Hospital versus home death: results from the Mexican Health and Aging Study

Global epidemiology of acute coronary syndromes

This Review provides an epidemiological overview of global mortality from acute coronary syndromes (ACS). Across the regions of the world where data are available, mortality from ACS - including premature (age <70 years) mortality from ACS - was higher in men than in women. In both sexes, age-standardized mortality rates (ASMRs) for ACS in 2020 were highest in lower-income global regions. However, 20 years earlier, ASMRs for ACS were highest in higher-income global regions, including Europe, Northern America and Oceania. These higher-income regions have seen progressive reductions in mortality from ACS during the past 20 years, which is in contrast to the more stable levels of mortality from ACS in Asia and in Latin America and the Caribbean. In the seven African countries with data available, a small upwards trend in ASMRs for ACS was observed, reflecting an epidemiological transition that is already well advanced in these regions. Consistent with these changes during the past 20 years were >50% reductions in ASMRs for ACS in the high-income countries of the world compared with <15% reductions in lower-middle-income countries. Policymakers need more complete epidemiological data across and within global regions to identify those countries in which the burden of death from ACS is greatest and the need to implement preventive strategies is most pressing.

Place of death among foreign-born individuals: a national population-based register study

Background

Relatively little is known about where foreign-born individuals die in Sweden and how birth region might influence place of death. Thus, there is a need for population-based studies investigating place of death and associated factors among foreign-born individuals.

Objectives

The aim of this study was to identify variations in place of death among foreign-born individuals residing in Sweden and to compare place of death between the foreign- and domestic-born population. We also examine the association between place of death, underlying cause of death and sociodemographic characteristics among the foreign-born population.

Design

A population-based register study.

Methods

All deceased individuals ⩾18 years of age in Sweden with a registered place of death between 2012 and 2019 (n = 682,697). Among these, 78,466 individuals were foreign-born. Univariable multinomial logistic regression modelling and multivariable multinomial logistic regression analyses were performed.

Results

Overall, hospital was the most common place of death among the foreign-born population. However, there were variations in place of death related to region of birth. Compared to domestic-born, a higher proportion of foreign-born individuals dies at home, the majority of whom were born on the African continent.

Conclusion

Region of birth is one of the several factors associated with place of death among foreign-born individuals. Further research is needed to explore both preferences and barriers to place of death among foreign-born individuals.

Cross-national differences in wealth inequality in health services and caregiving used near the end of life

Background

Socioeconomic inequality in access to and use of health services and social care provided near the end of life, or end-of-life care (EOLC), is not well understood in many countries. We examined wealth inequality in EOLC-hospital, nursing home, and hospice use and receipt of formal and informal caregiving-in 22 countries in Europe, Asia (South Korea), and North America (United States, Mexico).

Methods

We used harmonized data from nationally representative studies of people aged 50 and older that collected information on healthcare utilisation and caregiving receipt in the time preceding death. We categorized countries according to their level of public long-term care (LTC) spending and examined EOLC prevalence across countries. We used logistic regression models to estimate wealth inequality in each type of EOLC.

Findings

In the USA the least wealthy had more hospital (OR 1.30, p = 0.008) and nursing home/care use (OR 1.88, p < 0.001). In South Korea the least wealthy had more nursing home/care use (OR 2.24, p = 0.003). The least wealthy in high LTC Europe had less hospice use (OR 0.56, p = 0.003). The least wealthy were also less likely to be hospitalized in European countries with low LTC spending (OR 0.81, p = 0.04), but more likely to receive informal caregiving (OR 1.25, p = 0.033). Formal care was more common among the least wealthy in high LTC Europe (OR 1.57, p = 0.002), the USA (OR 1.42, p < 0.001) and South Korea (OR 1.69, p = 0.028), but less common among the least wealthy in Mexico (OR 0.17, p < 0.001).

Interpretation

Wealth inequality in EOLC exists across countries and reflects differences in the organization, financing, and delivery of care in different countries. The findings highlight the need to consider equity in current and future plans to improve EOLC access.

Funding

United States National Institute on Aging Grant R01AG030153.

Place of death and associated factors in 12 Latin American countries: A total population study using death certificate data

Background

Methods

Results

Conclusions

Feasibility of using death certificates for studying place of death in Latin America

Objective

This paper assesses the availability and quality of death certificate data in Latin America and the feasibility of using these data to study place of death and associated factors.

Methods

In this comparative study, we collected examples of current official death certificates and digital data files containing information about all deaths that occurred during 1 year in 19 Latin American countries. Data were collected from June 2019 to May 2020. The records for place of death and associated variables were studied. The criteria for data quality were completeness, number of ill-defined causes of death and timeliness.

Results

All 19 countries provided copies of current official death certificates and 18 of these registered the place of death. Distinguishing among hospital or other health care institution, home and other was possible for all countries. Digital data files with death certificate data were available from 12 countries and 1 region. Three countries had data considered to be of high quality and seven had data considered to be of medium quality. Categories for place of death and most of the predetermined factors possibly associated with place of death were included in the data files.

Conclusions

The quality of data sets was rated medium to high in 10 countries. Hence, death certificate data make it feasible to conduct an international comparative study on place of death and the associated factors in Latin America.

[Excess deaths during the COVID-19 pandemic: underreporting and regional inequalities in Brazil]

Brazil is one of the most heavily impacted countries by the COVID-19 pandemic, and the real number of deaths from the disease makes the scenario even more challenging. This study aimed to estimate the excess deaths and their differences in adults 20 years and older in Manaus (Amazonas State), Fortaleza (Ceará State), Rio de Janeiro, and São Paulo, according to place of death, demographic characteristics, and trajectory over time. The data were obtained from the Mortality Information System and the Central Information Office of the National Civil Registry. The estimates of expected deaths were obtained from quasi-Poisson generalized additive models, adjusting for overdispersion. From February 23 to June 13, 2020, 74,410 natural deaths were recorded in the four cities, with 46% excess deaths (95%CI: 44-47). The largest amount of excess deaths was in Manaus, with 112% (95%CI: 103-121), followed by Fortaleza with 72% (95%CI: 67-78), Rio de Janeiro with 42% (95%CI: 40-45), and São Paulo with 34% (95%CI: 32-36). Excess deaths were greater in males and non-significant in Epidemiologic Weeks (EW) 9-12, except in São Paulo, 10% (95%CI: 6-14). The peak in excess deaths generally occurred in EW 17-20. The number of excess deaths not explained directly by COVID-19 and deaths at home or on public byways is high, especially in Manaus. The high percentages of excess deaths, deaths not explained directly by COVID-19, and deaths outside the hospital suggest high underreporting of deaths from COVID-19 and reinforce the extensive spread of SARS-CoV-2, as well as the need for epidemiological surveillance services to review all causes of deaths associated with respiratory symptoms.

Relationship of place of death with care capacity and accessibility: a multilevel population study of system effects on place of death in Norway

BACKGROUND

While the majority of deaths in high-income countries currently occur within institutional settings such as hospitals and nursing homes, there is considerable variation in the pattern of place of death. The place of death is known to impact many relevant considerations about death and dying, such as the quality of the dying process, family involvement in care, health services design and health policy, as well as public versus private costs of end-of-life care. The objective of this study was to analyse how the availability and capacity of publicly financed home-based and institutional care resources are related to place of death in Norway.

METHODS

This study utilized a dataset covering all deaths in Norway in the years 2003-2011, contrasting three places of death, namely hospital, nursing home and home. The analysis was performed using a multilevel multinomial logistic regression model to estimate the probability of each outcome while considering the hierarchical nature of factors affecting the place of death. The analysis utilized variation in health system variables at the local community and hospital district levels. The analysis was based on data from two public sources: the Norwegian Cause of Death Registry and Statistics Norway.

RESULTS

Hospital accessibility, in terms of short travel time and hospital bed capacity, was positively associated with the likelihood of hospital death. Higher capacity of nursing home beds increased the likelihood of nursing home death, and higher capacity of home care increased the likelihood of home death. Contrasting three alternative places of death uncovered a pattern of service interactions, wherein hospital and home care resources together served as an alternative to end-of-life care in nursing homes.

CONCLUSIONS

Norway has a low proportion of home deaths compared with other countries. The proportion of home deaths varies between local communities. Increasing the availability of home care services is likely to enable more people to die at home, if that is what they prefer.

Returning home to die or leaving home to seek health care? Location of death of urban and rural residents in Burkina Faso and Senegal

Background: In sub-Saharan Africa, the literature on end of life is limited and focuses on place of death as an indicator of access and utilization of health-care resources. Little is known about population mobility at the end of life.

Objective: To document the magnitude, motivations and associated factors of short-term mobility before death among adults over 15 years of age in Burkina Faso and Senegal.

Methods: The study was based on deaths of adult residents reported in three Health and Demographic Surveillance System (HDSS) sites in urban (Ouagadougou) and semi-rural areas (Kaya) of Burkina Faso, and rural areas of Senegal (Mlomp). After excluding deaths from external causes, the analysis covered, respectively, 536 and 695 deaths recorded during the period 2012–2015 in Ouagadougou and Kaya. The period was extended to 2000–2015 in Mlomp, with a sample of 708 deaths. Binary logistic regressions were used to examine the effects of socio-demographic characteristics on place of death (health facility or not) and location of death (within or outside the HDSS).

Results: In Mlomp, Kaya and Ouagadougou, respectively 20.6%, 5.3% and 5.9% of adults died outside the HDSS site. In Mlomp and Kaya, these deaths were more likely to occur in a health facility than deaths that occurred within the site. The reverse situation was found in Ouagadougou. Age is the strongest determinant of mobility before death in Mlomp and Kaya. In Mlomp, young adults (15–39) were 10 times more likely to die outside the site than adults in the 60–79 age group. In Ouagadougou, non-natives were three times more likely to die outside the city than natives.

Conclusions: At the end of life, some rural residents move to urban areas for medical treatment while some urban dwellers return to their village for supportive care. These movements of dying individuals may affect the estimation of urban/rural mortality differentials.

Is the level of education associated with transitions between care settings in older adults near the end of life? A nationwide, retrospective cohort study

BACKGROUND

End-of-life transitions between care settings can be burdensome for older adults and their relatives.

AIM

To analyze the association between the level of education of older adults and their likelihood to experience care transitions during the final months before death.

DESIGN

Nationwide, retrospective cohort study using register data.

SETTING/PARTICIPANTS

Older adults (⩾65 years) who died in Sweden in 2013 ( n = 75,722). Place of death was the primary outcome. Institutionalization and multiple hospital admissions during the final months of life were defined as secondary outcomes. The decedents' level of education (primary, secondary, or tertiary education) was considered as the main exposure. Multivariable analyses were stratified by living arrangement and adjusted for sex, age at time of death, illness trajectory, and number of chronic diseases.

RESULTS

Among community-dwellers, older adults with tertiary education were more likely to die in hospitals than those with primary education (55.6% vs 49.9%; odds ratio (OR) = 1.21, 95% confidence interval (CI) = 1.14-1.28), but less likely to be institutionalized during the final month before death (OR = 0.83, 95% CI = 0.76-0.91). Decedents with higher education had greater odds of remaining hospitalized continuously during their final 2 weeks of life (OR = 1.12, 95% CI = 1.02-1.22). Among older adults living in nursing homes, we found no association between the decedents' level of education and their likelihood to be hospitalized or to die in hospitals.

CONCLUSION

Compared with those who completed only primary education, individuals with higher educational attainment were more likely to live at home until the end of life, but also more likely to be hospitalized and die in hospitals.

Factors predicting a home death among home palliative care recipients

Awareness of factors affecting the place of death could improve communication between healthcare providers and patients and their families regarding patient preferences and the feasibility of dying in the preferred place.This study aimed to evaluate factors predicting home death among home palliative care recipients.This is a population-based study using a national representative sample retrieved from the National Health Insurance Research Database. Subjects receiving home palliative care, from 2010 to 2012, were analyzed to evaluate the association between a home death and various characteristics related to illness, individual, and health care utilization. A multiple-logistic regression model was used to assess the independent effect of various characteristics on the likelihood of a home death.The overall rate of a home death for home palliative care recipients was 43.6%. Age; gender; urbanization of the area where the patients lived; illness; the total number of home visits by all health care professionals; the number of home visits by nurses; utilization of nasogastric tube, endotracheal tube, or indwelling urinary catheter; the number of emergency department visits; and admission to intensive care unit in previous 1 year were not significantly associated with the risk of a home death. Physician home visits increased the likelihood of a home death. Compared with subjects without physician home visits (31.4%) those with 1 physician home visit (53.0%, adjusted odds ratio [AOR]: 3.23, 95% confidence interval [CI]: 1.93-5.42) and those with ≥2 physician home visits (43.9%, AOR: 2.23, 95% CI: 1.06-4.70) had higher likelihood of a home death. Compared with subjects with hospitalization 0 to 6 times in previous 1 year, those with hospitalization ≥7 times in previous 1 year (AOR: 0.57, 95% CI: 0.34-0.95) had lower likelihood of a home death.Among home palliative care recipients, physician home visits increased the likelihood of a home death. Hospitalizations ≥7 times in previous 1 year decreased the likelihood of a home death.

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.

•

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

•

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

•

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

•

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

•

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

Unpacking the impact of older adults' home death on family care-givers' experiences of home

Public Health England (2013) survey data indicates that while the place of death is geographically uneven across England, given a choice, many older people nearing end of life would prefer to die at home. There is, however, a growing critique that policies designed to support home death fail to understand the needs and preferences of older people and the impact on family carers. Such policies also make assumption about within whose home the home death takes place. Hence, there are major gaps in our understanding of firstly, where and how care work undertaken by family members within domestic settings takes place; and secondly, how it can create tensions between home and care that fundamentally disrupt the physical and socio-emotional meaning of home for family carers, impacting on their sense of home post-death. This can have consequences for their own well-being. In this paper we draw on interview data from our 'Unpacking the Home' study to elicit an in-depth understanding of how facilitating a home death can create an ambiguity of place for family carers, where the issues faced by them in caring for a dying older person at home, and the home death itself, can fundamentally reshape the meaning and sense of home.

The determinants of home and nursing home death: a systematic review and meta-analysis

Background

Most Canadians die in hospital, and yet, many express a preference to die at home. Place of death is the result of the interaction among sociodemographic, illness- and healthcare-related factors. Although home death is sometimes considered a potential indicator of end-of-life/palliative care quality, some determinants of place of death are more modifiable than others. The objective of this systematic review was to evaluate the determinants of home and nursing home death in adult patients diagnosed with an advanced, life-limiting illness.

Methods

A systematic literature search was performed for studies in English published from January 1, 2004 to September 24, 2013 that evaluated the determinants of home or nursing home death compared to hospital death in adult patients with an advanced, life-limiting condition. The adjusted odds ratios, relative risks, and 95 % confidence intervals of each determinant were extracted from the studies. Meta-analyses were performed if appropriate. The quality of individual studies was assessed using the Newcastle-Ottawa scale and the body of evidence was assessed according to the GRADE Working Group criteria.

Results

Of the 5,900 citations identified, 26 retrospective cohort studies were eligible. The risk of bias in the studies identified was considered low. Factors associated with an increased likelihood of home versus hospital death included multidisciplinary home palliative care, preference for home death, cancer as opposed to other diagnoses, early referral to palliative care, not living alone, having a caregiver, and the caregiver’s coping skills.

Conclusions

Knowledge about the determinants of place of death can be used to inform care planning between healthcare providers, patients and family members regarding the feasibility of dying in the preferred location and may help explain the incongruence between preferred and actual place of death.

Modifiable factors such as early referral to palliative care, presence of a multidisciplinary home palliative care team were identified, which may be amenable to interventions that improve the likelihood of a patient dying in the preferred location. Place of death may not be a very good indicator of the quality of end-of-life/palliative care since it is determined by multiple factors and is therefore dependent on individual circumstances.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-016-0077-8) contains supplementary material, which is available to authorized users.

International study of the place of death of people with cancer: a population-level comparison of 14 countries across 4 continents using death certificate data

Background:

Where people die can influence a number of indicators of the quality of dying. We aimed to describe the place of death of people with cancer and its associations with clinical, socio-demographic and healthcare supply characteristics in 14 countries.

Methods:

Cross-sectional study using death certificate data for all deaths from cancer (ICD-10 codes C00-C97) in 2008 in Belgium, Canada, Czech Republic, England, France, Hungary, Italy, Mexico, the Netherlands, New Zealand, South Korea, Spain (2010), USA (2007) and Wales (N=1 355 910). Multivariable logistic regression analyses evaluated factors associated with home death within countries and differences across countries.

Results:

Between 12% (South Korea) and 57% (Mexico) of cancer deaths occurred at home; between 26% (Netherlands, New Zealand) and 87% (South Korea) occurred in hospital. The large between-country differences in home or hospital deaths were partly explained by differences in availability of hospital- and long-term care beds and general practitioners. Haematologic rather than solid cancer (odds ratios (ORs) 1.29–3.17) and being married rather than divorced (ORs 1.17–2.54) were most consistently associated with home death across countries.

Conclusions:

A large country variation in the place of death can partly be explained by countries' healthcare resources. Country-specific choices regarding the organisation of end-of-life cancer care likely explain an additional part. These findings indicate the further challenge to evaluate how different specific policies can influence place of death patterns.

Place of Death among Hospitalized Patients with Cancer at the End of Life

BACKGROUND

The majority of hospital deaths in the United States occur after ICU admission. The characteristics associated with the place of death within the hospital are not known for patients with cancer.

OBJECTIVE

The study objective was to identify patient characteristics associated with place of death among hospitalized patients with cancer who were at the end of life.

METHODS

A retrospective cohort study design was implemented. Subjects were consecutive patients hospitalized between 2003 and 2007 at a large comprehensive cancer center in the United States. Multinomial logistic regression analysis was used to identify patient characteristics associated with place of death (ICU, hospital following ICU, hospital without ICU) among hospital decedents.

RESULTS

Among 105,157 hospital discharges, 3860 (3.7%) died in the hospital: 42% in the ICU, 14% in the hospital following an ICU stay, and 44% in the hospital without ICU services. Individuals with the following characteristics had an increased risk of dying in the ICU: nonlocal residence, newly diagnosed hematologic or nonmetastatic solid tumor malignancies, elective admission, surgical or pediatric services. A palliative care consultation on admission was associated with dying in the hospital without ICU services.

CONCLUSIONS

Understanding existing patterns of care at the end of life will help guide decisions about resource allocation and palliative care programs. Patients who seek care at dedicated cancer centers may elect more aggressive care; thus the generalizability of this study is limited. Although dying in a hospital may be unavoidable for patients who have uncontrolled symptoms that cannot be managed at home, palliative care consultations with patients and their families in advance regarding end-of-life preferences may prevent unwanted admission to the ICU.

Patient Preferences versus Family Physicians' Perceptions Regarding the Place of End-of-Life Care and Death: A Nationwide Study in Taiwan

BACKGROUND

Enabling people to die in their preferred place is important for providing high-quality end-of-life care.

OBJECTIVE

The study objective was to explore patients' preferences regarding the place of end-of-life care and death and to compare these preferences with the perceptions of their family physicians.

METHODS

This cross-sectional study used stratified random sampling, surveying 400 registered patients and 200 of their family physicians nationwide, with a five-part, structured, self-report questionnaire.

RESULTS

Of the selected population, 310 patients (response rate 77.5%) and 169 physicians (response rate 84.5%) responded. Regarding the preferred place for end-of-life care, most of the patients would choose to receive care at home (60.6%) if home care services were available. Additionally, home was the most frequently preferred (66.5%) place of death. The family physicians' survey showed that a higher proportion of physicians selected home as the preferred place for end-of-life care and death (71.6% and 87.2%, respectively). The results of logistic regression analysis showed that patients younger than 50 years of age who believed in Chinese folk religion and who resided in a rural area were more likely to prefer to die at home.

CONCLUSIONS

The most commonly preferred place for end-of-life care and death is the patient's home. Establishing a community-based palliative care system should be encouraged to allow more individuals to die in their preferred locations. There were discrepancies in the preferred place of end-of-life care and death between the patients' preferences and their family physicians' perceptions. More effective physician-patient communication regarding end-of-life care is needed.

The Determinants of Place of Death: An Evidence-Based Analysis

BACKGROUND

According to a conceptual model described in this analysis, place of death is determined by an interplay of factors associated with the illness, the individual, and the environment.

OBJECTIVES

Our objective was to evaluate the determinants of place of death for adult patients who have been diagnosed with an advanced, life-limiting condition and are not expected to stabilize or improve.

DATA SOURCES

A literature search was performed using Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid Embase, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), and EBM Reviews, for studies published from January 1, 2004, to September 24, 2013.

REVIEW METHODS

Different places of death are considered in this analysis-home, nursing home, inpatient hospice, and inpatient palliative care unit, compared with hospital. We selected factors to evaluate from a list of possible predictors-i.e., determinants-of death. We extracted the adjusted odds ratios and 95% confidence intervals of each determinant, performed a meta-analysis if appropriate, and conducted a stratified analysis if substantial heterogeneity was observed.

RESULTS

From a literature search yielding 5,899 citations, we included 2 systematic reviews and 29 observational studies. Factors that increased the likelihood of home death included multidisciplinary home palliative care, patient preference, having an informal caregiver, and the caregiver's ability to cope. Factors increasing the likelihood of a nursing home death included the availability of palliative care in the nursing home and the existence of advance directives. A cancer diagnosis and the involvement of home care services increased the likelihood of dying in an inpatient palliative care unit. A cancer diagnosis and a longer time between referral to palliative care and death increased the likelihood of inpatient hospice death. The quality of the evidence was considered low.

LIMITATIONS

Our results are based on those of retrospective observational studies.

CONCLUSIONS

The results obtained were consistent with previously published systematic reviews. The analysis identified several factors that are associated with place of death.

Characteristics of visiting nurse agencies with high home death rates: A prefecture-wide study in Japan

AIM

The purpose of the present study was to identify characteristics of visiting nurse agencies (VNA) in Japan with high home death rates by a prefecture-wide survey.

METHODS

A cross-sectional study of visiting nurse agencies (n = 101) in Ibaraki Prefecture, Japan, was completed. Data included the basic characteristics of each VNA, the type of services provided, level of coordination with other service providers, total number of VNA patients who died per year and place of death and contractual relationship with home-care supporting clinics providing end-of-life care services in the home 24 h a day. The VNA characteristics were analyzed by logistic regression, using the home death rate per VNA as a dependent variable.

RESULTS

A total 69 agencies, excluding those that did not report number of deaths (n = 14) and those without deaths during the year (n = 6), were analyzed. The median home death rate of the 69 VNA was 29.8%. The results of logistic regression analysis showed that higher home death rate was significantly associated with lack of attachment to a hospital, existence of a contractual relationship with home-care supporting clinics and existence of an interactive information exchange through telephone/face-to-face communication with attending physicians.

CONCLUSIONS

In order to increase the home death rate of people using VNA, policymakers must consider establishing home-based service systems within the community that can provide home end-of-life care services 24 h a day, and support the interactive exchange of information between the visiting nurse and the attending physician.

End-of-life hospital referrals by out-of-hours general practitioners: a retrospective chart study

Background

Many patients are transferred from home to hospital during the final phase of life and the majority die in hospital. The aim of the study is to explore hospital referrals of palliative care patients for whom an out-of-hours general practitioner was called.

Methods

A retrospective descriptive chart study was conducted covering a one-year period (1/Nov/2005 to 1/Nov/2006) in all eight out-of-hours GP co-operatives in the Amsterdam region (Netherlands). All symptoms, sociodemographic and medical characteristics were recorded in 529 charts for palliative care patients. Multivariate logistic regression analysis was performed to identify the variables associated with hospital referrals at the end of life.

Results

In all, 13% of all palliative care patients for whom an out-of-hours general practitioner was called were referred to hospital. Palliative care patients with cancer (OR 5,1), cardiovascular problems (OR 8,3), digestive problems (OR 2,5) and endocrine, metabolic and nutritional (EMN) problems (OR 2,5) had a significantly higher chance of being referred. Patients receiving professional nursing care (OR 0,2) and patients for whom their own general practitioner had transferred information to the out-of-hours cooperative (OR 0,4) had a significantly lower chance of hospital referral. The most frequent reasons for hospital referral, as noted by the out-of-hours general practitioner, were digestive (30%), EMN (19%) and respiratory (17%) problems.

Conclusion

Whilst acknowledging that an out-of-hours hospital referral can be the most desirable option in some situations, this study provides suggestions for avoiding undesirable hospital referrals by out-of-hours general practitioners at the end of life. These include anticipating digestive, EMN, respiratory and cardiovascular symptoms in palliative care patients.