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Dalmau-Bueno A, Saura-Lazaro A, Busquets JM, Bullich-Marín I, García-Altés A. Advance directives and real-world end-of-life clinical practice: a case-control study. BMJ Support Palliat Care 2021; 12:bmjspcare-2020-002851. [PMID: 33753359 PMCID: PMC9380474 DOI: 10.1136/bmjspcare-2020-002851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Advance directives (ADs) have been legally regulated to promote autonomy over health decisions among patients who later lose decision-making capacity. AIMS AND OBJECTIVES To analyse the differences in clinical practice at end of life among people who had completed an AD versus those who had not. METHODS Retrospective case-control study (1:2), matched by age, sex, year, cause of death and region of residence. The data sources used were the ADs registry, central registry of insured persons, hospital discharge, pharmacy and billing databases, and the mortality registry. Conditional logistic regression models (crude and adjusted by socioeconomic level) were performed. The outcome variable was the frequency of medical procedures performed during the last year of life. RESULTS 1723 people with ADs who died in Catalonia during 2014-2015 were matched with 3446 dead controls (without ADs). Thoracentesis was the procedure with the greatest reduction among women with an AD (adjusted OR (ORadj) 0.54, 95% CI: 0.32 to 0.89) in conjunction with artificial nutrition (ORadj 0.54, 95% CI: 0.31 to 0.95). Intubation was the procedure with the greatest reduction (ORadj 0.56, 95% CI: 0.33 to 0.94) among men. Slight differences could be seen in the case of cancer deaths. There were no relevant differences when adjusting by socioeconomic level. CONCLUSIONS ADs are an effective tool to adjust the realisation of some procedures at end of life. These results can help better plan for the treatment of patients with ADs, as well as increase the awareness among clinical personnel, families and the general population.
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Affiliation(s)
- Albert Dalmau-Bueno
- Catalan Health System Observatory, Agency for Health Quality and Assessment (AQuAS), Barcelona, Spain
| | | | - Josep Ma Busquets
- Ministry of Health, Government of Catalonia, Barcelona, Catalonia, Spain
| | | | - Anna García-Altés
- Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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Hwang J, Shen J, Kim SJ, Chun SY, Kioka M, Sheraz F, Kim P, Byun D, Yoo JW. Ten-Year Trends of Utilization of Palliative Care Services and Life-Sustaining Treatments and Hospital Costs Associated With Patients With Terminally Ill Lung Cancer in the United States From 2005 to 2014. Am J Hosp Palliat Care 2019; 36:1105-1113. [DOI: 10.1177/1049909119852082] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: Palliative care services and life-sustaining treatments are provided to dying patients with lung cancer in the United States. However, data on the utilization trends of palliative care services and life-sustaining treatments of dying patients with lung cancer are not available. Methods: This study was a retrospective analysis of the National Inpatient Sample data (2005-2014) and included patients with lung cancer, aged ≥ 18 years, who died in the hospitals. Claims data of palliative care services and life-sustaining treatments that contained systemic procedures, local procedures, or surgeries were extracted. Compound annual growth rates (CAGRs) using Rao-Scott correction for χ2 tests were used to determine the statistical significance of temporal utilization trends of palliative care services and life-sustaining treatments and their hospital costs. Multilevel multivariate regressions were performed to identify factors associated with hospital costs. Results: A total of 120 144 weighted patients with lung cancer died in the hospitals and 41.9% of them received palliative care services. The CAGRs of systemic procedures, local procedures, surgeries, palliative care services, and hospital cost were 3.42%, 3.48%, 6.08%, 18.5%, and 5.0% (all P < .001), respectively. Increased hospital cost was attributed to systemic procedures (50.6%), local procedures (74.4%), and surgeries (68.5%; all P < .001), respectively. Palliative care services were related to decreasing hospital costs by 28.6% ( P < .001). Conclusion: The temporal trends of palliative care services indicate that their utilization has increased gradually. Palliative care services were associated with reduced hospital costs. However, life-sustaining treatments were associated with increased hospital costs.
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Affiliation(s)
- Jinwook Hwang
- Department of Cardiovascular and Thoracic Surgery, Korea University Medical Center, Ansan Hospital, Ansan, Gyeonggi-do, South Korea
- Department of Health Care Administration and Policy, School of Community Health Science, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Jay Shen
- Department of Health Care Administration and Policy, School of Community Health Science, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Sun Jung Kim
- Department of Health Administration and Management, Soonchunhyang University, Asan, Chungcheongnam-do, South Korea
| | - Sung-Youn Chun
- Department of Health Care Administration and Policy, School of Community Health Science, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Mutsumi Kioka
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Faizan Sheraz
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Pearl Kim
- Department of Health Care Administration and Policy, School of Community Health Science, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - David Byun
- Department of Medicine, Southern Nevada Veterans Affairs Health System, North Las Vegas, NV, USA
| | - Ji Won Yoo
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
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Liu X, Shen JJ, Kim P, Kim SJ, Ukken J, Choi Y, Hwang IC, Lee JH, Chun SY, Hwang J, Choi H, Yeom H, Lee YJ, Yoo JW. Trends in the Utilization of Life-Sustaining Procedures and Palliative Care Consultation Among Dying Patients With Advanced Chronic Pancreas Illnesses in US Hospitals: 2005 to 2014. J Palliat Care 2019; 34:232-240. [PMID: 30767641 DOI: 10.1177/0825859719827313] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AIM Pancreas cancer continues to carry a poor prognosis. Hospitalized patients with advanced chronic pancreatic illnesses increasingly receive palliative care due to its perceived clinical benefits. Meanwhile, a growing proportion of elderly patients are reportedly receiving life-sustaining procedures. Temporal trends in the utilization of life-sustaining procedures and palliative care consultation among dying patients with advanced chronic pancreatic illnesses in US hospitals were examined. METHODS AND MATERIALS A serial, cross-sectional analysis was carried out using the National Inpatient Sample Database. Decedents 18 years and older with a principal diagnosis of pancreas cancer or other advanced chronic pancreatic illnesses from 2005 through 2014. The compound annual growth rates (CAGRs) and Cochrane-Armitage correction of χ2 statistic were used. The receipt of life-sustaining systemic procedures, intra-abdominal local procedures and surgeries, and palliative care consultation were examined. Multilevel multivariate logistic regressions were performed to examine the association of various procedures with the utilization of palliative care consultation. RESULTS Among 77 394 183 hospitalizations, 29 515 patients were examined. The CAGRs of systemic procedures, intra-abdominal procedures, surgeries, and palliative care were -4.19% (P = .008), 2.17%, -1.40%, and 14.03% (P < .001), respectively. The receipt of systemic procedures (odds ratio [OR] = 2.40, 95% confidence interval [CI], 2.08-2.74), local intra-abdominal procedures (OR = 1.46, 95% CI, 1.27-1.70), and surgeries (OR = 2.51, 95% CI, 2.07-3.05) was associated with palliative care consultation (Ps < .001). CONCLUSIONS Among adults with pancreatic cancer or other advanced chronic pancreatic illnesses in the US hospitals from 2005 to 2014, the utilization of life-sustaining systemic procedures decreased while the prevalence of palliative care consultation increased.
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Affiliation(s)
- Xibei Liu
- Department of Medicine, University of Arizona College of Medicine, Tuscon, AZ, USA
| | - Jay J Shen
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Pearl Kim
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Sun Jung Kim
- Department of Health Administration and Management, Soon Chun Hyang University, Asan, Chungcheongnam-do, Korea
| | - Johnson Ukken
- University of Nevada Reno School of Medicine, Reno, NV, USA
| | - Younseon Choi
- Department of Family Medicine, Korea University of College of Medicine, Seoul, Korea
| | - In Choel Hwang
- Department of Family Medicine, Gachon University College of Medicine, Inchon, Korea
| | - Jae-Hoon Lee
- Department of Family Medicine, University of Nevada, Las Vegas
| | - Sung-Youn Chun
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Jinwook Hwang
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Haneul Choi
- Honors College, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Hyeyoung Yeom
- Department of Healthcare Administration and Policy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Yong-Jae Lee
- Department of Family Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Won Yoo
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
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Mauleon J, Staffileno BA. Integration of an Advance Care Planning Model in Home Health: Favorable Outcomes in End-of-Life Discussions, POLST Rates, and 60-day Hospital Readmissions. Home Healthc Now 2019; 37:337-344. [PMID: 31688468 DOI: 10.1097/nhh.0000000000000797] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Only 2.3% of patients at a Midwest home healthcare (HH) agency had documented advance directives (ADs), compared with 28% nationally. Of concern, this HH agency lacked standardized procedures for advance care planning (ACP) leading to inadequate staff knowledge regarding end-of-life, avoidable hospital readmissions, and delayed transitions into hospice care. Lack of ADs is directly correlated to higher hospital readmission rates and lower hospice length of stay. The purpose of this initiative was to develop evidence-based procedures using the Respecting Choices ACP model to: 1) educate staff, 2) increase ACP conversations offered and completed among high-risk patients, 3) increase Practitioner Orders for Life-Sustaining Treatment (POLST) rates, 4) reduce 60-day hospital readmissions, and 5) support hospice care admissions. Staff received discipline-specific education on ACP/ADs. The Knowledge-Attitudinal-Experiential Survey on Advance Directives (KAESAD), assessed staff ACP/AD knowledge, confidence, and experiences. Standardized electronic medical record tools were created to track ACP conversations, POLST rates, 60-day hospital readmissions, and hospice admissions. Paired t-test and chi-square analyses compared changes pre- and post implementation. The KAESAD survey was analyzed for 75 staff (100%) and demonstrates improvement in knowledge, confidence, and experiences. Data also demonstrate increases in: ACP offered 6% to 80% (p < .001); ACP conversations completed 4% to 31% (p < .001); POLST rates 26% to 43.6% (p = .059); decreased 60-day hospital readmissions 40% to 20% (p = .025); whereas hospice care admissions was not impacted ranging from 10% to 5.5% (p = .381). Respecting Choices serves as an effective ACP framework to improve ACP conversations, POLST rates, and hospital readmissions.
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Affiliation(s)
- Jessica Mauleon
- Jessica Mauleon, DNP, AGPCNP-C, is a Nurse Practitioner at an Internal Medicine practice in Lincolnshire, Illinois. Beth A. Staffileno, PhD, RN, FAHA, is an Associate Professor, Co-Director Center for Clinical Research and Scholarship, College of Nursing, Rush University, Chicago, Illinois
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Effects of hospital palliative care on health, length of stay, and in-hospital mortality across intensive and non-intensive-care units: A systematic review and metaanalysis. Palliat Support Care 2017; 15:741-752. [PMID: 28196551 DOI: 10.1017/s1478951516001164] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Hospital palliative care has been shown to improve quality of life and optimize hospital utilization for seriously ill patients who need intensive care. The present review examined whether hospital palliative care in intensive care (ICU) and non-ICU settings will influence hospital length of stay and in-hospital mortality. METHOD A systematic search of CINAHL/EBSCO, the Cochrane Library, Google Scholar, MEDLINE/Ovid, PubMed, and the Web of Science through 12 October 2016 identified 16 studies that examined the effects of hospital palliative care and reported on hospital length of stay and in-hospital death. Random-effects pooled odds ratios and mean differences with corresponding 95% confidence intervals were estimated. Heterogeneity was measured by the I 2 test. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was utilized to assess the overall quality of the evidence. RESULTS Of the reviewed 932 articles found in our search, we reviewed the full text of 76 eligible articles and excluded 60 of those, which resulted in a final total of 16 studies for analysis. Five studies were duplicated with regard to outcomes. A total of 18,330 and 9,452 patients were analyzed for hospital length of stay and in-hospital mortality from 11 and 10 studies, respectively. Hospital palliative care increased mean hospital length of stay by 0.19 days (pooled mean difference = 0.19; 95% confidence interval [CI 95%] = -2.22-2.61 days; p = 0.87; I 2 = 95.88%) and reduced in-hospital mortality by 34% (pooled odds ratio = 0.66; CI 95% = 0.52-0.84; p < 0.01; I 2 = 48.82%). The overall quality of evidence for both hospital length of stay and in-hospital mortality was rated as very low and low, respectively. SIGNIFICANCE OF RESULTS Hospital palliative care was associated with a 34% reduction of in-hospital mortality but had no correlation with hospital length of stay.
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Clinical implications and quality of evidence in metaanalysis about effects of palliative care in critically ill patients in the intensive care unit. Palliat Support Care 2017; 15:513-515. [DOI: 10.1017/s1478951516001036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Medical decision making for older adults: an international perspective comparing the United States and India. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2015; 12:329-34. [PMID: 26346983 PMCID: PMC4554781 DOI: 10.11909/j.issn.1671-5411.2015.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 07/03/2015] [Accepted: 07/03/2015] [Indexed: 12/02/2022]
Abstract
There has been a significant decline in cardiovascular morbidity and mortality amidst pervasive advances in care, including percutaneous revascularization, mechanical circulatory support, and transcatheter valvular therapies. While advancing therapies may add significant longevity, they also bring about new end-of-life decision-making challenges for patients and their families who also must weigh the advantages of reduced mortality to the possibility of longer lives consisting of high morbidity, frailty, pain, and poor quality of living. Advance care entails options of withholding or withdrawing therapies, and has become a familiar part of cardiovascular care for older patients in Western countries. However, as advanced cardiovascular practices extend to developing countries, the interrelated concept of advance care is rarely straight forward as it is affected by local cultural traditions and mores, and can lead to very different inferences and use. This paper discusses the concepts of advance care planning, surrogate decision-making, orders for resuscitation and futility in patients with cardiac disease with comparisons of West to East, focusing particularly on the United States versus India.
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