Access to Palliative Care during a Terminal Hospitalization

Utilization rates and heart transplantation outcomes of donation after circulatory death donors with prior cardiopulmonary resuscitation

BACKGROUND

Heart donation after circulatory death (DCD) involves mandatory exposure to warm ischemic injury (WII) due to donor cardiac arrest resulting from withdrawal of life-support (WLS). However, potential DCD donors may also experience a cardiac arrest and undergo cardiopulmonary resuscitation (CPR) and associated WII before WLS. We sought to investigate the effect of previous donor-CPR in DCD heart-transplantation (HT).

METHODS

Between January-2020 and April-2023, we identified 11,415 adult HTs in UNOS of whom 9456 met study criteria and had information on donor-CPR. Follow-up was available till April-2024. Study cohort was divided into four groups based on DCD vs. donation after brain death (DBD) status and donor-CPR i.e., DCD/CPR+ (n = 387), DCD/noCPR (n = 305), DBD/CPR+ (n = 5158) and DBD/noCPR (n = 3606); and compared for HT characteristics and outcomes.

RESULTS

With DBD/noCPR HTs as reference cohort, there were no significant differences in mortality in other HT cohorts (DCD/CPR+, DCD/noCPR and DBD/CPR+) upto 1-year of follow up using Kaplan-Meier analysis; and both unadjusted and adjusted Cox hazards-ratio models. Results were similar in propensity-matched cohorts. Duration of donor-CPR (≤20 min vs >20 min) did not influence HT survival; and rates of in-hospital secondary outcomes were similar. The utilization rates of both adult DCD/CPR+ (3.39 % to 9.71 %) and DCD/noCPR donors (4.41 % to 10.34 %) increased significantly (p < 0.01) during study period.

CONCLUSIONS

The utilization rates of both DCD/CPR+ and DCD/noCPR donors have increased at an equal pace. A significant proportion of DCD HTs were from donors with prior CPR, but this was not associated with worse short-term survival.

Supporting the Heterogeneous and Evolving Treatment Preferences of Patients With Heart Failure Through Collaborative Home-Based Palliative Care

Background We characterized the treatment preferences, care setting, and end-of-life outcomes among patients with advanced heart failure supported by a collaborative home-based model of palliative care. Methods and results This decedent cohort study included 250 patients with advanced heart failure who received collaborative home-based palliative care for a median duration of 1.9 months of follow-up in Ontario, Canada, from April 2013 to July 2019. Patients were categorized into 1 of 4 groups according to their initial treatment preferences. Outcomes included location of death (out of hospital versus in hospital), changes in treatment preferences, and health service use. Among patients who initially prioritized quantity of life, 21 of 43 (48.8%) changed their treatment preferences during follow-up (mean 0.28 changes per month). The majority of these patients changed their preferences to avoid hospitalization and focus on comfort at home (19 of 24 changes, 79%). A total of 207 of 250 (82.8%) patients experienced an out-of-hospital death. Patients who initially prioritized quantity of life had decreased odds of out-of-hospital death (versus in-hospital death; adjusted odds ratio, 0.259 [95% CI, 0.097-0.693]) and more frequent hospitalizations (mean 0.45 hospitalizations per person-month) compared with patients who initially prioritized quality of life at home. Conclusions Our results yield a more detailed understanding of the interaction of advanced care planning and patient preferences. Shared decision making for personalized treatment is dynamic and can be enacted earlier than at the very end of life.

Symptom experience and care needs of Turkish palliative care patients

BACKGROUND

Nurses need to focus on supporting patients' quality of life, supporting their families, reducing the morbidity rate, providing psychosocial support services to improve symptom management and delivering high-quality care.

AIM

This study aimed to determine the symptom experience and care needs of Turkish patients who received inpatient treatment in palliative care units.

METHODS

This descriptive research was conducted between May 2019 and May 2020. The study sample was composed of 200 palliative care patients selected using a convenience-purposive sampling method. The personal and disease-related characteristics were collected using the Patient Information Survey and the Functional Assessment of Chronic Illness Therapy-Palliative Care scale.

FINDINGS

The mean age of the sample was 75±15 years, and 56.5% were women. The patients' overall quality of life scores were below average (mean 84.05±19.44). The functional wellbeing and other concerns subscales of the scale were affected the most adversely. The Physical Wellbeing subscale was affected minimally, while the Emotional Wellbeing and Social Wellbeing subscales were affected moderately. Conclusion: The palliative care patients mostly needed support for the prevention and management of infections, management of respiratory distress and swallowing problems, dealing with confusion and improving compliance with treatment. The low quality of life scores emphasise the importance of urgent interventions for improving the functional wellbeing and symptom management in these patients.

Association between high cost user status and end-of-life care in hospitalized patients: A national cohort study of patients who die in hospital

BACKGROUND

Studies comparing end-of-life care between patients who are high cost users of the healthcare system compared to those who are not are lacking.

AIM

The objective of this study was to describe and measure the association between high cost user status and several health services outcomes for all adults in Canada who died in acute care, compared to non-high cost users and those without prior healthcare use.

SETTINGS AND PARTICIPANTS

We used administrative data for all adults who died in hospital in Canada between 2011 and 2015 to measure the odds of admission to the intensive care unit (ICU), receipt of invasive interventions, major surgery, and receipt of palliative care during the hospitalization in which the patient died. High cost users were defined as those in the top 10% of acute healthcare costs in the year prior to a person's hospitalization in which they died.

RESULTS

Among 252,648 people who died in hospital, 25,264 were high cost users (10%), 112,506 were non-high cost users (44.5%) and 114,878 had no prior acute care use (45.5%). After adjustment for age and sex, high cost user status was associated with a 14% increased odds of receiving an invasive intervention, a 15% increased odds of having major surgery, and an 8% lower odds of receiving palliative care compared to non-high cost users, but opposite when compared to patients without prior healthcare use.

CONCLUSIONS

Many patients receive aggressive elements of end-of-life care during the hospitalization in which they die and a substantial number do not receive palliative care. Understanding how this care differs between those who were previously high- and non-high cost users may provide an opportunity to improve end of life care for whom better care planning and provision ought to be an equal priority.

Symptom trajectories of non-cancer patients in the last six months of life: Identifying needs in a population-based home care cohort

INTRODUCTION

The end-of-life symptom prevalence of non-cancer patients have been described mostly in hospital and institutional settings. This study aims to describe the average symptom trajectories among non-cancer patients who are community-dwelling and used home care services at the end of life.

MATERIALS AND METHODS

This is a retrospective, population-based cohort study of non-cancer patients who used home care services in the last 6 months of life in Ontario, Canada, between 2007 and 2014. We linked the Resident Assessment Instrument for Home Care (RAI-HC) (standardized home care assessment tool) and the Discharge Abstract Databases (for hospital deaths). Patients were grouped into four non-cancer disease groups: cardiovascular, neurological, respiratory, and renal (not mutually exclusive). Our outcomes were the average prevalence of these outcomes, each week, across the last 6 months of life: uncontrolled moderate-severe pain as per the Pain Scale, presence of shortness of breath, mild-severe cognitive impairment as per the Cognitive Performance Scale, and presence of caregiver distress. We conducted a multivariate logistic regression to identify factors associated with having each outcome respectively, in the last 6 months.

RESULTS

A total of 20,773 non-cancer patient were included in our study, which were analyzed by disease groups: cardiovascular (n = 12,923); neurological (n = 6,935); respiratory (n = 6,357); and renal (n = 3,062). Roughly 80% of patients were > 75 years and half were female. In the last 6 months of life, moderate to severe pain was frequent in the cardiovascular (57.2%), neurological (42.7%), renal (61.0%) and respiratory (58.3%) patients. Patients with renal disease had significantly higher odds for reporting uncontrolled moderate to severe pain (odds ratio [OR] = 1.21; 95% CI: 1.08 to 1.34) than those who did not. Patients with respiratory disease reported significantly higher odds for shortness of breath (5.37; 95% CI, 5.00 to 5.80) versus those who did not. Patients with neurological disease compared to those without were 9.65 times more likely to experience impaired cognitive performance and had 56% higher odds of caregiver distress (OR = 1.56; 95% CI: 1.43 to 1.71).

DISCUSSION

In our cohort of non-cancer patients dying in the community, pain, shortness of breath, impaired cognitive function and caregiver distress are important symptoms to manage near the end of life even in non-institutional settings.

The association between varying levels of palliative care involvement on costs during terminal hospitalizations in Canada from 2012 to 2015

Background

Inpatient palliative care is associated with lower inpatient costs; however, this has yet to be studied using a more nuanced, multi-tiered measure of inpatient palliative care and a national population-representative dataset. Using a population-based cohort of Canadians who died in hospital, our objectives were to: describe patients’ receipt of palliative care and active interventions in their terminal hospitalization; and examine the relationship between inpatient palliative care and hospitalization costs.

Methods

Retrospective cohort study using data from the Discharge Abstract Database in Canada between fiscal years 2012 and 2015. The cohort were Canadian adults (age ≥ 18 years) who died in hospital between April 1st, 2012 and March 31st, 2015 (N = 250,640). The exposure was level of palliative care involvement defined as: medium-high, low, or no palliative care. The main measure was acute care costs calculated using resource intensity weights multiplied by the cost of standard hospital stay, represented in 2014 Canadian dollars (CAD). Descriptive statistics were represented as median (IQR), and n(%). We modelled cost as a function of palliative care using a gamma generalized estimating equation (GEE) model, accounting for clustering by hospital.

Results

There were 250,640 adults who died in hospital. Mean age was 76 (SD 14), 47% were female. The most common comorbidities were: metastatic cancer (21%), heart failure (21%), and chronic obstructive pulmonary disease (16%). Of the decedents, 95,450 (38%) had no palliative care involvement, 98,849 (38%) received low involvement, and 60,341 (24%) received medium to high involvement. Controlling for age, sex, province and predicted hospital mortality risk at admission, the cost per day of a terminal hospitalization was: $1359 (95% CI 1323: 1397) (no involvement), $1175 (95% CI 1146: 1206) (low involvement), and $744 (95% CI 728: 760) (medium-high involvement).

Conclusions

Increased involvement of palliative care was associated with lower costs. Future research should explore whether this relationship holds for non-terminal hospitalizations, and whether palliative care in other settings impacts inpatient costs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06335-1.

Comparison of Palliative Care Delivery in the Last Year of Life Between Adults With Terminal Noncancer Illness or Cancer

IMPORTANCE

Palliative care improves health outcomes, but studies of the differences in the delivery of palliative care to patients with different types of serious illness are lacking.

OBJECTIVE

To examine the delivery of palliative care among adults in their last year of life who died of terminal noncancer illness compared with those who died of cancer.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used linked health administrative data of adults who received palliative care in their last year of life and died between January 1, 2010, and December 31, 2017, in Ontario, Canada.

EXPOSURES

Cause of death (chronic organ failure, dementia, or cancer).

MAIN OUTCOMES AND MEASURES

Components of palliative care delivery, including timing and location of initiation, model of care, physician mix, care settings, and location of death.

RESULTS

A total of 145 709 adults received palliative care (median age, 78 years; interquartile range, 67-86 years; 50.7% female); 21 054 died of chronic organ failure (4704 of heart failure, 5715 of chronic obstructive pulmonary disease, 3785 of end-stage kidney disease, 579 of cirrhosis, and 6271 of stroke), 14 033 died of dementia, and 110 622 died of cancer. Palliative care was initiated earlier (>90 days before death) in patients with cancer (32 010 [28.9%]) than in those with organ failure (3349 [15.9%]; absolute difference, 13.0%) or dementia (2148 [15.3%]; absolute difference, 13.6%). A lower proportion of patients with cancer had palliative care initiated in the home (16 088 [14.5%]) compared with patients with chronic organ failure (6904 [32.8%]; absolute difference, -18.3%) or dementia (3922 [27.9%]; absolute difference, -13.4%). Patients with cancer received palliative care across multiple care settings (92 107 [83.3%]) more often than patients with chronic organ failure (12 061 [57.3%]; absolute difference, 26.0%) or dementia (7553 [53.8%]; absolute difference, 29.5%). Palliative care was more often delivered to patients with cancer (80 615 [72.9%]) using a consultative or specialist instead of a generalist model compared with patients with chronic organ failure (9114 [43.3%]; absolute difference, 29.6%) or dementia (5634 [40.1%]; absolute difference, 32.8%). Patients with cancer (42 718 [38.6%]) received shared palliative care more often from general practitioners and physicians with subspecialty training, compared with patients with chronic organ failure (3599 [17.1%]; absolute difference, 21.5%) or dementia (1989 [14.2%]; absolute difference, 24.4%).

CONCLUSIONS AND RELEVANCE

In this cohort study, there were substantial patient- and practitioner-level differences in the delivery of palliative care across distinct types of serious illness. These patient- and practitioner-level differences have important implications for the organization and scaled implementation of palliative care programs, including enhancement of practitioner education and training and improvements in equitable access to care across all settings.