 33% of patients and longer than 1 year in 28% of patients. The professional caregivers expected for most of the patients (73%), that the treatment would improve patient comfort rather than prolong life. Antibiotics, transfusions, treatments specific to the pathology, and artificial nutrition were administered in 90%, 78%, 57% and 50% of the patients, respectively, but were generally given with a view to controlling the symptoms.

CONCLUSIONS

This analysis presents a first national estimate of the palliative inpatient population. Our results confirm that hospitals play a major role at the end-of-life, with one out of ten inpatients identified as a "palliative" patient. These data also demonstrate the complexity of the palliative population and the substantial diversity of care that they can require.

Place of death in metropolitan regions: metropolitan versus non-metropolitan variation in place of death in Belgium, The Netherlands and England

Place of death is an important societal indicator of end-of-life quality for the terminally ill. Using death certificate data, we examined metropolitan/non-metropolitan variation in place of death of patients with life-limiting conditions in Belgium, The Netherlands and England. Metropolitan patients were less likely to die at home and, in England, less likely to die in care homes, than non-metropolitan terminally ill. We found a lesser degree of social support and lower availability of care home beds as partial explanations of the metropolitan/non-metropolitan discrepancy. These findings warrant specific approaches to end-of-life care in metropolitan areas.