Are We Evolving Toward Greater and Earlier Use of Palliative Home Care Support? A Trend Analysis Using Population-Level Data From 2010 to 2015

Enhancing End-of-Life Care with Home-Based Palliative Interventions: A Systematic Review

CONTEXT

Home-Based Palliative Care (HPC) interventions have emerged as a promising approach to deliver patient-centered care in familiar surroundings, aligning with patients' preferences and improving quality of life (QOL).

OBJECTIVES

This review aimed to systematically assess the impact of HPC interventions on symptom management, QOL, healthcare resource utilization and place of death among patients with severe, progressive illnesses requiring end-of-life care.

METHODS

A comprehensive search was conducted across PubMed, Cochrane, and Scopus databases to identify relevant studies published between January 1, 2013, and December 31, 2023. Eligible studies included randomized controlled trials and clinical studies evaluating the effectiveness of HPC interventions compared to usual care. Risk of bias assessment was performed using Cochrane tools.

RESULTS

Nine publications meeting inclusion criteria were identified. Findings indicate that HPC interventions, delivered by specialized teams or integrated care approaches, significantly improve QOL and increase the likelihood of patients dying at home. Moreover, HPC is associated with reduced healthcare utilization, including fewer hospital admissions, emergency department visits, and shorter hospital stays. No significant differences were observed in symptom management.

CONCLUSION

HPC interventions demonstrate significant benefits in addressing the complex needs of patients with advanced illnesses. These findings underscore the importance of integrating HPC into healthcare systems to optimize outcomes and promote quality end-of-life care. Future research should focus on expanding access to HPC services, enhancing interdisciplinary collaboration, and incorporating patient preferences to further improve care delivery in this vulnerable population.

Palliative Care in Early Dementia

BACKGROUND

Palliative care is recommended for all people with dementia from diagnosis through end-of-life. However, palliative care needs and effective elements of palliative care are not well-defined for the earlier stages of dementia.

OBJECTIVE

To systematically map current research on palliative care early in the disease trajectory of dementia.

DESIGN

Scoping review of scientific literature.

DATA SOURCES

PubMed, CINAHL, EMBASE, Cochrane, PsycINFO, Web of Science.

REVIEW METHODS

We included studies published in English over the last decade (through March 2022) that focused on palliative care in early stages of dementia and targeted outcomes in palliative care domains. Two authors independently screened abstracts and full texts and scored the quality of included studies using tools by the Joanna Briggs Institute.

RESULTS

Among the 77 papers reviewed, few addressed early stages of dementia specifically. We found that: 1) While "early" palliative care was not well-defined in the literature, evidence indicated that palliative care needs were present at or before diagnosis and across the trajectory. Notable opportunities for palliative care arise at 'tipping points' (i.e., when symptoms, functional status, or caregiving needs change). 2) Palliative care needs in early dementia include advocacy for goal-aligned care in the future, reassurance against the threat of negligence and abandonment by caregivers, planning for future scenarios of care (practical, individual, and relational needs), and establishing of long-term relationships with providers entrusted for care later in disease. 3) Elements of effective palliative care in early dementia could include dementia-specific ACP and goals of care discussions, navigation for building a network of support, provision of tools and resources for family, tailored care and knowledge of the person, and well-prepared dementia-care providers. The scarcity of palliative care studies aimed at early disease indicates a gap in the evidence in dementia care.

CONCLUSION

The literature on palliative care in early dementia is sparse. Future studies should focus on assessment tools for optimizing timing of palliative care in early dementia, gaining better understanding of patient and family needs during early phases of disease, and providing training for providers and families in long-term relationships and communication around goals of care and future planning.

Recent Trends in Palliative Care Utilization in Patients With Decompensated Liver Disease: 2016-2020 National Analysis

Background: Patients with end-stage liver disease (ESLD) have a poor quality of life, which often worsens as disease severity increases. Palliative care (PC) has emerged as a management option in ESLD patients, especially for those who are not candidates for a liver transplant. Objective: To assess the associated factors and trends in PC utilization in recent years. Design: We used the 2016-2020 National Inpatient Sample (NIS) database of the United States to identify patients with decompensated cirrhosis who suffered in-hospital mortality. Information regarding patient demographics, hospital characteristics, etiology and decompensations, Elixhauser comorbidities, and interventions was collected. The multivariate regression model was used to identify factors associated with PC use. Results: Out of 98,160 patients, 52,645 patients (53.6%) received PC consultations. PC utilization increased from 49.11% in 2016 to 56.85% in 2019, with a slight decrease to 54.47% in 2020. Patients with PC use had decreased incidence of blood transfusions (28.85% vs. 36.53%, p < 0.001), endoscopy (18% vs. 20.26%, p 0.0001), liver transplantation (0.28% vs. 0.69%, p < 0.001), and mechanical ventilation (46.22% vs. 56.37%, p < 0.001). African American, Hispanic, and Asian/Pacific Islander patients had 29%, 27%, and 23% lower odds of receiving PC than White patients. Patients in the two lowest income quartiles had 12% and 22% lower odds of receiving PC compared with the highest quartile. Conclusions: PC utilization in patients with ESLD is associated with decreased invasive procedures, shorter lengths of stay, and lower hospitalization charges. Minorities, as well as patients in the lower income quartiles, were less likely to receive PC.

Prognosis does not change the landscape: palliative home care clients experience high rates of pain and nausea, regardless of prognosis

BACKGROUND

Most individuals who typically receive palliative care (PC) tend to have cancer and a relatively short prognosis (< 6 months). People with other life-limiting illnesses can also benefit from a palliative care approach. However, little is known about those who receive palliative home care in Ontario, Canada's largest province. To address this gap, the goal of this project was to understand the needs, symptoms and potential differences between those with a shorter (< 6 months) and longer prognosis (6+ months) for individuals receiving PC in the community.

METHODS

A cross-sectional analysis was conducted using interRAI Palliative Care (interRAI PC) assessment data collected between 2011 and 2018. Individuals with a shorter prognosis (< 6 months; n = 48,019 or 64.1%) were compared to those with a longer prognosis (6+ months; n = 26,945) across several clinical symptoms. The standardized difference (stdiff), between proportions, was calculated to identify statistically meaningful differences between those with a shorter and longer prognosis. Values of the stdiff of 0.2 or higher (absolute value) indicated a statistically significant difference.

RESULTS

Overall, cancer was the most prevalent diagnosis (83.2%). Those with a shorter prognosis were significantly more likely to experience fatigue (75.3% vs. 59.5%; stdiff = 0.34) and shortness of breath at rest (22.1% vs. 13.4%; stdiff = 0.23). However, the two groups were similar in terms of severe pain (73.5% vs. 66.5%; stdiff = - 0.15), depressive symptoms (13.2% vs. 10.7%; stdiff = 0.08) and nausea (35.7% vs. 29.4%; stdiff = 0.13).

CONCLUSIONS

These results highlight the importance of earlier identification of individuals who could benefit from a palliative approach to their care as individuals with a longer prognosis also experience high rates of symptoms such as pain and nausea. Providing PC earlier in the illness trajectory has the potential to improve an individual's overall quality of life throughout the duration of their illness.

Improved quality of care and reduced healthcare costs at the end-of-life among older people with dementia who received palliative home care: A nationwide propensity score-matched decedent cohort study

BACKGROUND

While palliative home care is advocated for people with dementia, evidence of its effectiveness is lacking.

AIM

To evaluate the effects of palliative home care on quality and costs of end-of-life care for older people with dementia.

DESIGN

Decedent cohort study using linked nationwide administrative databases and propensity score matching.

SETTING/PARTICIPANTS

All home-dwelling older people who died with dementia between 2010 and 2015 in Belgium (N = 23,670).

EXPOSURE

Receiving palliative home care support for the first time between 360 and 15 days before death.

RESULTS

Five thousand six hundred and thirty-seven (23.8%) received palliative home care support in the last 2 years of life, of whom 2918 received it for the first time between 360 and 15 days before death. Two thousand eight hundred and thirty-nine people who received support were matched to 2839 people who received usual care. After matching, those using palliative home care support, in the last 14 days of life, had lower risk of hospital admission (17.5% vs 50.5%; relative risk (RR) = 0.21), undergoing diagnostic testing (17.0% vs 53.6%; RR = 0.20) and receiving inappropriate medications, but were more likely to die at home (75.7% vs 32.6%; RR = 6.45) and to have primary care professional contacts (mean 11.7 vs mean 5.2), compared with those who did not. Further, they had lower mean total costs of care in the last 30 days of life (incremental cost:-€2129).

CONCLUSIONS

Palliative home care use by home-dwelling older people with dementia is associated with improved quality and reduced costs of end-of-life care. Access remains low and should be increased.

"The system is well intentioned, but complicated and fallible" interviews with caregivers and decision makers about palliative care in Canada

Background

Canadian palliative care (PC) philosophy seeks to support individuals in a person-centered and sensitive manner. Unfortunately, philosophy does not necessarily translate into practice and this divide may leave patients without appropriate care at the end of life, causing distress for some families. The primary goal of the study was to identify key factors affecting perceptions of quality PC from the perspective of informal caregivers and decision makers (e.g., program managers) and to understand how their experiences within the health care system may have influenced their perceptions.

Methods

Nine caregivers and 11 decision makers from Yukon Territory, British Columbia, Alberta, Ontario, & Nova Scotia shared their experiences in PC via interview or focus group. Audio recordings were transcribed verbatim and qualitatively analyzed for themes.

Results

Three themes emerged, including the Caregiver as Anchor, Bewildering System, and Patient, Caregiver, and Family-Centered Care. While these results resembled other studies on caregivers and individuals receiving PC, the present study also uncovered systemic concerns. There was agreement between the two participant groups across most subthemes, however only caregivers reported feelings of being trapped by the health care system and a general lack of respect from health care professionals. Additionally, caregivers stressed the importance of preserving some sort of normalcy in daily life despite the individual’s illness.

Conclusions

Caregivers are critical. The health care system expects them to help a great deal, but they often do not feel supported or respected and the system is lacking the capacity and resources to meet their needs while they are grieving loss and struggling to meet demands.

What should be measured to assess the quality of community-based palliative care? Results from a collaborative expert workshop

OBJECTIVES

The need for palliative care (PC) will continue to increase in Canada with population aging. Many older adults prefer to "age in place" and receive care in their own homes. Currently, there is a lack of standardized quality indicators (QIs) for PC delivered in the community in Canada.

METHODS

A one-day workshop collected expert opinions on what should be measured to capture quality PC. Three brainstorming sessions were focused on addressing the following questions: (1) what is important to measure to support quality PC, regardless of setting? (2) Of the identified measures, are any of special importance to care provided in the home? (3) What are the challenges, barriers, and opportunities for creating these measures? The National Consensus Project (NCP) for Quality Palliative Care framework was used as a guide to group together important comments into key themes.

RESULTS

The experts identified four themes that are important for measuring quality, regardless of care setting, including access to care in the community by a multidisciplinary team, care for the individual with PC needs, support for the informal caregiver (e.g., family, friends), and symptom management for individuals with PC needs. Two additional themes were of special importance to measuring quality PC in the home, including spiritual care for individuals with PC needs and home as the preferred place of death. The challenges, barriers, and potential opportunities to these quality issues were also discussed.

SIGNIFICANCE OF RESULTS

PC experts, through this collaborative process, made a substantial contribution to the creation of a standardized set of QIs for community-based PC. Having a standardized set of QIs will enable health care professionals and decision makers to target areas for improvement, implement interventions to improve the quality of care, and ultimately, optimize the health and well-being of individuals with a serious illness.

Earlier initiation of palliative care in the disease trajectory of people living with dementia: a scoping review protocol

INTRODUCTION

While the need for palliative care for people living with dementia has widely been recognised, they continue to be a disadvantaged group when it comes to timely initiation, and controversies remain regarding appropriate timing, or what elements constitute high quality palliative care early in the disease trajectory. To date, no literature review has summarised this debate or offered insights. The aim of this scoping review is to provide a general overview of research regarding palliative care in mild or moderate dementia, to identify existing controversies, and to examine what are key components of palliative care in dementia, specifically when initiated earlier in the disease trajectory.

METHODS AND ANALYSIS

Consistent with recent guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, we carried out a search for academic literature in PubMed, CINAHL, EMBASE, Cochrane Library, PsycINFO, Web of Science; on 5 November 2019 and an updated search on 2 February 2021. We will include studies with different study designs published in English over the last decade that focused on palliative care in early stages of dementia. We will include models targeting at least one outcome domain of palliative care (physical, psychological, social or spiritual) and advance care planning, and will exclude hospice models with limited prognosis similar to the requirements in the USA. We will report study characteristics and quality. We aim to apply narrative synthesis techniques to develop a theoretical model of how, for whom and why palliative care can be relevant in early stages of dementia, and what are facilitators and barriers. We anticipate to also describe if and how the concept of (early) palliative care in dementia changed across time and studies.

ETHICS AND DISSEMINATION

No ethical review required. Results will identify research gaps and lay out basic principles for conceptualising palliative care in early stages of dementia.