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Balasubramanian I, Malhotra C. Why is end-of-life inpatient cost high among cancer patients? A prospective cohort study. Cancer Med 2024; 13:e7057. [PMID: 38457240 PMCID: PMC10923043 DOI: 10.1002/cam4.7057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/23/2024] [Accepted: 02/16/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Inpatient cost for cancer patients is high during the last year of life, but reasons for this are not understood. We aim to understand the type of hospital admissions and inpatient services associated with an increase in inpatient cost in last year of life. METHODS We used survey and billing records of 439 deceased patients with a solid metastatic cancer, enrolled in a prospective cohort study. Based on cost per day of inpatient admissions, we classified admissions as low- or high-intensity. We decomposed the inpatient cost into cost for different inpatient services. We examined the inpatient cost in the last year of life. We also assessed patient characteristics associated with higher inpatient cost in the next 3 months. RESULTS Towards death, proportion of inpatient cost for "maintenance care" increased while that for intensive care unit (ICU) and surgeries decreased. Low-intensity, compared to high-intensity admissions had a higher proportion of cost for "maintenance care" and a lower proportion for surgeries and ICU. Number of low-intensity admissions increased more steeply towards death than high-intensity admissions. Both admission types contributed equally to the share of inpatient cost. Older patients were less likely to have a high-intensity admission (β:-0.01, CI: -0.02, 0.00). Greater preference for life extension (β: 0.06, CI: 0.01, 0.11) and inaccurate prognostic belief were associated with higher cost of high-intensity admissions (β: 0.32, CI: 0.03, 0.62). CONCLUSIONS Findings suggest that inpatient costs in last year of life may be reduced if maintenance care is availed in low-cost settings such as hospice/palliative care alongside steps to reduce non-beneficial surgeries and ICU admissions.
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Affiliation(s)
| | - Chetna Malhotra
- Lien Centre for Palliative Care, Duke‐NUS Medical SchoolSingaporeSingapore
- Program in Health Services and Systems Research, Duke‐NUS Medical SchoolSingaporeSingapore
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Thomas D, Kamalumpundi V, Thampi A, Lockman K, Carter MB, Vidwan N, Broderick A. Antibiotic stewardship in Indian palliative care: a single-center retrospective study. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e196. [PMID: 38028900 PMCID: PMC10654949 DOI: 10.1017/ash.2023.468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 09/18/2023] [Accepted: 09/18/2023] [Indexed: 12/01/2023]
Abstract
Objective Characterize antibiotic prescribing behaviors at an Indian palliative care center after the initiation of the Antibiotic Order Form (AOF): an antibiotic stewardship program involving a paper form to track antibiotic use and to provide prescription guidelines. Design Retrospective chart review. Setting Trivandrum Institute of Palliative Sciences (TIPS) is a palliative care organization in Kerala, India. Methods Antibiotic prescription data and patient data were collected for adult patients treated at TIPS between January 1, 2017, and October 31, 2019. Descriptive statistics and a Zero-Inflated Poisson regression model were used to analyze antibiotic prescriptions. AOF completion and prescription concordance with institutional guidelines were also evaluated. Results Out of 7,450 unique patients, 675 (9%) were prescribed 1,448 antibiotics. Age was the strongest factor in determining the number of antibiotic courses with each additional year of age decreasing the expected antibiotic prescription count by 2% per year. The most common antibiotics prescribed were topical metronidazole (44%) and penicillins (29%). Among patients who died, 5% were prescribed antibiotics within the final month of life. In total, 32% of antibiotic prescriptions were documented in AOFs, and 18% were concordant with all institutional antibiotic prescribing guidelines. Conclusions This study is the first to analyze an antibiotic stewardship intervention in a palliative care setting within a low- and middle-income country. This retrospective study provides a benchmark of antibiotic use within Indian palliative care and highlights areas for future stewardship research including topical metronidazole use within palliative care and higher rates of antibiotic use among younger palliative care patients.
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Affiliation(s)
- David Thomas
- University of Louisville, School of Medicine, Louisville, KY, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | | | | | - Mary B. Carter
- University of Louisville, School of Medicine, Louisville, KY, USA
| | - Navjyot Vidwan
- University of Louisville, School of Medicine, Louisville, KY, USA
| | - Ann Broderick
- Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
- Iowa City VA Medical Center, Iowa City, IA, USA
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3
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Webber C, Hafid S, Gayowsky A, Howard M, Tanuseputro P, Jones A, Scott MM, Hsu AT, Downar J, Manuel D, Conen K, Isenberg SR. End-of-life interventions in patients with cancer. BMJ Support Palliat Care 2023:spcare-2023-004222. [PMID: 37536756 DOI: 10.1136/spcare-2023-004222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 07/25/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVES To describe variations in the receipt of potentially inappropriate interventions in the last 100 days of life of patients with cancer according to patient characteristics and cancer site. METHODS We conducted a population-based retrospective cohort study of cancer decedents in Ontario, Canada who died between 1 January 2013 and 31 December 2018. Potentially inappropriate interventions, including chemotherapy, major surgery, intensive care unit admission, cardiopulmonary resuscitation, defibrillation, dialysis, percutaneous coronary intervention, mechanical ventilation, feeding tube placement, blood transfusion and bronchoscopy, were captured via hospital discharge records. We used Poisson regression to examine associations between interventions and decedent age, sex, rurality, income and cancer site. RESULTS Among 151 618 decedents, 81.3% received at least one intervention, and 21.4% received 3+ different interventions. Older patients (age 95-105 years vs 19-44 years, rate ratio (RR) 0.36, 95% CI 0.34 to 0.38) and women (RR 0.94, 95% CI 0.93 to 0.94) had lower intervention rates. Rural patients (RR 1.09, 95% CI 1.08 to 1.10), individuals in the highest area-level income quintile (vs lowest income quintile RR 1.02, 95% CI 1.01 to 1.04), and patients with pancreatic cancer (vs colorectal cancer RR 1.10, 95% CI 1.07 to 1.12) had higher intervention rates. CONCLUSIONS Potentially inappropriate interventions were common in the last 100 days of life of cancer decedents. Variations in interventions may reflect differences in prognostic awareness, healthcare access, and care preferences and quality. Earlier identification of patients' palliative care needs and involvement of palliative care specialists may help reduce the use of these interventions at the end of life.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Shuaib Hafid
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Aaron Jones
- ICES, Hamilton, Ontario, Canada
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mary M Scott
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - James Downar
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Doug Manuel
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Katrin Conen
- Department of Medicine, Walker Family Cancer Centre and Niagara Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Sarina Roslyn Isenberg
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
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Yang Y, Qu T, Yang J, Ma B, Leng A. Confucian Familism and Shared Decision Making in End-of-Life Care for Patients with Advanced Cancers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191610071. [PMID: 36011706 PMCID: PMC9408283 DOI: 10.3390/ijerph191610071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/11/2022] [Accepted: 08/12/2022] [Indexed: 05/27/2023]
Abstract
Shared decision-making (SDM) has been institutionally recognized as clinically effective by many Western healthcare systems. Nevertheless, it appears culturally unattractive in China, a country that adheres to Confucian familism which strongly prefers collective family decisions. This study examined this conflict and assessed the influence of Confucian familism on SDM in end-of-life (EOL) care for advanced cancer patients. Between August and November 2018, 188 EOL advanced-cancer patients were randomly recruited from 640 cancer hospital medical records at a Tertiary A-level hospital in Shandong province. Eventually, 164 (87.23%) sample patients were included in the statistical analysis after the non-responsive cases (4.79%) and missing value (7.98%) were removed. SDM was measured through SDM-Q-9, and the patient's siblings were used as indicators of Confucian Familism. Of the 164 patients, the mean SDM score was 38/100; 47.6% were thoroughly unfamiliar with their treatment plans and fell outside the decision-making procedure. Each patient had four siblings on average. Ceteris paribus, more siblings led to lower SDM. Moreover, being 56-65 years old and open-minded were associated with higher SDM, while higher satisfaction of the quality of EOL care yielded lower SDM. In conclusion, Confucian familism weakened patient-clinician SDM in EOL care for advanced cancer patients.
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Affiliation(s)
- Yuexi Yang
- School of Political Science and Public Administration, Shandong University, Qingdao 266237, China
| | | | - Jinyue Yang
- Qingdao Center for Women and Children’s Health and Family Planning Service, Qingdao 266034, China
| | - Ben Ma
- School of Political Science and Public Administration, Shandong University, Qingdao 266237, China
| | - Anli Leng
- School of Political Science and Public Administration, Shandong University, Qingdao 266237, China
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Intensity of care in cancer patients in the last year of life: a retrospective data linkage study. Br J Cancer 2022; 127:712-719. [PMID: 35545681 PMCID: PMC9092325 DOI: 10.1038/s41416-022-01828-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/06/2022] [Accepted: 04/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background Delivering high-quality palliative and end-of-life care for cancer patients poses major challenges for health services. We examine the intensity of cancer care in England in the last year of life. Methods We included cancer decedents aged 65+ who died between January 1, 2010 and December 31, 2017. We analysed healthcare utilisation and costs in the last 12 months of life including hospital-based activities and primary care. Results Healthcare utilisation and costs increased sharply in the last month of life. Hospital costs were the largest cost elements and decreased with age (0.78, 95% CI: 0.73–0.72, p < 0.005 for age group 90+ compared to age 65–69 and increased substantially with comorbidity burden (2.2, 95% CI: 2.09–2.26, p < 0.005 for those with 7+ comorbidities compared to those with 1–3 comorbidities). The costs were highest for haematological cancers (1.45, 95% CI: 1.38–1.52, p < 0.005) and those living in the London region (1.10, 95% CI: 1.02–1.19, p < 0.005). Conclusions Healthcare in the last year of life for advanced cancer patients is costly and offers unclear value to patients and the healthcare system. Further research is needed to understand distinct cancer populations’ pathways and experiences before recommendations can be made about the most appropriate models of care.
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Leng A, Maitland E, Wang S, Nicholas S, Lan K, Wang J. Preferences for End-of-Life Care Among Patients With Terminal Cancer in China. JAMA Netw Open 2022; 5:e228788. [PMID: 35467732 PMCID: PMC9039770 DOI: 10.1001/jamanetworkopen.2022.8788] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 03/07/2022] [Indexed: 11/18/2022] Open
Abstract
Importance In China, little is known about end-of-life (EOL) care preferences of patients with terminal cancer. Understanding these patients' treatment preferences is needed to improve patient-centered health care, better inform surrogates and medical staff about patient preferences, and enhance the quality of EOL care. Objective To examine preferences for EOL care among patients with terminal cancer in China. Design, Setting, and Participants In this survey study, patients older than 50 years who had terminal cancer were randomly selected from medical records at a single hospital in China. Data on patients' EOL care preferences were collected by discrete choice experiment (DCE) from August to November 2018 and were analyzed from October 2020 to March 2021. Main Outcomes and Measures The main outcome was patient preferences in EOL care, derived using a mixed logit model. Each DCE scenario described 6 attributes: hospitalization days, life extension, quality of life, adverse treatment events, place-of-death preference, and out-of-pocket costs. The marginal willingness to pay (WTP) in US dollars was estimated from regression coefficients. Results Of 188 patients selected for the survey, 183 participated (97.3%). Among the respondents, the mean [SD] age was 61 [8.4] years, and 128 (69.8%) were male. Patients' preferences for moderate increase in survival time, better quality of life, death at home, and lower out-of-pocket costs were significantly associated with their choices between treatment models. Extending life by 10 months (vs 4 months: β, 1.63; 95% CI, 0.81-2.44) and a better quality of life (very good vs poor: β, 1.79; 95% CI, 0.96-2.62) were the most important attributes to patients. The uptake rate for a treatment scenario increased by 61.6% when the quality of life improved from poor to very good, and when life extension increased from 4 months to 10, the uptake rate increased by 57.2%. The uptake increased by 12.5% when the place of death changed from hospital to home. However, it decreased by 31.4% when the costs increased to $21 174. The study found a WTP of $38 854 (95% CI, $19 468-$95 096) to improve quality of life from a poor to a very good level, substantially higher than the WTP for a life extension of 6 months ($35 308; 95% CI, $17 745-$80 279) or 1 year ($27 572; 95% CI, $16 389-$58 027) compared with the baseline scenario of a 4-month extension. Patients were willing to pay $8860 (95% CI, $621-$26 474) to die at home rather than in a hospital. Conclusions and Relevance The findings suggest that in addition to extending life moderately for patients with terminal cancer, improving quality of life during EOL care and supporting home deaths may deserve greater attention. The findings also suggest that physicians and surrogates should ask about patients' care preferences and better inform them of their choices to improve EOL care outcomes.
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Affiliation(s)
- Anli Leng
- School of Political Science and Public Administration, Shandong University, Qingdao, China
- Center for Health Preferences Research, Shandong University, Jinan, China
| | | | - Siyuan Wang
- Faculty of Business and Economics, University of Melbourne, North Melbourne, Victoria, Australia
| | - Stephen Nicholas
- Australian National Institute of Management and Commerce, Australian Technology Park, Sydney, New South Wales, Australia
- Newcastle Business School, University of Newcastle, Newcastle, New South Wales, Australia
| | - Kuixu Lan
- Publicity Department, The Affiliated Hospital of Qingdao University, Shinan District, Qingdao, China
| | - Jian Wang
- Dong Fureng Institute of Economic and Social Development, Wuhan University, Beijing, China
- Center for Health Economics and Management at the School of Economics and Management, Wuhan University, Wuhan, China
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Stefan MS, Eltanbedawi A, Devoe NC, Khan S, Zhou Y, Latef T, Esposito A, Fatima A, Knee AB, Lagu TC. Death among patients hospitalized with symptomatic COVID-19: Implications for high-risk patients. J Hosp Med 2022; 17:252-258. [PMID: 35535924 PMCID: PMC9088345 DOI: 10.1002/jhm.12805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND We aimed to examine the role played by the COVID-19 infection in patients' death and to determine the proportion of patients for whom it was a major contributor to death. METHODS We included patients ≥50 years old who were hospitalized with COVID-19 infection and died between March 1, 2020 and September 30, 2020 in a tertiary medical center. We considered COVID-19 infection to be a major cause for death if the patient had well-controlled medical conditions and death was improbable without coronavirus infection, and a minor cause for death if the patient had serious illnesses and had an indication for palliative care. RESULTS Among 243 patients, median age was 80 (interquartile intervals: 72-86) and 40% were female. One in two had moderate or severe frailty and 41% had dementia. Nearly 60% of the patients were classified as having advanced, serious illnesses present prior to the hospitalization, with death being expected within 12 months, and among this group 39% were full code at admission. In the remaining 40% of patients, deaths were classified as unexpected based on patients' prior conditions, suggesting that COVID-19 infection complications were the primary contributor to death. CONCLUSIONS For slightly less than half (40%) of patients who died of complications of COVID-19, death was an unexpected event. Among the 60% of patients for whom death was not a surprise, our findings identify opportunities to improve end-of-life discussions and implement shared decision-making in high-risk patients early on or prior to hospitalization.
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Affiliation(s)
- Mihaela S. Stefan
- Institute for Healthcare Delivery and Population ScienceUniversity of Massachusetts Medical School‐BaystateSpringfieldMassachusettsUSA
- Department of MedicineUniversity of Massachusetts Chan Medical School‐BaystateSpringfieldMassachusettsUSA
| | - Ahmed Eltanbedawi
- Department of MedicineUniversity of Massachusetts Chan Medical School‐BaystateSpringfieldMassachusettsUSA
- Department of Medicine, Internal Medicine Residency ProgramUniversity of Massachusetts Chan Medical School‐BaystateSpringfieldMassachusettsUSA
| | - Neil C. Devoe
- Department of MedicineUniversity of Massachusetts Chan Medical School‐BaystateSpringfieldMassachusettsUSA
- Department of Medicine, Internal Medicine Residency ProgramUniversity of Massachusetts Chan Medical School‐BaystateSpringfieldMassachusettsUSA
| | - Sabiha Khan
- Department of MedicineUniversity of Massachusetts Chan Medical School‐BaystateSpringfieldMassachusettsUSA
- Department of Medicine, Internal Medicine Residency ProgramUniversity of Massachusetts Chan Medical School‐BaystateSpringfieldMassachusettsUSA
| | - Ya Zhou
- Department of MedicineUniversity of Massachusetts Chan Medical School‐BaystateSpringfieldMassachusettsUSA
- Department of Medicine, Internal Medicine Residency ProgramUniversity of Massachusetts Chan Medical School‐BaystateSpringfieldMassachusettsUSA
| | - Taroob Latef
- Department of MedicineUniversity of Massachusetts Chan Medical School‐BaystateSpringfieldMassachusettsUSA
- Department of Medicine, Internal Medicine Residency ProgramUniversity of Massachusetts Chan Medical School‐BaystateSpringfieldMassachusettsUSA
| | - Anthony Esposito
- Department of MedicineUniversity of Massachusetts Chan Medical School‐BaystateSpringfieldMassachusettsUSA
- Department of Medicine, Internal Medicine Residency ProgramUniversity of Massachusetts Chan Medical School‐BaystateSpringfieldMassachusettsUSA
| | - Anum Fatima
- Department of MedicineUniversity of Massachusetts Chan Medical School‐BaystateSpringfieldMassachusettsUSA
- Department of Medicine, Internal Medicine Residency ProgramUniversity of Massachusetts Chan Medical School‐BaystateSpringfieldMassachusettsUSA
| | - Alexander B. Knee
- Department of MedicineUniversity of Massachusetts Chan Medical School‐BaystateSpringfieldMassachusettsUSA
- Department of Academic Affairs, Epidemiology/Biostatistics Research CoreOffice of Research, Baystate Medical CenterSpringfieldMassachusettsUSA
| | - Tara C. Lagu
- Center for Health Services and Outcomes Research, Institute of Public Health and MedicineNorthwestern Feinberg School of MedicineChicagoIllinoisUSA
- Department of Medicine, Division of Hospital MedicineNorthwestern Feinberg School of MedicineChicagoIllinoisUSA
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Barbiellini Amidei C, Macciò S, Cantarutti A, Gessoni F, Bardin A, Zanier L, Canova C, Simonato L. Hospitalizations and emergency department visits trends among elderly individuals in proximity to death: a retrospective population-based study. Sci Rep 2021; 11:21472. [PMID: 34728661 PMCID: PMC8563963 DOI: 10.1038/s41598-021-00648-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 10/11/2021] [Indexed: 11/25/2022] Open
Abstract
Acute healthcare services are extremely important, particularly during the COVID-19 pandemic, as healthcare demand has rapidly intensified, and resources have become insufficient. Studies on specific prepandemic hospitalization and emergency department visit (EDV) trends in proximity to death are limited. We examined time-trend specificities based on sex, age, and cause of death in the last 2 years of life. Datasets containing all hospitalizations and EDVs of elderly residents in Friuli-Venezia Giulia, Italy (N = 411,812), who died between 2002 and 2014 at ≥ 65 years, have been collected. We performed subgroup change-point analysis of monthly trends in the 2 years preceding death according to sex, age at death (65-74, 75-84, 85-94, and ≥ 95 years), and main cause of death (cancer, cardiovascular, or respiratory disease). The proportion of decedents (N = 142,834) accessing acute healthcare services increased exponentially in proximity to death (hospitalizations = 4.7, EDVs = 3.9 months before death). This was inversely related to age, with changes among the youngest and eldest decedents at 6.6 and 3.5 months for hospitalizations and at 4.6 and 3.3 months for EDVs, respectively. Healthcare use among cancer patients intensified earlier in life (hospitalizations = 6.8, EDVs = 5.8 months before death). Decedents from respiratory diseases were most likely to access hospital-based services during the last month of life. No sex-based differences were found. The greater use of acute healthcare services among younger decedents and cancer patients suggests that policies potentiating primary care support targeting these at-risk groups may reduce pressure on hospital-based services.
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Affiliation(s)
- Claudio Barbiellini Amidei
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, 35131, Padua, Italy.
| | - Silvia Macciò
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, 35131, Padua, Italy
| | - Anna Cantarutti
- Division of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
| | - Francesca Gessoni
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, 35131, Padua, Italy
| | - Andrea Bardin
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, 35131, Padua, Italy
| | - Loris Zanier
- Epidemiological Service, Health Directorate, Friuli-Venezia Giulia Region, Udine, Italy
| | - Cristina Canova
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, 35131, Padua, Italy.
| | - Lorenzo Simonato
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, 35131, Padua, Italy
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Quality of End-of-Life Care for People with Advanced Non-Small Cell Lung Cancer in Ontario: A Population-Based Study. ACTA ACUST UNITED AC 2021; 28:3297-3315. [PMID: 34590598 PMCID: PMC8406090 DOI: 10.3390/curroncol28050286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/13/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022]
Abstract
Ensuring high quality end of life (EOL) care is necessary for people with advanced non-small-cell lung cancer (NSCLC), given its high incidence, mortality and symptom burden. Aggressive EOL care can adversely affect the quality of life of NSCLC patients without providing meaningful oncologic benefit. Objectives: (1) To describe EOL health services quality indicators and timing of palliative care consultation provided to patients dying of NSCLC. (2) To examine associations between aggressive and supportive care and patient, disease and treatment characteristics. Methods: This retrospective population-based cohort study describes those who died of NSCLC in Ontario, Canada from 2009–2017. Socio-demographic, patient, disease and treatment characteristics as well as EOL health service quality and use of palliative care consultation were investigated. Multivariable logistic regression models examined factors associated with receiving aggressive or supportive care. Results: Aggressive care quality indicators were present in 50.3% and supportive care indicators in 60.3% of the cohort (N = 37,203). Aggressive care indicators decreased between 2009 and 2017 (57.4% to 45.3%) and increased for supportive care (54.2% to 67.5%). Benchmarks were not met by 2017 in 3 of 4 cases. Male sex and greater comorbidity were associated with more aggressive EOL care and less supportive care. Older age was negatively associated and rurality positively associated with aggressive care. No palliative care consultation occurred in 56.0%. Conclusions: While improvements in the use of supportive rather than aggressive care were noted, established Canadian benchmarks were not met. Moreover, there is variation in EOL quality between groups and use of earlier palliative care must improve.
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Nipp RD, Subbiah IM, Loscalzo M. Convergence of Geriatrics and Palliative Care to Deliver Personalized Supportive Care for Older Adults With Cancer. J Clin Oncol 2021; 39:2185-2194. [PMID: 34043435 PMCID: PMC8260927 DOI: 10.1200/jco.21.00158] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/07/2021] [Accepted: 02/23/2021] [Indexed: 02/06/2023] Open
Affiliation(s)
- Ryan D. Nipp
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ishwaria M. Subbiah
- Department of Palliative, Rehabilitation and Integrative Medicine, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
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Brazee RL, Nugent BD, Sereika SM, Rosenzweig M. The Quality of End-of-Life Care for Women Deceased From Metastatic Breast Cancer. J Hosp Palliat Nurs 2021; 23:238-247. [PMID: 33782263 DOI: 10.1097/njh.0000000000000746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Metastatic breast cancer (MBC) carries unique disease burdens with potential for poor-quality end-of-life (EOL) care. It is the purpose of this article to explore the association of poor-quality EOL care indicators according to key tumor, demographic, social, and clinical factors. End-of-life quality indicators were based on Emanuel and Emanuel's good death model in conjunction with Earle et al (2003). A single-institution retrospective chart review of women deceased from MBC between November 2016 and November 2019 with double-verification chart review was completed. Data were analyzed with descriptive, correlative, and comparative statistics. Total sample was N = 167 women, with 14.4% (n = 24) Black and 85.6% (n = 143) White. Mean (SD) age was 55.3 (11.73) years. Overall, MBC survival was 3.12 years (SD, 3.31): White women, 41.2 months (3.4 years), and Black women, 19 months (1.6 years). A total of 64.1% (n = 107) experienced 1 or more indicators of poor-quality EOL care. Patients more likely to experience poor-quality EOL care were older (P = .03), estrogen negative (P = .08), human epidermal growth factor receptor 2 negative (P = .07), from more deprived neighborhoods (P = .02), married (P = .05), and with physical (P = .001) and mental (P = .002) comorbidities. Understanding sociodemographic and clinical factors associated with poor EOL MBC care may be useful for proactive patient navigation.
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Doble B, Wong WHM, Finkelstein E. End-of-life cost trajectories and the trade-off between treatment costs and life-extension: Findings from the Cost and Medical Care of Patients with Advanced Serious Illness (COMPASS) cohort study. Palliat Med 2021; 35:893-903. [PMID: 33730947 DOI: 10.1177/0269216321999576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Few studies have assessed how patient preferences influence end-of-life costs. AIM To estimate mean monthly healthcare costs in 2019 Singapore Dollars (SGD) at five time points within the last year of life and identify how patients' preferences for the trade-off between treatment cost containment and life-extension and other factors affect these costs. DESIGN Mean monthly costs were quantified in the last 1, 3, 6, 9, and 12-months before death. Univariate and multivariate analyses were conducted. SETTING/PARTICIPANTS Billing records for 286 deceased participants in the Cost and Medical Care of Patients with Advanced Serious Illness (COMPASS) cancer cohort study in Singapore. RESULTS Mean monthly costs were $5140 (95% CI: $4750; $5520) in the 12-months before death and rose to $8350 (95% CI: $7110; $9590) 1-month before death. Participants preferring higher cost containment/less life-extension defied the trend of increasing costs closer to death (mean monthly costs of $4630 (95% CI: $3690; $ 5580) and $4850 (95% CI: $2850; $6850) (12-months and 1-month before death respectively). Participants preferring lower cost containment/more life-extension had costs that were $1050 (95% CI: $49; $2051) and $5220 (95% CI: $2320; $8130) higher than those preferring lower costs/less life-extension 12-months and 1-month before death respectively. CONCLUSIONS On average, cancer patients in Singapore can expect to spend $61,680 in the last year of life. Of broader relevance is that patient preferences and other observable factors clearly influence these costs, suggesting that policymakers and patients can better predict and budget for end-of-life costs by considering these factors.
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Affiliation(s)
- Brett Doble
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Programme for Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Wei Han Melvin Wong
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Programme for Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Eric Finkelstein
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore.,Programme for Health Services and Systems Research, Duke-NUS Medical School, Singapore
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13
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Taneja R, Sibbald R, Elliott L, Burke E, Bishop KA, Jones PM, Goldszmidt M. Exploring and reconciling discordance between documented and preferred resuscitation preferences for hospitalized patients: a quality improvement study. Can J Anaesth 2021; 68:530-540. [PMID: 33452662 DOI: 10.1007/s12630-020-01906-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/02/2020] [Accepted: 10/07/2020] [Indexed: 10/22/2022] Open
Abstract
PURPOSE A discordance, predominantly towards overtreatment, exists between patients' expressed preferences for life-sustaining interventions and those documented at hospital admission. This quality improvement study sought to assess this discordance at our institution. Secondary objectives were to explore if internal medicine (IM) teams could identify patients who might benefit from further conversations and if the discordance can be reconciled in real-time. METHODS Two registered nurses were incorporated into IM teams at a tertiary hospital to conduct resuscitation preference conversations with inpatients either specifically referred to them (group I, n = 165) or randomly selected (group II, n = 164) from 1 August 2016 to 31 August 2018. Resuscitation preferences were documented and communicated to teams prompting revised resuscitation orders where appropriate. Multivariable logistic regression was used to determine potential risk factors for discordance. RESULTS Three hundred and twenty-nine patients were evaluated with a mean (standard deviation) age of 80 (12) and Charlson Comorbidity Index Score of 6.8 (2.6). Discordance was identified in 63/165 (38%) and 27/164 (16%) patients in groups I and II respectively. 42/194 patients (21%) did not want cardiopulmonary resuscitation (CPR) and 15/36 (41%) did not prefer intensive care unit (ICU) admission, despite these having been indicated in their initial preferences. 93% (84/90) of patients with discordance preferred de-escalation of care. Discordance was reconciled in 77% (69/90) of patients. CONCLUSION Hospitalized patients may have preferences documented for CPR and ICU interventions contrary to their preferences. Trained nurses can identify inpatients who would benefit from further in-depth resuscitation preference conversations. Once identified, discordance can be reconciled during the index admission.
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Affiliation(s)
- Ravi Taneja
- Division of Critical Care, University of Western Ontario, London, ON, Canada.
- Department of Medicine, Division of Internal Medicine, University of Western Ontario, London, ON, Canada.
- Centre for Education Research and Innovation, University of Western Ontario, London, ON, Canada.
- London Health Sciences Centre, University Hospital, B2-223, 339 Windermere Road, London, ON, N6A 5A5, Canada.
| | - Robert Sibbald
- Centre for Education Research and Innovation, University of Western Ontario, London, ON, Canada
- Department of Clinical and Corporate Ethics, London Health Sciences Centre, London, ON, Canada
| | - Launa Elliott
- Division of Critical Care, University of Western Ontario, London, ON, Canada
- Department of Clinical and Corporate Ethics, London Health Sciences Centre, London, ON, Canada
| | - Elizabeth Burke
- Division of Critical Care, University of Western Ontario, London, ON, Canada
| | - Kristen A Bishop
- Centre for Education Research and Innovation, University of Western Ontario, London, ON, Canada
| | - Philip M Jones
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, ON, Canada
- Department of Epidemiology & Biostatistics, University of Western Ontario, London, ON, Canada
| | - Mark Goldszmidt
- Department of Medicine, Division of Internal Medicine, University of Western Ontario, London, ON, Canada
- Centre for Education Research and Innovation, University of Western Ontario, London, ON, Canada
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14
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Cross SH, Kaufman BG, Quest TE, Warraich HJ. National Trends in Hospice Facility Deaths in the United States, 2003-2017. J Pain Symptom Manage 2021; 61:350-357. [PMID: 32858165 DOI: 10.1016/j.jpainsymman.2020.08.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 11/16/2022]
Abstract
CONTEXT Hospice facilities are increasingly preferred as a location of death, but little is known about the characteristics of patients who die in these facilities in the U.S. OBJECTIVES We sought to examine the trends and factors associated with death in a hospice facility. METHODS Retrospective cross-sectional study using mortality data for years 2003-2017 for deaths attributed to natural causes in the U.S. RESULTS The proportion of natural deaths occurring in hospice facilities increased from 0.2% in 2003 to 8.3% in 2017, resulting in nearly 1.7 million deaths during this time frame. Females had increased odds of hospice facility deaths (odds ratio [OR] = 1.04; 95% CI = 1.04, 1.05). Nonwhite race was associated with lower odds of hospice facility death (black [OR = 0.915; 95% CI = 0.890, 0.940]; Native American [OR = 0.559; 95% CI = 0.515, 0.607]; and Asian [OR = 0.655; 95% CI = 0.601, 0.713]). Being married was associated with hospice facility death (OR = 1.06; 95% CI = 1.04, 1.07). Older age was associated with increased odds of hospice facility death (85 and older [OR = 1.40; 95% CI = 1.39, 1.41]). Having at least some college education was associated with increased odds of hospice facility death (OR = 1.13; 95% CI = 1.11, 1.15). Decedents from cardiovascular disease had the lowest odds of hospice facility death (OR = 0.278; 95% CI = 0.274, 0.282). CONCLUSION Hospice facility deaths increased among all patient groups; however, striking differences exist by age, sex, race, marital status, education level, cause of death, and geography. Factors underlying these disparities should be examined.
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Affiliation(s)
- Sarah H Cross
- Sanford School of Public Policy, Duke University, Durham, North Carolina, USA.
| | - Brystana G Kaufman
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA; Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Tammie E Quest
- Department of Emergency Medicine, Emory University, Atlanta, Georgia, USA; Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
| | - Haider J Warraich
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiology Section, Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
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15
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González-González AI, Schmucker C, Nothacker J, Nury E, Dinh TS, Brueckle MS, Blom JW, van den Akker M, Röttger K, Wegwarth O, Hoffmann T, Gerlach FM, Straus SE, Meerpohl JJ, Muth C. End-of-Life Care Preferences of Older Patients with Multimorbidity: A Mixed Methods Systematic Review. J Clin Med 2020; 10:E91. [PMID: 33383951 PMCID: PMC7795676 DOI: 10.3390/jcm10010091] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/23/2020] [Accepted: 12/24/2020] [Indexed: 11/16/2022] Open
Abstract
Unpredictable disease trajectories make early clarification of end-of-life (EoL) care preferences in older patients with multimorbidity advisable. This mixed methods systematic review synthesizes studies and assesses such preferences. Two independent reviewers screened title/abstracts/full texts in seven databases, extracted data and used the Mixed Methods Appraisal Tool to assess risk of bias (RoB). We synthesized findings from 22 studies (3243 patients) narratively and, where possible, quantitatively. Nineteen studies assessed willingness to receive life-sustaining treatments (LSTs), six, the preferred place of care, and eight, preferences regarding shared decision-making processes. When unspecified, 21% of patients in four studies preferred any LST option. In three studies, fewer patients chose LST when faced with death and deteriorating health, and more when treatment promised life extension. In 13 studies, 67% and 48% of patients respectively were willing to receive cardiopulmonary resuscitation and mechanical ventilation, but willingness decreased with deteriorating health. Further, 52% of patients from three studies wished to die at home. Seven studies showed that unless incapacitated, most patients prefer to decide on their EoL care themselves. High non-response rates meant RoB was high in most studies. Knowledge of EoL care preferences of older patients with multimorbidity increases the chance such care will be provided.
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Affiliation(s)
- Ana I. González-González
- Institute of General Practice, Goethe University, 60590 Frankfurt am Main, Germany; (T.S.D.); (M.-S.B.); (M.v.d.A.); (F.M.G.); (C.M.)
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), 28035 Madrid, Spain
| | - Christine Schmucker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany; (C.S.); (J.N.); (E.N.); (J.J.M.)
| | - Julia Nothacker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany; (C.S.); (J.N.); (E.N.); (J.J.M.)
| | - Edris Nury
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany; (C.S.); (J.N.); (E.N.); (J.J.M.)
| | - Truc Sophia Dinh
- Institute of General Practice, Goethe University, 60590 Frankfurt am Main, Germany; (T.S.D.); (M.-S.B.); (M.v.d.A.); (F.M.G.); (C.M.)
| | - Maria-Sophie Brueckle
- Institute of General Practice, Goethe University, 60590 Frankfurt am Main, Germany; (T.S.D.); (M.-S.B.); (M.v.d.A.); (F.M.G.); (C.M.)
| | - Jeanet W. Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, 2300 RC Leiden, The Netherlands;
| | - Marjan van den Akker
- Institute of General Practice, Goethe University, 60590 Frankfurt am Main, Germany; (T.S.D.); (M.-S.B.); (M.v.d.A.); (F.M.G.); (C.M.)
- Department of Family Medicine, School CAPHRI, Maastricht University, 6200 Maastricht, The Netherlands
- Academic Center for General Practice, Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
| | - Kristian Röttger
- Patient Representative, Federal Joint Committee “Gemeinsamer Bundseausschuss”, 10587 Berlin, Germany;
| | - Odette Wegwarth
- Center for Adaptive Rationality, Max Planck-Institute for Human Development, 14195 Berlin, Germany;
| | - Tammy Hoffmann
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD 4226, Australia;
| | - Ferdinand M. Gerlach
- Institute of General Practice, Goethe University, 60590 Frankfurt am Main, Germany; (T.S.D.); (M.-S.B.); (M.v.d.A.); (F.M.G.); (C.M.)
| | - Sharon E. Straus
- Department of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada;
| | - Joerg J. Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany; (C.S.); (J.N.); (E.N.); (J.J.M.)
- Cochrane Germany, Cochrane Germany Foundation, 79110 Freiburg, Germany
| | - Christiane Muth
- Institute of General Practice, Goethe University, 60590 Frankfurt am Main, Germany; (T.S.D.); (M.-S.B.); (M.v.d.A.); (F.M.G.); (C.M.)
- Department of General Practice and Family Medicine, Medical Faculty OWL, University of Bielefeld, 33615 Bielefeld, Germany
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16
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Levoy K, Tarbi EC, De Santis JP. End-of-life decision making in the context of chronic life-limiting disease: a concept analysis and conceptual model. Nurs Outlook 2020; 68:784-807. [PMID: 32943221 PMCID: PMC7704858 DOI: 10.1016/j.outlook.2020.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 06/26/2020] [Accepted: 07/10/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Conceptual ambiguities prevent advancements in end-of-life decision making in clinical practice and research. PURPOSE To clarify the components of and stakeholders (patients, caregivers, healthcare providers) involved in end-of-life decision making in the context of chronic life-limiting disease and develop a conceptual model. METHOD Walker and Avant's approach to concept analysis. FINDINGS End-of-life decision making is a process, not a discrete event, that begins with preparation, including decision maker designation and iterative stakeholder communication throughout the chronic illness (antecedents). These processes inform end-of-life decisions during terminal illness, involving: 1) serial choices 2) weighed in terms of potential outcomes 3) through patient and caregiver collaboration (attributes). Components impact patients' death, caregivers' bereavement, and healthcare systems' outcomes (consequences). DISCUSSION Findings provide a foundation for improved inquiry into and measurement of the end-of-life decision making process, accounting for the dose, content, and quality the antecedent and attribute factors that collectively contribute to outcomes.
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Affiliation(s)
- Kristin Levoy
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA.
| | - Elise C Tarbi
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Joseph P De Santis
- University of Miami School of Nursing and Health Studies, Coral Gables, FL
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17
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de Man Y, Groenewoud S, Oosterveld-Vlug MG, Brom L, Onwuteaka-Philipsen BD, Westert GP, Atsma F. Regional variation in hospital care at the end-of-life of Dutch patients with lung cancer exists and is not correlated with primary and long-term care. Int J Qual Health Care 2020; 32:190-195. [PMID: 32186705 PMCID: PMC7238674 DOI: 10.1093/intqhc/mzaa004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 12/11/2019] [Accepted: 01/28/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To examine the regional variation in hospital care utilization in the last 6 months of life of Dutch patients with lung cancer and to test whether higher degrees of hospital utilization coincide with less general practitioner (GP) and long-term care use. DESIGN Cross-sectional claims data study. SETTING The Netherlands. PARTICIPANTS Patients deceased in 2013-2015 with lung cancer (N = 25 553). MAIN OUTCOME MEASURES We calculated regional medical practice variation scores, adjusted for age, gender and socioeconomic status, for radiotherapy, chemotherapy, CT-scans, emergency room contacts and hospital admission days during the last 6 months of life; Spearman Rank correlation coefficients measured the association between the adjusted regional medical practice variation scores for hospital admissions and ER contacts and GP and long-term care utilization. RESULTS The utilization of hospital services in high-using regions is 2.3-3.6 times higher than in low-using regions. The variation was highest in 2015 and lowest in 2013. For all 3 years, hospital care was not significantly correlated with out-of-hospital care at a regional level. CONCLUSIONS Hospital care utilization during the last 6 months of life of patients with lung cancer shows regional medical practice variation over the course of multiple years and seems to increase. Higher healthcare utilization in hospitals does not seem to be associated with less intensive GP and long-term care. In-depth research is needed to explore the causes of the variation and its relation to quality of care provided at the level of daily practice.
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Affiliation(s)
- Yvonne de Man
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Stef Groenewoud
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Mariska G Oosterveld-Vlug
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands, Van der Boechorststraat 7, 1081, BT, Amsterdam, The Netherlands, and
| | - Linda Brom
- IKNL, Netherlands Comprehensive Cancer Organization, Godebaldkwartier 419, 3511 DT Utrecht, the Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands, Van der Boechorststraat 7, 1081, BT, Amsterdam, The Netherlands, and
| | - Gert P Westert
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Femke Atsma
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
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18
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Fliedner MC, Hagemann M, Eychmüller S, King C, Lohrmann C, Halfens RJG, Schols JMGA. Does Time for (in)Direct Nursing Care Activities at the End of Life for Patients With or Without Specialized Palliative Care in a University Hospital Differ? A Retrospective Analysis. Am J Hosp Palliat Care 2020; 37:844-852. [PMID: 32180430 DOI: 10.1177/1049909120905779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Nurses' end of life (EoL) care focuses on direct (eg, physical) and indirect (e,g, coordination) care. Little is known about how much time nurses actually devote to these activities and if activities change due to support by specialized palliative care (SPC) in hospitalized patients. AIMS (1) Comparing care time for EoL patients receiving SPC to usual palliative care (UPC);(2) Comparing time spent for direct/indirect care in the SPC group before and after SPC. METHODS Retrospective observational study; nursing care time for EoL patients based on tacs® data using nonparametric and parametric tests. The Swiss data method tacs measures (in)direct nursing care time for monitoring and cost analyses. RESULTS Analysis of tacs® data (UPC, n = 642; SPC, n = 104) during hospitalization before death in 2015. Overall, SPC patients had higher tacs® than UPC patients by 40 direct (95% confidence interval [CI]: 5.7-75, P = .023) and 14 indirect tacs® (95% CI: 6.0-23, P < .001). No difference for tacs® by day, as SPC patients were treated for a longer time (mean number of days 7.2 vs 16, P < .001).Subanalysis for SPC patients showed increased direct care time on the day of and after SPC (P < .001), whereas indirect care time increased only on the day of SPC. CONCLUSIONS This study gives insight into nurses' time for (in)direct care activities with/without SPC before death. The higher (in)direct nursing care time in SPC patients compared to UPC may reflect higher complexity. Consensus-based measurements to monitor nurses' care activities may be helpful for benchmarking or reimbursement analysis.
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Affiliation(s)
- Monica C Fliedner
- Department of Oncology, University Center for Palliative Care, Inselspital, University Hospital, Bern, Switzerland.,Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Monika Hagemann
- Department of Oncology, University Center for Palliative Care, Inselspital, University Hospital, Bern, Switzerland
| | - Steffen Eychmüller
- Department of Oncology, University Center for Palliative Care, Inselspital, University Hospital, Bern, Switzerland
| | | | - Christa Lohrmann
- Institute of Nursing Science, Medical University Graz, Graz, Austria
| | - Ruud J G Halfens
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Jos M G A Schols
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands.,Department of Family Medicine; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
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19
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Lee RY, Brumback LC, Sathitratanacheewin S, Lober WB, Modes ME, Lynch YT, Ambrose CI, Sibley J, Vranas KC, Sullivan DR, Engelberg RA, Curtis JR, Kross EK. Association of Physician Orders for Life-Sustaining Treatment With ICU Admission Among Patients Hospitalized Near the End of Life. JAMA 2020; 323:950-960. [PMID: 32062674 PMCID: PMC7042829 DOI: 10.1001/jama.2019.22523] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Patients with chronic illness frequently use Physician Orders for Life-Sustaining Treatment (POLST) to document treatment limitations. OBJECTIVES To evaluate the association between POLST order for medical interventions and intensive care unit (ICU) admission for patients hospitalized near the end of life. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of patients with POLSTs and with chronic illness who died between January 1, 2010, and December 31, 2017, and were hospitalized 6 months or less before death in a 2-hospital academic health care system. EXPOSURES POLST order for medical interventions ("comfort measures only" vs "limited additional interventions" vs "full treatment"), age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury. MAIN OUTCOMES AND MEASURES The primary outcome was the association between POLST order and ICU admission during the last hospitalization of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments: mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation. For evaluating factors associated with POLST-discordant care, the outcome was ICU admission contrary to POLST order for medical interventions during the last hospitalization of life. RESULTS Among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment. ICU admissions occurred in 31% (95% CI, 26%-35%) of patients with comfort-only orders, 46% (95% CI, 42%-49%) with limited-interventions orders, and 62% (95% CI, 58%-66%) with full-treatment orders. One or more life-sustaining treatments were delivered to 14% (95% CI, 11%-17%) of patients with comfort-only orders and to 20% (95% CI, 17%-23%) of patients with limited-interventions orders. Compared with patients with full-treatment POLSTs, those with comfort-only and limited-interventions orders were significantly less likely to receive ICU admission (comfort only: 123/401 [31%] vs 406/656 [62%], aRR, 0.53 [95% CI, 0.45-0.62]; limited interventions: 349/761 [46%] vs 406/656 [62%], aRR, 0.79 [95% CI, 0.71-0.87]). Across patients with comfort-only and limited-interventions POLSTs, 38% (95% CI, 35%-40%) received POLST-discordant care. Patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer (comfort only: 41/181 [23%] vs 80/220 [36%], aRR, 0.60 [95% CI, 0.43-0.85]; limited interventions: 100/321 [31%] vs 215/440 [49%], aRR, 0.63 [95% CI, 0.51-0.78]). Patients with dementia and comfort-only orders were significantly less likely to receive POLST-discordant care than those without dementia (23/111 [21%] vs 98/290 [34%], aRR, 0.44 [95% CI, 0.29-0.67]). Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care (comfort only: 29/64 [45%] vs 92/337 [27%], aRR, 1.52 [95% CI, 1.08-2.14]; limited interventions: 51/91 [56%] vs 264/670 [39%], aRR, 1.36 [95% CI, 1.09-1.68]). In patients with limited-interventions orders, older age was significantly associated with less POLST-discordant care (aRR, 0.93 per 10 years [95% CI, 0.88-1.00]). CONCLUSIONS AND RELEVANCE Among patients with POLSTs and with chronic life-limiting illness who were hospitalized within 6 months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission compared with full-treatment POLSTs. However, 38% of patients with treatment-limiting POLSTs received intensive care that was potentially discordant with their POLST.
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Affiliation(s)
- Robert Y. Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Lyndia C. Brumback
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Department of Biostatistics, University of Washington, Seattle
| | - Seelwan Sathitratanacheewin
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - William B. Lober
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
- Department of Bioinformatics and Medical Education, University of Washington, Seattle
| | - Matthew E. Modes
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - Ylinne T. Lynch
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | | | - James Sibley
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
- Department of Bioinformatics and Medical Education, University of Washington, Seattle
| | - Kelly C. Vranas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland
- Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Donald R. Sullivan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland
- Health Services Research and Development, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
| | - J. Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
- Department of Bioethics and Humanities, University of Washington, Seattle
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle
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20
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Halpern SD, Small DS, Troxel AB, Cooney E, Bayes B, Chowdhury M, Tomko HE, Angus DC, Arnold RM, Loewenstein G, Volpp KG, White DB, Bryce CL. Effect of Default Options in Advance Directives on Hospital-Free Days and Care Choices Among Seriously Ill Patients: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e201742. [PMID: 32227179 PMCID: PMC7315782 DOI: 10.1001/jamanetworkopen.2020.1742] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE There is limited evidence regarding how patients make choices in advance directives (ADs) or whether these choices influence subsequent care. OBJECTIVE To examine whether default options in ADs influence care choices and clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial included 515 patients who met criteria for having serious illness and agreed to participate. Patients were enrolled at 20 outpatient clinics affiliated with the University of Pennsylvania Health System and the University of Pittsburgh Medical Center from February 2014 to April 2016 and had a median follow-up of 18 months. Data analysis was conducted from November 2018 to April 2019. INTERVENTIONS Patients were randomly assigned to complete 1 of the 3 following ADs: (1) a comfort-promoting plan of care and nonreceipt of potentially life-sustaining therapies were selected by default (comfort AD), (2) a life-extending plan of care and receipt of potentially life-sustaining therapies were selected by default (life-extending AD), or (3) no choices were preselected (standard AD). MAIN OUTCOMES AND MEASURES This trial was powered to rule out a reduction in hospital-free days in the intervention groups. Secondary outcomes included choices in ADs for an overall comfort-oriented approach to care, choices to forgo 4 forms of life support, patients' quality of life, decision conflict, place of death, admissions to hospitals and intensive care units, and costs of inpatient care. RESULTS Among 515 patients randomized, 10 withdrew consent and 13 were later found to be ineligible, leaving 492 (95.5%) in the modified intention-to-treat (mITT) sample (median [interquartile range] age, 63 [56-70] years; 279 [56.7%] men; 122 [24.8%] black; 363 [73.8%] with cancer). Of these, 264 (53.7%) returned legally valid ADs and were debriefed about their assigned intervention. Among these, patients completing comfort ADs were more likely to choose comfort care (54 of 85 [63.5%]) than those returning standard ADs (45 of 91 [49.5%]) or life-extending ADs (33 of 88 [37.5%]) (P = .001). Among 492 patients in the mITT sample, 57 of 168 patients [33.9%] who completed the comfort AD, 47 of 165 patients [28.5%] who completed the standard AD, and 35 of 159 patients [22.0%] who completed the life-extending AD chose comfort care (P = .02), with patients not returning ADs coded as not selecting comfort care. In mITT analyses, median (interquartile range) hospital-free days among 168 patients assigned to comfort ADs and 159 patients assigned to life-extending default ADs were each noninferior to those among 165 patients assigned to standard ADs (standard AD: 486 [306-717] days; comfort AD: 554 [296-833] days; rate ratio, 1.05; 95% CI, 0.90-1.23; P < .001; life-extending AD: 550 [325-783] days; rate ratio, 1.03; 95% CI, 0.88-1.20; P < .001). There were no differences among groups in other secondary outcomes. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, default options in ADs altered the choices seriously ill patients made regarding their future care without changing clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02017548.
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Affiliation(s)
- Scott D Halpern
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
| | - Dylan S Small
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Statistics Department, the Wharton School, the University of Pennsylvania, Philadelphia
| | - Andrea B Troxel
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Division of Biostatistics, New York University School of Medicine, New York
- Department of Population Health, New York University School of Medicine, New York
| | - Elizabeth Cooney
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
| | - Brian Bayes
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
| | - Marzana Chowdhury
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
| | - Heather E Tomko
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Institute for Doctor-Patient Communication, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Palliative and Supportive Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - George Loewenstein
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Carnegie Mellon University, Department of Social and Decision Sciences, Pittsburgh, Pennsylvania
| | - Kevin G Volpp
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, the University of Pennsylvania, Philadelphia
- The Wharton School, Health Care Management Department, the University of Pennsylvania, Philadelphia
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Program of Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Cindy L Bryce
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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21
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Gonzalez AI, Schmucker C, Nothacker J, Motschall E, Nguyen TS, Brueckle MS, Blom J, van den Akker M, Röttger K, Wegwarth O, Hoffmann T, Straus SE, Gerlach FM, Meerpohl JJ, Muth C. Health-related preferences of older patients with multimorbidity: an evidence map. BMJ Open 2019; 9:e034485. [PMID: 31843855 PMCID: PMC6924802 DOI: 10.1136/bmjopen-2019-034485] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 10/23/2019] [Accepted: 11/01/2019] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES To systematically identify knowledge clusters and research gaps in the health-related preferences of older patients with multimorbidity by mapping current evidence. DESIGN Evidence map (systematic review variant). DATA SOURCES MEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL and Science Citation Index/Social Science Citation Index/-Expanded from inception to April 2018. STUDY SELECTION Studies reporting primary research on health-related preferences of older patients (mean age ≥60 years) with multimorbidity (≥2 chronic/acute conditions). DATA EXTRACTION Two independent reviewers assessed studies for eligibility, extracted data and clustered the studies using MAXQDA-18 content analysis software. RESULTS The 152 included studies (62% from North America, 28% from Europe) comprised 57 093 patients overall (range 9-9105). All used an observational design except for one interventional study: 63 (41%) were qualitative (59 cross-sectional, 4 longitudinal), 85 (57%) quantitative (63 cross-sectional, 22 longitudinal) and 3 (2%) used mixed methods. The setting was specialised care in 85 (56%) and primary care in 54 (36%) studies. We identified seven clusters of studies on preferences: end-of-life care (n=51, 34%), self-management (n=34, 22%), treatment (n=32, 21%), involvement in shared decision making (n=25, 17%), health outcome prioritisation/goal setting (n=19, 13%), healthcare service (n=12, 8%) and screening/diagnostic testing (n=1, 1%). Terminology (eg, preferences, views and perspectives) and concepts (eg, trade-offs, decision regret, goal setting) used to describe health-related preferences varied substantially between studies. CONCLUSION Our study provides the first evidence map on the preferences of older patients with multimorbidity. Included studies were mostly conducted in developed countries and covered a broad range of issues. Evidence on patient preferences concerning decision-making on screening and diagnostic testing was scarce. Differences in employed terminology, decision-making components and concepts, as well as the sparsity of intervention studies, are challenges for future research into evidence-based decision support seeking to elicit the preferences of older patients with multimorbidity and help them construct preferences. TRIAL REGISTRATION NUMBER Open Science Framework (OSF): DOI 10.17605/OSF.IO/MCRWQ.
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Affiliation(s)
- Ana Isabel Gonzalez
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas, Madrid, Spain
| | - Christine Schmucker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Baden-Württemberg, Germany
| | - Julia Nothacker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Baden-Württemberg, Germany
| | - Edith Motschall
- Institute of Medical Biometry and Statistics, University of Freiburg Faculty of Medicine, Freiburg, Baden-Württemberg, Germany
| | - Truc Sophia Nguyen
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
| | - Maria-Sophie Brueckle
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
| | - Jeanet Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Marjan van den Akker
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Limburg, Netherlands
| | - Kristian Röttger
- Patient Representative, Federal Joint Committee, Gemeinsamer Bundesausschuss, Berlin, Germany
| | - Odette Wegwarth
- Center for Adaptative Rationality, Max-Planck-Institute for Human Development, Berlin, Germany
| | - Tammy Hoffmann
- Institute for Evidence-Based Healthcare, Bond University Faculty of Health Sciences and Medicine, Gold Coast, Queensland, Australia
| | - Sharon E Straus
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ferdinand M Gerlach
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center, University of Freiburg Faculty of Medicine, Freiburg, Baden-Württemberg, Germany
| | - Christiane Muth
- Institute of General Practice, Johann Wolfgang Goethe-University Frankfurt am Main, Frankfurt am Main, Hessen, Germany
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22
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Panarella M, Saarela O, Esensoy AV, Jakda A, Liu Z(A. Regional Variation in Palliative Care Receipt in Ontario, Canada. J Palliat Med 2019; 22:1370-1377. [DOI: 10.1089/jpm.2018.0573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michela Panarella
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Olli Saarela
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Ahmed Jakda
- Ontario Palliative Care Network, Toronto, Ontario, Canada
- Grand River Regional Cancer Centre, Kitchener, Ontario, Canada
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Zhihui (Amy) Liu
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
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23
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Loh KP, Abdallah M, Shieh MS, Stefan MS, Pekow PS, Lindenauer PK, Mohile SG, Babu D, Lagu T. Use of Inpatient Palliative Care Services in Patients With Advanced Cancer Receiving Critical Care Therapies. J Natl Compr Canc Netw 2019; 16:1055-1064. [PMID: 30181417 DOI: 10.6004/jnccn.2018.7039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/26/2018] [Indexed: 01/03/2023]
Abstract
Background: Invasive mechanical ventilation (IMV), dialysis for acute kidney failure, and other critical care therapies (CCTs) are associated with a high risk for complications in patients with metastatic cancer. Inpatient palliative care (IPC) can assist in assessing patients' preferences for life-prolonging treatment at the end of life. This study investigated the use pattern of IPC, outcomes (in-hospital mortality, length of stay [LOS], discharge destination, and cost of care), and predictors of IPC use in patients with metastatic cancer who received CCTs. We hypothesized that IPC services are underused in this cohort. Methods: In this retrospective cohort study, we used the 2010 California State Inpatient Databases to identify adults with metastatic cancer who received CCTs that are common and reliably coded (IMV, tracheostomy, percutaneous endoscopic gastrostomy tube, dialysis for acute kidney failure, and total parenteral nutrition). We determined IPC use in all patients, in those who received IMV, and across 4 cancer subtypes (lung, breast, colorectal, and genitourinary). Outcomes were assessed based on IPC use. Multivariable analyses were used to investigate factors associated with IPC use. Results: We identified 5,862 hospitalizations, 19.8% of which used IPC services. IPC use varied across cancer subtypes (lung, 28.3%; breast, 22.4%; colorectal, 12.8%; genitourinary, 16.1%; P<.01). Patients who received and did not receive IPC services had high in-hospital mortality rates (63.9% and 29.8%, respectively), and costs of care and LOS were lower in survivors who received IPC compared with those who did not. Predictors of IPC use were lung cancer (vs colorectal or genitourinary cancer), higher comorbidity score, do-not-resuscitate status on admission or within 24 hours of admission, infections (vs cancer-related diagnoses), and higher hospital bed count. Conclusions: Use of IPC was low in the cohort who received CCTs with poor outcomes, although data on outpatient palliative care services is lacking. Predictors of IPC use may be used to identify patients who may benefit from these services.
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24
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Wen FH, Chen JS, Chang WC, Chou WC, Hsieh CH, Tang ST. Accurate prognostic awareness and preference states influence the concordance between terminally ill cancer patients' states of preferred and received life-sustaining treatments in the last 6 months of life. Palliat Med 2019; 33:1069-1079. [PMID: 31185815 DOI: 10.1177/0269216319853488] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Factors facilitating/hindering concordance between preferred and received life-sustaining treatments may be distorted if preferences and predictors are measured long before death. AIM To examine factors facilitating/hindering concordance between cancer patients' preferred and received life-sustaining-treatment states in their last 6 months. DESIGN Longitudinal, observational design. SETTING/PARTICIPANTS States of preferred and received life-sustaining treatments (cardio-pulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, and nasogastric tube feeding) were examined in 218 Taiwanese cancer patients by a latent transition model with hidden Markov modeling. Multivariate logistic regression modeling was used to examine factors facilitating/hindering concordance between preferred and received life-sustaining-treatment states. RESULTS Concordance between preferred and received life-sustaining-treatment states was poor (40.8%, kappa value (95% confidence interval): 0.05 [-0.03, 0.14]). Patients who accurately understood their prognosis and preferred comfort care were significantly more likely to receive preferred life-sustaining treatments before death than those who did not know their prognosis but wanted to know, those who were uniformly uncertain about what life-sustaining treatments they preferred to receive, and those who preferred nutritional support but declined other life-sustaining treatments. Patient age, physician-patient end-of-life-care discussions, symptom distress, and functional dependence were not associated with concordance between preferred and received life-sustaining-treatment states. CONCLUSION Prognostic awareness and preferred states of life-sustaining treatments were significantly associated with concordance between preferred and received life-sustaining-treatment states. Personalized interventions should be developed to cultivate terminally ill cancer patients' accurate prognostic awareness, allowing them to formulate realistic life-sustaining-treatment preferences and facilitating their receiving value-concordant end-of-life care.
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Affiliation(s)
- Fur-Hsing Wen
- 1 Department of International Business, Soochow University, Taipei
| | - Jen-Shi Chen
- 2 Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan
| | - Wen-Cheng Chang
- 2 Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan
| | - Wen-Chi Chou
- 2 Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan
| | - Chia-Hsun Hsieh
- 2 Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan
| | - Siew Tzuh Tang
- 2 Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan.,3 Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiugn
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25
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Hirano H, Shimizu C, Kawachi A, Ozawa M, Higuchi A, Yoshida S, Shimizu K, Tatara R, Horibe K. Preferences Regarding End-of-Life Care Among Adolescents and Young Adults With Cancer: Results From a Comprehensive Multicenter Survey in Japan. J Pain Symptom Manage 2019; 58:235-243.e1. [PMID: 31077783 DOI: 10.1016/j.jpainsymman.2019.04.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/29/2019] [Accepted: 04/30/2019] [Indexed: 12/31/2022]
Abstract
CONTEXT Patient preferences influence end-of-life (EOL) care which patients receive. However, preferences regarding EOL care among adolescent and young adult (AYA) cancer population remain unclear. OBJECTIVES The objective of the study was to evaluate preferences regarding EOL care among AYA cancer population. METHODS We evaluated preferences regarding EOL care as a part of a comprehensive multicenter questionnaire study investigating the experience and needs of Japanese AYA cancer population. RESULTS A total of 349 AYA cancer population (213 AYA cancer patients and 136 AYA cancer survivors) were evaluated. Eighty-six percent (296/344), 53% (180/338), 88% (301/341), and 61% (207/342) of participants with valid response preferred to have prognostic disclosure, receive palliative chemotherapy for incurable cancer with limited efficacy at the expense of considerable toxicity, actively use palliative care, and stay home at EOL, respectively. In multivariate analysis, the preference regarding prognostic disclosure was associated positively with no child status (odds ratio [OR] = 3.05, P = 0.003) and negatively with history of chemotherapy (OR = 0.23, P = 0.009), the preference regarding palliative chemotherapy for incurable cancer with limited efficacy at the expense of considerable toxicity was associated positively with status under active cancer treatment (OR = 1.74, P = 0.03), and the preference of staying home at EOL was positively associated with anxiety (OR = 1.72, P = 0.04). CONCLUSION This study elucidated preferences regarding EOL care among Japanese AYA cancer population. These findings may help health care practitioners to have better understanding of preferences regarding EOL care among this population.
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Affiliation(s)
- Hidekazu Hirano
- Department of Breast and Medical Oncology, National Cancer Center Hospital, Tokyo, Japan; Department of Gastrointestinal Medical Oncology, National Cancer Center Hospital, Tokyo, Japan; Department of Medicine, Keio University Graduate School of Medicine, Tokyo, Japan
| | - Chikako Shimizu
- Department of Breast Medical Oncology, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Asuka Kawachi
- Department of Breast and Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Miwa Ozawa
- Department of Pediatrics, St. Luke's International Hospital, Tokyo, Japan
| | - Akiko Higuchi
- Children's Cancer Association of Japan, Tokyo, Japan
| | - Saran Yoshida
- Graduate School of Education, Tohoku University, Sendai, Miyagi, Japan
| | - Ken Shimizu
- Department of Psycho-oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Ryohei Tatara
- Department of Psycho-oncology, National Cancer Center Hospital, Tokyo, Japan; Clinical Department of Palliative Medicine, Osaka City General Hospital, Osaka, Japan
| | - Keizo Horibe
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
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26
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Grief CJ, Grossman D, Rootenberg M, Mah L. Attitudes of Terminally Ill Older Adults toward Complementary and Alternative Medicine Therapies. J Palliat Care 2018. [DOI: 10.1177/082585971302900401] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aim: The aim of this study was to characterize the attitudes of older adults on an inpatient palliative care unit toward complementary and alternative medicine (CAM) therapies. Methods: A consecutive sample of 33 inpatients (61 to 98 years old) completed a questionnaire that examined their attitudes toward CAM to determine the acceptability of these therapies. Corresponding questionnaires were gathered from 10 substitute decision makers (SDMs). Preferences for specific CAM modalities were identified. Correlational analyses were performed between interest in CAM therapies and demographic variables and clinical status, including physical and psychological distress. Results: A total of 27 patients (82 percent) were interested in trying CAM therapies. The greatest interest was shown in music therapy (61 percent) and massage therapy (58 percent). All of the SDMs were interested in having CAM therapies available for their loved ones to try. Discussion: Attitudes toward CAM therapies of terminally ill older inpatients and their SDMs are highly favourable. CAM treatments merit closer evaluation as a means of enhancing end-of-life care.
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Affiliation(s)
- Cindy J. Grief
- CJ Grief (corresponding author) Division of Geriatric Psychiatry, Department of Psychiatry, University of Toronto, and Department of Psychiatry, Baycrest, 4W02A-3560 Bathurst Street, Toronto, Ontario, Canada M6A2E1
| | - Daphna Grossman
- Department of Family and Community Medicine, Baycrest, and Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mark Rootenberg
- Department of Family and Community Medicine, Baycrest, Toronto, Ontario, Canada
| | - Linda Mah
- Rotman Research Institute, and Department of Psychiatry, Baycrest, and Division of Geriatric Psychiatry, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Hsieh CH, Rau CS, Wu SC, Liu HT, Huang CY, Hsu SY, Hsieh HY. Risk Factors Contributing to Higher Mortality Rates in Elderly Patients with Acute Traumatic Subdural Hematoma Sustained in a Fall: A Cross-Sectional Analysis Using Registered Trauma Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15112426. [PMID: 30388747 PMCID: PMC6265997 DOI: 10.3390/ijerph15112426] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 10/25/2018] [Accepted: 10/29/2018] [Indexed: 12/23/2022]
Abstract
Background: We aimed to explore the risk factors that contribute to the mortality of elderly trauma patients with acute subdural hematoma (SDH) resulting from a fall. Mortality rates of the elderly were compared to those of young adults. Methods: A total of 444 patients with acute traumatic subdural hematoma resulting from a fall, admitted to a level I trauma center from 1 January 2009 to 31 December 2016 were enrolled in this study. Patients were categorized into two groups: elderly patients (n = 279) and young adults (n = 165). The primary outcome of this study was patient mortality in hospital. The adjusted odds ratio (AOR) with 95% confidence interval (CI) for mortality was calculated according to gender and pre-existing comorbidities. Univariate and multivariate logistic regression analyses were performed to identify factors related to mortality in the elderly. Results: The odds ratio for mortality caused by falls in the elderly patients was four-fold higher than in the young adults, after adjusting for gender and pre-existing comorbidities. In addition, the presence of pre-existing coronary artery disease (OR 3.2, 95% CI 1.09–9.69, p = 0.035), end-stage renal disease (OR 4.6, 95% CI 1.48–14.13, p = 0.008), hematoma volume (OR 1.2, 95% CI 1.11–1.36, p < 0.001), injury severity score (OR 1.3, 95% CI 1.23–1.46, p < 0.001), and coagulopathy (OR 4.0, 95% CI 1.47–11.05, p = 0.007) were significant independent risk factors for mortality in patients with acute traumatic SDH resulting from a fall. Conclusions: In this study, we identified that pre-existing CAD, ESRD, hematoma volume, ISS, and coagulopathy were significant independent risk factors for mortality in patients with acute traumatic SDH. These results suggest that death following acute SDH is influenced both by the extent of neurological damage and the overall health of the patient at the time of injury.
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Affiliation(s)
- Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan.
| | - Cheng-Shyuan Rau
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan.
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan.
| | - Hang-Tsung Liu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan.
| | - Chun-Ying Huang
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan.
| | - Shiun-Yuan Hsu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan.
| | - Hsiao-Yun Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan.
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28
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Wen FH, Chen JS, Su PJ, Chang WC, Hsieh CH, Hou MM, Chou WC, Tang ST. Terminally Ill Cancer Patients' Concordance Between Preferred Life-Sustaining Treatment States in Their Last Six Months of Life and Received Life-Sustaining Treatment States in Their Last Month: An Observational Study. J Pain Symptom Manage 2018; 56:509-518.e3. [PMID: 30025938 DOI: 10.1016/j.jpainsymman.2018.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 07/02/2018] [Accepted: 07/03/2018] [Indexed: 12/29/2022]
Abstract
CONTEXT/OBJECTIVE The extent to which patients' preferences for end-of-life (EOL) care are honored may be distorted if preferences are measured long before death, a common approach of existing research. We examined the concordance between cancer patients' states of life-sustaining treatments (LSTs) received in their last month and LST preference states assessed longitudinally over their last six months. METHODS We examined states of preferred and received LSTs (cardiopulmonary resuscitation, intensive care unit care, chest compression, intubation with mechanical ventilation, intravenous nutrition, and nasogastric tube feeding) in 271 cancer patients' last six months by a transition model with hidden Markov modeling (HMM). The extent of concordance was measured by a percentage and a kappa value. RESULTS HMM identified four LST preference states: life-sustaining preferring, comfort preferring, uncertain, and nutrition preferring. HMM identified four LST states received in patients' last month: generally received LSTs, LSTs uniformly withheld, selectively received LSTs, and received intravenous nutrition only. LSTs received concurred poorly with patients' preferences estimated right before death (39.5% and kappa value: 0.06 [95% CI: -0.02, 0.13]). Patients in the life-sustaining-preferring, uncertain, and nutrition-preferring states primarily received no LSTs, and patients in three of four states received intravenous nutrition against their preferences. Concordance was strongest for comfort-preferring patients. CONCLUSIONS Concordance was poor between patients' preferred and received LST states. Interventions are needed to clarify patients' EOL care goals and to facilitate their understanding about LST's ineffectiveness in prolonging life at EOL. Such interventions might increase patients' comfort preference and ensure concordance between their preferred and received EOL care.
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Affiliation(s)
- Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Po-Jung Su
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Ming-Mo Hou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan.
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Johnson SB, Butow PN, Kerridge I, Bell ML, Tattersall MHN. How Well Do Current Measures Assess the Impact of Advance Care Planning on Concordance Between Patient Preferences for End-of-Life Care and the Care Received: A Methodological Review. J Pain Symptom Manage 2018; 55:480-495. [PMID: 28943359 DOI: 10.1016/j.jpainsymman.2017.09.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/04/2017] [Accepted: 09/04/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Research has begun to focus on whether Advance Care Planning (ACP) has the capacity to influence care, and to examine whether ACP can be effective in meeting patients' wishes at the end of their lives. Little attention has been paid, however, to the validity and clinical relevance of existing measures. METHODS A search of Medline and CINHAL identified ACP studies measuring concordance between end-of-life (EoL) preferences and the care received. Databases were searched from 2000 to August 2016. We developed a checklist to evaluate the quality of included studies. Data were collected on the proportion of patients who received concordant care, extracted from manuscript tables or calculated from the text. OUTCOMES Of 2941 papers initially identified, nine eligible studies were included. Proportions of patients who received concordant care varied from 14% to 98%. Studies were heterogeneous and methodologically poor, with limited attention paid to bias/external validity. Studies varied with regards to design of measures, the meaning of relevant terms like "preference" "EoL care" and "concordance," and the completeness of reported data. CONCLUSION Methodological variations and weaknesses compromise the validity of study results, and prevent meaningful comparisons between studies or synthesis of the results. Effectively evaluating whether ACP interventions enhance a patient's capacity to receive the care they want requires harmonization of research. This demands standardization of methods across studies, validating of instruments, and consensus based on a consistent conceptual framework regarding what constitutes a meaningful outcome measure.
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Sathitratanacheewin S, Engelberg RA, Downey L, Lee RY, Fausto JA, Starks H, Dunlap B, Sibley J, Lober W, Loggers ET, Khandelwal N, Curtis JR. Temporal Trends Between 2010 and 2015 in Intensity of Care at End-of-Life for Patients With Chronic Illness: Influence of Age Under vs. Over 65 Years. J Pain Symptom Manage 2018; 55:75-81. [PMID: 28887270 PMCID: PMC5734983 DOI: 10.1016/j.jpainsymman.2017.08.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/25/2017] [Accepted: 08/25/2017] [Indexed: 11/21/2022]
Abstract
CONTEXT Recent analyses of Medicare data show decreases over time in intensity of end-of-life care. Few studies exist regarding trends in intensity of end-of-life care for those under 65 years of age. OBJECTIVES To examine recent temporal trends in place of death, and both hospital and intensive care unit (ICU) utilization, for age-stratified decedents with chronic, life-limiting diagnoses (<65 vs. ≥65 years) who received care in a large healthcare system. METHODS Retrospective cohort using death certificates and electronic health records for 22,068 patients with chronic illnesses who died between 2010 and 2015. We examined utilization overall and stratified by age using multiple regression. RESULTS The proportion of deaths at home did not change, but hospital admissions in the last 30 days of life decreased significantly from 2010 to 2015 (hospital b = -0.026; CI = -0.041, -0.012). ICU admissions in the last 30 days also declined over time for the full sample and for patients aged 65 years or older (overall b = -0.023; CI = -0.039, -0.007), but was not significant for younger decedents. Length of stay (LOS) did not decrease for those using the hospital or ICU. CONCLUSION From 2010 to 2015, we observed a decrease in hospital admissions for all age groups and in ICU admissions for those over 65 years. As there were no changes in the proportion of patients with chronic illness who died at home nor in hospital or ICU LOS in the last 30 days, hospital and ICU admissions in the last 30 days may be a more responsive quality metric than site of death or LOS for palliative care interventions.
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Affiliation(s)
- Seelwan Sathitratanacheewin
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - James A Fausto
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Family Medicine, University of Washington, Seattle, Washington, USA
| | - Helene Starks
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
| | - Ben Dunlap
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - James Sibley
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioinformatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - William Lober
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioinformatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - Elizabeth T Loggers
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Seattle Cancer Care Alliance, Seattle, Washington, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Nita Khandelwal
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA.
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Tang ST, Wen FH, Chang WC, Hsieh CH, Chou WC, Chen JS, Hou MM. Preferences for Life-Sustaining Treatments Examined by Hidden Markov Modeling Are Mostly Stable in Terminally Ill Cancer Patients' Last Six Months of Life. J Pain Symptom Manage 2017; 54:628-636.e2. [PMID: 28782702 DOI: 10.1016/j.jpainsymman.2017.07.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/22/2017] [Accepted: 07/25/2017] [Indexed: 02/06/2023]
Abstract
CONTEXT Stability of life-sustaining treatment (LST) preferences at end of life (EOL) has not been well established for terminally ill cancer patients nor have transition probabilities been explored between different types of preferences. OBJECTIVE We assessed the stability of cancer patients' LST preferences at EOL by identifying distinct LST preference states and examining the probability of each state transitioning to other states between consecutive time points. METHODS Stability of LST preferences (cardiopulmonary resuscitation, intensive care unit [ICU] care, cardiac massage, intubation with mechanical ventilation, intravenous nutrition support, and nasogastric tube feeding) was examined among 303 cancer patients in their last six months by hidden Markov modeling. RESULTS Six distinct LST preference states (initial size) were identified: uniformly preferring (8.3%), uniformly rejecting (33.8%), and uniformly uncertain about (20.5%) LST, favoring intravenous nutrition support but rejecting other treatments (19.9%), and favoring (3.6%) or uncertain about (14.0%) nutrition support and ICU care while rejecting other treatments. Shifts between LST preference states were relatively small between any two time points (transition probability of staying at the same state was 92.1% to 97.5%), except for the state characterized by uncertainty about nutrition support and ICU care while rejecting other treatments, in which 8.3% of patients shifted LST preferences toward uniform uncertainty at a subsequent assessment. CONCLUSIONS Our patients' LST preferences remained stable without prominent shifts toward preferring less aggressive LSTs even when death approached. Clarifying patients' understanding and expectations about LST efficacy and tailoring interventions to the unique needs of patients in each state may provide personalized EOL care.
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Affiliation(s)
- Siew Tzuh Tang
- Chang Gung University, School of Nursing, Tao-Yuan, Taiwan, ROC; Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, ROC; Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC.
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan, ROC
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Ming-Mo Hou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
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Ebenau A, van Gurp J, Hasselaar J. Life values of elderly people suffering from incurable cancer: A literature review. PATIENT EDUCATION AND COUNSELING 2017; 100:1778-1786. [PMID: 28578833 DOI: 10.1016/j.pec.2017.05.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 04/28/2017] [Accepted: 05/21/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Due to aging Western societies, older patients suffering from incurable cancer will present themselves more often to health care professionals. To be of service to these severely ill elderly patients, more knowledge is needed on which life values are guiding them through their last phases of life. This review aims to describe which life values play an important part in the lives of elderly people suffering from incurable cancer. METHODS We conducted a literature review with a structured search to identify empirical studies (January 1950-February 2016) using six databases. RESULTS The analysis of thirty articles resulted in the extensive description of eight life values: comfort, continuity, humility, dignity, honesty, optimism, hope and preparedness. CONCLUSION Elderly patients suffering from incurable cancer use the abovementioned life values to give meaning to a life interrupted by disease. Furthermore, these values will play a role in communication and decision-making. PRACTICE IMPLICATIONS Knowledge about life values can help professionals discuss and clarify personal preferences with elderly patients suffering from incurable cancer, contributing to more personalized care and treatment. Communication should focus on to what extent patient empowerment, life-prolonging treatment and the involvement of the patient's supporting systems suit the wishes of these patients.
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Affiliation(s)
- Anne Ebenau
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands.
| | - Jelle van Gurp
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Department of IQ Healthcare, Section Ethics, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands.
| | - Jeroen Hasselaar
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands.
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Diamond EL, Panageas KS, Dallara A, Pollock A, Applebaum AJ, Carver AC, Pentsova E, DeAngelis LM, Prigerson HG. Frequency and Predictors of Acute Hospitalization Before Death in Patients With Glioblastoma. J Pain Symptom Manage 2017; 53:257-264. [PMID: 27810565 PMCID: PMC5253315 DOI: 10.1016/j.jpainsymman.2016.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/25/2016] [Accepted: 09/06/2016] [Indexed: 11/16/2022]
Abstract
CONTEXT Glioblastoma (GBM) is a devastating and incurable neuro-oncologic disease, and issues related to the end of life are almost invariably a matter of "when," not a matter of "if." Optimizing symptom management and quality of life in later stages of disease is of the utmost priority. OBJECTIVES To examine the frequency of and factors associated with late acute hospital admission before death in patients with GBM. METHODS Case-control study comparing patients with GBM admitted to the hospital within one month of death to those without late hospital admission. RESULTS Of 385 GBM patients followed to death at Memorial Sloan Kettering Cancer Center, 164 (42.6%) were admitted within a month of death, most frequently (140, or 85%) to manage neurologic decline. Of these, 56 (34%) had intensive care unit care during this admission and 22 (13%), 18 (11%), and 2 (1%) received mechanical ventilation, enteral feeding tubes, or cardiopulmonary resuscitation, respectively. In multivariable analysis, in-hospital chaplaincy consultation, and participation in a therapeutic clinical trial, both at any time in the GBM disease course, were significantly associated with late hospital admission. CONCLUSIONS Late hospitalization is frequent in GBM and often involves intensive care unit care in the management of clinical events that are part of the GBM dying process. Patients with a tendency to use religious support and those enrolled in clinical trials may be at greater risk for late hospitalization. Dedicated prospective study is needed to determine predictors of late hospitalization and to examine the impact of late acute medical care on quality of life in GBM.
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Affiliation(s)
- Eli L Diamond
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Palliative Medicine Service, Division of Survivorship and Supportive Care, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Center for Research on End-of-Life Care, Weill Cornell Medical College, New York, New York, USA.
| | - Katherine S Panageas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alexis Dallara
- Department of Neurology, Columbia University Medical Center, New York, New York, USA
| | - Ariel Pollock
- Icahn School of Medicine, Mount Sinai Medical Center, New York, New York, USA
| | - Allison J Applebaum
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alan C Carver
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Palliative Medicine Service, Division of Survivorship and Supportive Care, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Elena Pentsova
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Holly G Prigerson
- Center for Research on End-of-Life Care, Weill Cornell Medical College, New York, New York, USA
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Ngwenya N, Kenten C, Jones L, Gibson F, Pearce S, Flatley M, Hough R, Stirling LC, Taylor RM, Wong G, Whelan J. Experiences and Preferences for End-of-Life Care for Young Adults with Cancer and Their Informal Carers: A Narrative Synthesis. J Adolesc Young Adult Oncol 2017; 6:200-212. [PMID: 28075655 PMCID: PMC5467142 DOI: 10.1089/jayao.2016.0055] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
To review the qualitative literature on experiences of and preferences for end-of-life care of people with cancer aged 16–40 years (young adults) and their informal carers. A systematic review using narrative synthesis of qualitative studies using the 2006 UK Economic and Social Research Council research methods program guidance. Seven electronic bibliographic databases, two clinical trials databases, and three relevant theses databases were searched from January 2004 to October 2015. Eighteen articles were included from twelve countries. The selected studies included at least 5% of their patient sample within the age range 16–40 years. The studies were heterogeneous in their aims, focus, and sample, but described different aspects of end-of-life care for people with cancer. Positive experiences included facilitating adaptive coping and receiving palliative home care, while negative experiences were loss of “self” and nonfacilitative services and environment. Preferences included a family-centered approach to care, honest conversations about end of life, and facilitating normality. There is little evidence focused on the end-of-life needs of young adults. Analysis of reports including some young adults does not explore experience or preferences by age; therefore, it is difficult to identify age-specific issues clearly. From this review, we suggest that supportive interventions and education are needed to facilitate open and honest communication at an appropriate level with young people. Future research should focus on age-specific evidence about the end-of-life experiences and preferences for young adults with cancer and their informal carers.
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Affiliation(s)
- Nothando Ngwenya
- 1 Cancer Clinical Trials Unit, University College Hospital , London, United Kingdom
| | - Charlotte Kenten
- 1 Cancer Clinical Trials Unit, University College Hospital , London, United Kingdom
| | - Louise Jones
- 2 Division of Psychiatry, Palliative Care Research Department, University College London , London, United Kingdom
| | - Faith Gibson
- 3 Centre for Outcomes and Experiences Research in Children's Health, Great Ormond Street Hospital for Children NHS Foundation Trust , London, United Kingdom .,4 School of Health Sciences, University of Surrey , London, United Kingdom
| | - Susie Pearce
- 5 Department of Oncology, University College Hospital , London, United Kingdom
| | | | - Rachael Hough
- 7 Children and Young Peoples Cancer Service, University College Hospital , London, United Kingdom
| | - L Caroline Stirling
- 8 Camden, Islington ELiPSe and UCLH & HCA Palliative Care Service, Central and North West London NHS Trust , London, United Kingdom
| | - Rachel M Taylor
- 5 Department of Oncology, University College Hospital , London, United Kingdom
| | - Geoff Wong
- 9 Nuffield Department of Primary Care Health Sciences, University of Oxford , Oxford, United Kingdom
| | - Jeremy Whelan
- 5 Department of Oncology, University College Hospital , London, United Kingdom
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Preferences for Aggressive End-of-life Care and Their Determinants Among Taiwanese Terminally Ill Cancer Patients. Cancer Nurs 2016; 38:E9-E18. [PMID: 24915466 DOI: 10.1097/ncc.0000000000000155] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Studies on factors influencing preferences for aggressive end-of-life (EOL) care have focused predominantly on preferred goals of EOL and seldom comprehensively incorporate patients' predisposing, enabling, and need factors into their analyses. OBJECTIVE The aim of this study was to investigate the determinants of preferences for a wide range of aggressive EOL care from the aforementioned factors. METHODS A cross-sectional survey was conducted using a convenience sample of 2329 terminally ill cancer patients recruited from 23 hospitals throughout Taiwan. RESULTS Among these Taiwanese terminally ill cancer patients, 8.2% preferred prolonging life as their goal for EOL care. When combining those who wanted and those who were undecided as wanting that specific treatment, 27.9% preferred cardiopulmonary resuscitation when their life was in danger, and 36.0%, 27.3%, 24.3%, and 26.7% preferred to receive care at intensive care unit, cardiac massage, intubation, and mechanical ventilation support, respectively. Those at risk of preferring aggressive EOL care were men, younger than 45 years, married, diagnosed within 6 months, and with comorbidity and their physician had not accurately disclosed their prognosis or discussed EOL care issues to/with them. CONCLUSIONS Few Taiwanese terminally ill cancer patients preferred to prolong life as their goal for EOL care, cardiopulmonary resuscitation when their life was in danger, and life-sustaining treatments at EOL. Preferences for aggressive EOL care are determined by patients' predisposing, enabling, and need factors. IMPLICATIONS FOR PRACTICE Terminally ill cancer patients at risk of preferring aggressive EOL care should receive interventions to help them appropriately weigh the burdens and benefits of such aggressive treatments.
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Ng CWL, Cheong SK, Govinda Raj A, Teo W, Leong I. End-of-life care preferences of nursing home residents: Results of a cross-sectional study. Palliat Med 2016; 30:843-53. [PMID: 26962065 DOI: 10.1177/0269216316634242] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative care services were not available in nursing homes in Singapore. Project CARE (Care At the end-of-life for Residents in homes for the Elderly) was a pilot programme that aimed to promote advance care planning and improve end-of-life care in nursing homes. AIM We aimed to examine end-of-life care preferences among nursing home residents, and identify factors associated with preference for medical intervention, cardiopulmonary resuscitation and place of death. DESIGN AND SETTING/PARTICIPANTS A cross-sectional study using data from advance care planning discussions was conducted from September 2009 to April 2012 across seven nursing homes. The advance care planning discussion was conducted with the resident (with a prognosis of 6 months or 1 year), their families and staff from the nursing home and hospital. RESULTS A total of 600 residents and their families completed the advance care planning discussion. Majority (93.2%) preferred not to proceed with cardiopulmonary resuscitation, 52.3% opted for limited additional intervention at the nursing home with escalation to the hospital if necessary and 77.0% preferred to die at the nursing home. Residents 85+ years (relative risk ratio: 3.34, 95% confidence interval: 1.13-9.93, p = 0.030) were more likely to prefer medical intervention at the nursing home only. No associations were found with the preference for cardiopulmonary resuscitation. Residents who were single, or who were Christians or Catholics (adjusted odds ratio: 2.09, 95% confidence interval: 1.04-4.19, p = 0.039), were more likely to prefer to die at the nursing home. CONCLUSION Preferences for medical interventions in nursing homes provide support to extend palliative care services to nursing homes, which may benefit residents who are older, single, or Christians or Catholics.
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Affiliation(s)
- Charis Wei Ling Ng
- Health Services & Outcomes Research, National Healthcare Group, Singapore
| | - S K Cheong
- Continuing and Community Care Department, Tan Tock Seng Hospital, Singapore
| | - A Govinda Raj
- Health Services & Outcomes Research, National Healthcare Group, Singapore
| | - Wsk Teo
- Health Services & Outcomes Research, National Healthcare Group, Singapore
| | - Iyo Leong
- Continuing and Community Care Department, Tan Tock Seng Hospital, Singapore
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Bluhm M, Connell CM, Janz N, Bickel K, DeVries R, Silveira M. Oncologists’ End of Life Treatment Decisions. J Appl Gerontol 2016. [DOI: 10.1177/0733464815595510] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Optimal treatment decisions for older end-stage cancer patients are complicated, and are influenced by oncologists’ attitudes and beliefs about older patients. Nevertheless, few studies have explored oncologists’ perspectives on how patient age affects their treatment decisions. Methods: In-depth interviews were conducted with 17 oncologists to examine factors that influence their chemotherapy decisions for adults with incurable cancer near death. Transcripts of recorded interviews were coded and content analyzed. Results: Oncologists identified patient age as a key factor in their chemotherapy decisions. They believed older adults were less likely to want or tolerate treatment, and felt highly motivated to treat younger patients. Discussion: Qualitative analysis of in-depth interviews resulted in a nuanced understanding of how patient age influences oncologists’ chemotherapy decisions. Such understanding may inform practice efforts aimed at enhancing cancer care at the end of life for older patients.
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Affiliation(s)
| | | | | | - Kathleen Bickel
- Veterans Affairs White River Junction Medical Center, Geisel School of Medicine at Dartmouth, USA
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Tang ST, Wen FH, Hsieh CH, Chou WC, Chang WC, Chen JS, Chiang MC. Preferences for Life-Sustaining Treatments and Associations With Accurate Prognostic Awareness and Depressive Symptoms in Terminally Ill Cancer Patients' Last Year of Life. J Pain Symptom Manage 2016; 51:41-51.e1. [PMID: 26386187 DOI: 10.1016/j.jpainsymman.2015.08.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/20/2015] [Accepted: 09/03/2015] [Indexed: 11/23/2022]
Abstract
CONTEXT The stability of life-sustaining treatment (LST) preferences at end of life (EOL) has been established. However, few studies have assessed preferences more than two times. Furthermore, associations of LST preferences with modifiable variables of accurate prognostic awareness, physician-patient EOL care discussions, and depressive symptoms have been investigated in cross-sectional studies only. OBJECTIVES To explore longitudinal changes in LST preferences and their associations with accurate prognostic awareness, physician-patient EOL care discussions, and depressive symptoms in terminally ill cancer patients' last year. METHODS LST preferences (cardiopulmonary resuscitation, intensive care unit [ICU] care, intubation, and mechanical ventilation) were measured approximately every two weeks. Changes in LST preferences and their associations with independent variables were examined by hierarchical generalized linear modeling with logistic regression. RESULTS Participants (n = 249) predominantly rejected cardiopulmonary resuscitation, ICU care, intubation, and mechanical ventilation at EOL without significant changes as death approached. Patients with inaccurate prognostic awareness were significantly more likely than those with accurate understanding to prefer ICU care, intubation, and mechanical ventilation than to reject these LSTs. Patients with more severe depressive symptoms were less likely to prefer ICU care and to be undecided about wanting ICU care and mechanical ventilation than to reject such LSTs. LST preferences were not associated with physician-patient EOL care discussions, which were rare in our sample. CONCLUSION LST preferences are stable in cancer patients' last year. Facilitating accurate prognostic awareness and providing adequate psychological support may counteract the increasing trend for aggressive EOL care and minimize emotional distress during EOL care decisions.
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Affiliation(s)
- Siew Tzuh Tang
- School of Nursing, Chang Gung University, Taoyuan, Taiwan.
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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Turley M, Wang S, Meng D, Kanter MH, Garrido T. An information model for automated assessment of concordance between advance care preferences and care delivered near the end of life. J Am Med Inform Assoc 2015; 23:e118-24. [PMID: 26567328 DOI: 10.1093/jamia/ocv149] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 08/29/2015] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To develop an information model for automating evaluation of concordance between patient preferences and end-of-life care. METHODS We modeled and validated 15 end-of-life care preference option domains, to which we mapped preferences recorded in standardized advance care planning documents and 232 end-of-life care events defined by procedure and medication codes. Patient preferences and end-of-life care events were available in electronic health records. Data from Kaiser Permanente Southern California modeling and testing populations were evaluated for concordance between patients' preferences and the end-of-life care events they experienced. RESULTS The information model successfully assessed concordance between patient preferences and end-of-life care events. Among 388 expired patients in the modeling population, 4164 care events occurred, 4100 (98%) of which were preference-concordant, and 64 (2%) of which were preference-discordant. Including end-of-life care events that did not occur increased the number of observations to 6029; 99% were preference-concordant. At the level of individuals, 72% (278) of patients experienced only preference-concordant care events, 13% (50) experienced at least one preference-discordant care event, and 15% (60) experienced no preference-related care events. DISCUSSION Model limitations pertain to assumptions that are required to match advance care planning documents with patient preference options and exclusion of preferred care that did not occur. Further research is required to apply the model to larger populations and to investigate the need for additional preference options. CONCLUSION An information model for automating the assessment of the concordance between patients' advance care planning preferences and the end-of-life care they received was effective in a small population and has the potential to assess population-level preference-concordance on an ongoing basis.
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Affiliation(s)
- Marianne Turley
- Health Information Technology Transformation and Analytics, Kaiser Permanente, Portland OR 97210, USA
| | - Susan Wang
- Southern California Permanente Medical Group, Los Angeles, CA 90027, USA
| | - Di Meng
- Health Information Technology Transformation and Analytics, Kaiser Permanente, Oakland, CA 94612, USA
| | - Michael H Kanter
- Southern California Permanente Medical Group, Pasadena, CA 91188, USA
| | - Terhilda Garrido
- Health Information Technology Transformation and Analytics, Kaiser Permanente, Oakland, CA 94612, USA
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Kress MAS, Jensen RE, Tsai HT, Lobo T, Satinsky A, Potosky AL. Radiation therapy at the end of life: a population-based study examining palliative treatment intensity. Radiat Oncol 2015; 10:15. [PMID: 25582217 PMCID: PMC4314753 DOI: 10.1186/s13014-014-0305-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 12/15/2014] [Indexed: 12/25/2022] Open
Abstract
Background To examine factors associated with the use of radiation therapy (RT) at the end of life in patients with breast, prostate, or colorectal cancer. Methods Using data from the Surveillance, Epidemiology, and End Results (SEER) – Medicare database, patients were over age 65 and diagnosed between January 1, 2004 and December 31, 2011 with any stage of cancer when the cause of death, as defined by SEER, was cancer; or with stage 4 cancer, who died of any cause. We employed multiple logistic regression models to identify patient and health systems factors associated with palliative radiation use. Results 50% of patients received RT in the last 6 months of life. RT was used less frequently in older patients and in non-Hispanic white patients. Similar patterns were observed in the last 14 days of life. Chemotherapy use in the last 6 months of life was strongly correlated with receiving RT in the last 6 months (OR 2.72, 95% CI: 2.59-2.88) and last 14 days of life (OR 1.55, 95% CI: 1.40-1.66). Patients receiving RT accrued more emergency department visits, radiographic exams and physician visits (all comparisons p < 0.0001). Conclusions Among patients with breast, colorectal, and prostate cancer, palliative RT use was common. End-of-life RT correlated with end-of-life chemotherapy use, including in the last 14 days of life, when treatment may cause increased treatment burden without improved quality of life. Research is needed optimize the role and timing of RT in palliative care. Electronic supplementary material The online version of this article (doi:10.1186/s13014-014-0305-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Roxanne E Jensen
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven St, NW Suite 4000, Washington, DC, 20007, USA.
| | - Huei-Ting Tsai
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven St, NW Suite 4000, Washington, DC, 20007, USA.
| | - Tania Lobo
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven St, NW Suite 4000, Washington, DC, 20007, USA.
| | - Andrew Satinsky
- Huron River Radiation Oncology, 5301 E Huron River Dr Ann Arbor, Michigan, 48106, USA.
| | - Arnold L Potosky
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven St, NW Suite 4000, Washington, DC, 20007, USA.
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Nurses' knowledge and comfort levels using the Physician Orders for Life-sustaining Treatment (POLST) form in the progressive care unit. Geriatr Nurs 2015; 36:21-4. [DOI: 10.1016/j.gerinurse.2014.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 09/01/2014] [Accepted: 09/08/2014] [Indexed: 11/20/2022]
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Teaster PB, O'Brien JG. The Elder Mistreatment of Overtreatment at End of Life. ACTA ACUST UNITED AC 2014. [DOI: 10.1093/ppar/pru025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Turnbull AE, Lau BM, Ruhl AP, Mendez-Tellez PA, Shanholtz CB, Needham DM. Age and decisions to limit life support for patients with acute lung injury: a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R107. [PMID: 24886945 PMCID: PMC4075260 DOI: 10.1186/cc13890] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 05/06/2014] [Indexed: 01/09/2023]
Abstract
Introduction The proportion of elderly Americans admitted to the intensive care unit (ICU) in the last month of life is rising. Hence, challenging decisions regarding the appropriate use of life support are increasingly common. The objective of this study was to estimate the association between patient age and the rate of new limitations in the use of life support, independent of daily organ dysfunction status, following acute lung injury (ALI) onset. Methods This was a prospective cohort study of 490 consecutive patients without any limitations in life support at the onset of ALI. Patients were recruited from 11 ICUs at three teaching hospitals in Baltimore, Maryland, USA, and monitored for the incidence of six pre-defined limitations in life support, with adjustment for baseline comorbidity and functional status, duration of hospitalization before ALI onset, ICU severity of illness, and daily ICU organ dysfunction score. Results The median patient age was 52 (range: 18 to 96), with 192 (39%) having a new limitation in life support in the ICU. Of patients with a new limitation, 113 (59%) had life support withdrawn and died, 53 (28%) died without resuscitation, and 26 (14%) survived to ICU discharge. Each ten-year increase in patient age was independently associated with a 24% increase in the rate of limitations in life support (Relative Hazard 1.24; 95% CI 1.11 to 1.40) after adjusting for daily ICU organ dysfunction score and all other covariates. Conclusions Older critically ill patients are more likely to have new limitations in life support independent of their baseline status, ICU-related severity of illness, and daily organ dysfunction status. Future studies are required to determine whether this association is a result of differences in patient preferences by age, or differences in the treatment options discussed with the families of older versus younger patients.
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Pasman HRW, Kaspers PJ, Deeg DJH, Onwuteaka-Philipsen BD. Preferences and Actual Treatment of Older Adults at the End of Life. A Mortality Follow-Back Study. J Am Geriatr Soc 2013; 61:1722-9. [DOI: 10.1111/jgs.12450] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- H. Roeline W. Pasman
- Department of Public and Occupational Health; Expertise Center for Palliative Care; Amsterdam The Netherlands
| | - Pam J. Kaspers
- Department of Public and Occupational Health; Expertise Center for Palliative Care; Amsterdam The Netherlands
| | - Dorly J. H. Deeg
- Department of Epidemiology and Biostatistics; Longitudinal Aging Study Amsterdam VU University Medical Center; EMGO Institute for Health and Care Research; Amsterdam the Netherlands
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Mudumbai SC, Cronkite R, Hu KU, Heidenreich PA, Gonzalez C, Bertaccini E, Stafford RS, Cason BA, Mariano ER, Wagner T. Association of age and packed red blood cell transfusion to 1-year survival--an observational study of ICU patients. Transfus Med 2013; 23:231-7. [PMID: 23480030 PMCID: PMC4012294 DOI: 10.1111/tme.12010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 12/31/2012] [Accepted: 01/09/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare the 1-year survival for different age strata of intensive care unit (ICU) patients after receipt of packed red blood cell (PRBC) transfusions. BACKGROUND Despite guidelines documenting risks of PRBC transfusion and data showing that increasing age is associated with ICU mortality, little data exist on whether age alters the transfusion-related risk of decreased survival. METHODS We retrospectively examined data on 2393 consecutive male ICU patients admitted to a tertiary-care hospital from 2003 to 2009 in age strata: 21-50, 51-60, 61-70, 71-80 and >80 years. We calculated Cox regression models to determine the modifying effect of age on the impact of PRBC transfusion on 1-year survival by using interaction terms between receipt of transfusion and age strata, controlling for type of admission and Charlson co-morbidity indices. We also examined the distribution of admission haematocrit and whether transfusion rates differed by age strata. RESULTS All age strata experienced statistically similar risks of decreased 1-year survival after receipt of PRBC transfusions. However, patients age >80 were more likely than younger cohorts to have haematocrits of 25-30% at admission and were transfused at approximately twice the rate of each of the younger age strata. DISCUSSION We found no significant interaction between receipt of red cell transfusion and age, as variables, and survival at 1 year as an outcome.
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Affiliation(s)
- S C Mudumbai
- Anesthesiology and Perioperative Care Service; Center for Health Care Evaluation, VA Palo Alto Health Care System, Palo Alto, CA 94304, USA.
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Prigerson HG, Maciejewski PK. Dartmouth Atlas: putting end-of-life care on the map but missing psychosocial detail. ACTA ACUST UNITED AC 2011; 10:25-8. [PMID: 22005216 DOI: 10.1016/j.suponc.2011.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Revised: 05/26/2011] [Accepted: 06/02/2011] [Indexed: 10/17/2022]
Affiliation(s)
- Holly G Prigerson
- Dana-Farber Cancer Institute, Brigham amd Women's Hospital, Boston, MA, USA.
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Ohta B, Kronenfeld JJ. Intensity of acute care services at the end of life: nonclinical determinants of treatment variation in an older adult population. J Palliat Med 2011; 14:722-8. [PMID: 21548789 DOI: 10.1089/jpm.2010.0360] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Technological advances in medicine have led to increasing complexity in health care decision making, and subsequently, greater opportunity for variation in the delivery of end-of-life care. Factors such as age, race/ethnicity, physician and hospital system characteristics, and geographic location have been found to be strong predictors of variation in acute interventions before death, even when controlling for medical acuity. The study presented here explores factors affecting health care utilization at end of life for a hospitalized older adult population in a major metropolitan area of Arizona. The study results reveal that effects of age, minority status, health plan, and hospital characteristics all affect hospital utilization and intensity of care above and beyond clinical factors.
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Affiliation(s)
- Brenda Ohta
- New York University Medical Center, New York, New York 10016, USA.
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Decision making among older people with advanced heart failure as they transition to dependency and death. Curr Opin Support Palliat Care 2011; 4:238-42. [PMID: 20966758 DOI: 10.1097/spc.0b013e328340684f] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review critically considers recent research, identifying patient experiences of, and preferences for, participation in decision making during the end-of-life transition. RECENT FINDINGS Clinicians typically experience significant difficulties in engaging older patients with advanced heart failure in discussions about palliative and end-of-life care and involving them in shared decision making. Advanced care planning is proposed as an approach to ensure greater patient involvement in end-of-life care management, although evidence regarding effective interventions in this area is limited. Policy initiatives and guidelines appear not to reflect clinical reality and healthcare professionals experience significant barriers in transferring the required knowledge and skills into their practice. The notion of transition itself as a process that healthcare professionals could use for assessment and management requires further research, but does offer more than just a focus on heart failure management at the end-of-life. SUMMARY This review indicates a need to think carefully about how policy recommendations and guidance relating to patient participation in decision making at the end-of-life can be effectively implemented in practice. The need for continuity of involvement from key health workers is identified as very important in this regard. 'Transition' is also considered as a concept that may offer health professionals a different approach for assessment and management of heart failure patients over a longer period and means of integrating heart failure management with palliative care.
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