Factors associated with hospital deaths in the oldest old: a cross-sectional study

Implementation of advance care planning in the routine care for acutely admitted patients in geriatric units: protocol for a cluster randomized controlled trial

BACKGROUND

Acutely ill and frail older adults and their next of kin are often poorly involved in treatment and care decisions. This may lead to either over- or undertreatment and unnecessary burdens. The aim of this project is to improve user involvement and health services for frail older adults living at home, and their relatives, by implementing advance care planning (ACP) in selected hospital wards, and to evaluate the clinical and the implementation interventions.

METHODS

This is a cluster randomized trial with 12 hospital units. The intervention arm receives implementation support for 18 months; control units receive the same support afterwards. The ACP intervention consists of 1. Clinical intervention: ACP; 2. Implementation interventions: Implementation team, ACP coordinator, network meetings, training and supervision for health care personnel, documentation tools and other resources, and fidelity measurements with tailored feedback; 3. Implementation strategies: leadership commitment, whole ward approach and responsive evaluation. Fidelity will be measured three times in the intervention arm and twice in the control arm. Here, the primary outcome is the difference in fidelity changes between the arms. We will also include 420 geriatric patients with one close relative and an attending clinician in a triadic sub-study. Here, the primary outcomes are quality of communication and decision-making when approaching the end of life as perceived by patients and next of kin, and congruence between the patient's preferences for information and involvement and the clinician's perceptions of the same. For patients we will also collect clinical data and health register data. Additionally, all clinical staff in both arms will be invited to answer a questionnaire before and during the implementation period. To explore barriers and facilitators and further explore the significance of ACP, qualitative interviews will be performed in the intervention units with patients, next of kin, health care personnel and implementation teams, and with other stakeholders up to national level. Lastly, we will evaluate resource utilization, costs and health outcomes in a cost-effectiveness analysis.

DISCUSSION

The project may contribute to improved implementation of ACP as well as valuable knowledge and methodological developments in the scientific fields of ACP, health service research and implementation science.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT05681585. Registered 03.01.23.

Factors Influencing Family Members in Choosing the Preferred Place of Death for Hospitalized Dying Older Patients

This study aims to explore the factors that influence family members in choosing the preferred place of death for hospitalized dying older patients in Taiwan. This study enrolled 100 family members. The relevant factors influencing the families' choice of the preferred place of death for older patients were family members' previous discussions with the patients about their expected place of death; patients' education levels; family members' incomes; whether they were hiring a caregiver to take care of the patients at the hospital; their degree of social support; and their family functioning. The logistic regression analysis showed that family members who had discussed the preferred place of death with the patients, and those with better family functioning, were 1.41 and 2.72 times more likely, respectively, to chose for patients to return home to die than for the patients to die in a hospital.

Family experiences of in-hospital end-of-life care for adults: A systematic review of qualitative evidence

AIM

To systematically identify, appraise, aggregate and synthesise qualitative evidence on family members' experiences of end-of-life care (EoLC) in acute hospitals.

METHODS

A systematic review and qualitative evidence synthesis based on the Joanna Briggs Institute methodology. Primary research, published 2014 onwards was identified using a sequential strategy of electronic and hand searches. Six databases (CINAHL, Medline, Embase, EMCare, PsycINFO, BNI) were systematically searched. Studies that met pre-determined inclusion/exclusion criteria were uniformly appraised using the Critical Appraisal Skills Programme checklist for qualitative research, and synthesised using a meta-aggregative approach. The ENTREQ statement was used as a checklist for reporting the review.

RESULTS

Sixteen studies of European, Australasian and North American origin formed the review. The quality of each study was considered very good in view of a 'yes' response to most screening questions. Extracted findings were assembled into 12 categories, and five synthesised findings: Understanding of approaching end of life; essential care at the end of life; interpersonal interactions; environment of care; patient and family care after death.

CONCLUSION

Enabling and improving peoples' experience of EoLC must remain part of the vision and mission of hospital organisations. Consideration must be given to the fulfilment of family needs and apparent hallmarks of quality care that appear to influence experiential outcomes.

RELEVANCE TO CLINICAL PRACTICE

This review of qualitative research represents the first-stage development of a family-reported experience measure for adult EoLC in the hospital setting. The synthesised findings provide a Western perspective of care practices and environmental factors that are perceived to impact the quality of the care experience. Collectively, the review findings serve as a guide for evidence-informed practice, quality improvement, service evaluation and future research. A developed understanding of the families' subjective reflections creates reciprocal opportunity to transform experiential insights into practical strategies for professional growth and practice development.

Underutilisation of EPaCCS (Electronic Palliative Care Coordination Systems) in end-of life-care: a cross-sectional study

OBJECTIVE

To support greater personalisation of end-of-life care, Electronic Palliative Care Coordination Systems (EPaCCS) have been implemented across England. Here, we describe patient factors associated with dying with an EPaCCS record and explore the association between having an EPaCCS record with cause and place of death.

METHOD

This is a cross-sectional study using routinely collected data. Data were extracted from primary care records in 20 of 86 general practices within one Clinical Commissioning Group in England. All deaths (n=1723) recorded between 22 February 2018 and 21 February 2019 were included to determine whether the deceased patient had an EPaCCS record at the time of death, a range of demographic factors, place of death and cause of death.

RESULTS

Only 18% of the sample died with an EPaCCS record, and people who died of a non-cancer cause were less likely to have an EPaCCS record than those who died of cancer (OR=0.41; 95% CI 0.31 to 0.55). Adjusting for patient demographic factors and cause of death, having an EPaCCS record was strongly associated with dying in the community (OR=5.10; 95% CI 3.70 to 7.03).

CONCLUSIONS

A small proportion of this sample died with an EPaCCS record, despite evidence of an association with dying in the community.

The difference an end-of-life diagnosis makes: qualitative interviews with providers of community health care for frail older people

BACKGROUND

Increasing numbers of people die of the frailty and multimorbidity associated with old age, often without receiving an end-of-life diagnosis. Compared to those with a single life-limiting condition such as cancer, frail older people are less likely to access adequate community care. To address this inequality, guidance for professional providers of community health care encourages them to make end-of-life diagnoses more often in such people. These diagnoses centre on prognosis, making them difficult to establish given the inherent unpredictability of age-related decline. This difficulty makes it important to ask how care provision is affected by not having an end-of-life diagnosis.

AIM

To explore the role of an end-of-life diagnosis in shaping the provision of health care outside acute hospitals.

DESIGN AND SETTING

Qualitative interviews with 19 healthcare providers from community-based settings, including nursing homes and out-of-hours services.

METHOD

Semi-structured interviews (nine individual, three small group) were conducted. Data were analysed thematically and using constant comparison.

RESULTS

In the participants' accounts, it was unusual and problematic to consider frail older people as candidates for end-of-life diagnosis. Participants talked of this diagnosis as being useful to them as care providers, helping them prioritise caring for people diagnosed as 'end-of-life' and enabling them to offer additional services. This prioritisation and additional help was identified as excluding people who die without an end-of-life diagnosis.

CONCLUSION

End-of-life diagnosis is a first-class ticket to community care; people who die without such a diagnosis are potentially disadvantaged as regards care provision. Recognising this inequity should help policymakers and practitioners to mitigate it.

Hospitalisation at the end of life among cancer and non-cancer patients in Denmark: a nationwide register-based cohort study

OBJECTIVES

End-of-life hospitalisations may not be associated with improved quality of life. Studies indicate differences in end-of-life care for cancer and non-cancer patients; however, data on hospital utilisation are sparse. This study aimed to compare end-of-life hospitalisation and place of death among patients dying from cancer, heart failure or chronic obstructive pulmonary disease (COPD).

DESIGN

A nationwide register-based cohort study.

SETTING

Data on all in-hospital admissions obtained from nationwide Danish medical registries.

PARTICIPANTS

All decedents dying from cancer, heart failure or COPD disease in Denmark between 2006 and 2015.

OUTCOME MEASURES

Data on all in-hospital admissions within 6 months and 30 days before death as well as place of death. Comparisons were made according to cause of death while adjusting for age, sex, comorbidity, partner status and residential region.

RESULTS

Among 154 235 decedents, the median total bed days in hospital within 6 months before death was 19 days for cancer patients, 10 days for patients with heart failure and 11 days for patients with COPD. Within 30 days before death, this was 9 days for cancer patients, and 6 days for patients with heart failure and COPD. Compared with cancer patients, the adjusted relative bed day use was 0.65 (95% CI, 0.63 to 0.68) for heart failure patients and 0.68 (95% CI, 0.66 to 0.69) for patients with COPD within 6 months before death. Correspondingly, this was 0.65 (95% CI, 0.63 to 0.68) and 0.70 (95% CI, 0.68 to 0.71) within 30 days before death.Patients had almost the same risk of dying in hospital independently of death cause (46.2% to 56.0%).

CONCLUSION

Patients with cancer, heart failure and COPD all spent considerable part of their end of life in hospital. Hospital use was highest among cancer patients; however, absolute differences were small.

Stories from the fourth age: autonomy and the lives of older care home residents

Transition to a care home often follows a hospital admission and can be distressing. Care home settings play an important role in the care of many people at the end of life. This longitudinal study employed a narrative approach, aiming to explore the perspectives of older care home residents on transitions to, and life and death within, care homes. Five participants, aged 85 years and over, were recruited from two privately owned care homes in the South-West of England. All participants had a diagnosis of an advanced progressive condition (excluding advanced dementia), or were thought to be frail. Longitudinal interviews (19 in total) were conducted over a ten-month period. A structural narrative analysis was performed and participants’ narratives are presented under three headings, with one participant's story chosen to illustrate each narrative type: ‘becoming a care home resident’, ‘living in a care home’ and ‘death and dying’. Findings revealed that care home residents experience a loss of autonomy and a lack of agency; they are often excluded from decision-making. Older care home residents have few choices with regard to care at the end of life. Further work is required to improve transition into care homes, including support and advocacy during decision-making, which often takes place in hospitals at a time of crisis.

Availability of home palliative care services and dying at home in conditions needing palliative care: A population-based death certificate study

BACKGROUND

Avoiding inappropriate care transition and enabling people with chronic diseases to die at home have become important health policy issues. Availability of palliative home care services may be related to dying at home.

AIM

After controlling for the presence of hospital beds and primary care physicians, we examined the association between availability of home palliative care services and dying at home in conditions requiring such services.

DESIGN

Death certificate data in Japan in 2016 were linked with regional healthcare statistics.

SETTING/PARTICIPANTS

All adults (18 years or older) who died from conditions needing palliative care in 2016 in Japan were included.

RESULTS

There were 922,756 persons included for analysis. Malignant neoplasm (37.4%) accounted for most decedents, followed by heart disease including cerebrovascular disease (31.4%), respiratory disease (14.7%) and dementia/Alzheimer's disease/senility (11.5%). Of decedents, 20.8% died at home or in a nursing home and 79.2% died outside home (hospital/geriatric intermediate care facility). Death at home was more likely in health regions with fewer hospital beds and more primary care physicians, in total and per condition needing palliative care. Number of home palliative care services was negatively associated with death at home. The adjustment for home palliative care services disappeared in heart disease including cerebrovascular disease and reversed in respiratory disease.

CONCLUSION

Specialised home palliative care services may be suboptimal, and primary care services may serve as a key access point in providing baseline palliative care to people with conditions needing palliative care. Therefore, primary care services should aim to enhance their palliative care workforce.

'It was peaceful, it was beautiful': A qualitative study of family understandings of good end-of-life care in hospital for people dying in advanced age

BACKGROUND

Hospitals are important sites of end-of-life care, particularly for older people. A need has been identified to understand best practice in hospital end-of-life care from the service-user perspective.

AIM

The aim of this study was to identify examples of good care received in the hospital setting during the last 3 months of life for people dying in advanced age from the perspective of bereaved family members.

DESIGN

A social constructionist framework underpinned a qualitative research design. Data were analysed thematically drawing on an appreciative enquiry framework.

SETTING/PARTICIPANTS

Interviews were conducted with 58 bereaved family carers nominated by 52 people aged >80 years participating in a longitudinal study of ageing. Data were analysed for the 21 of 34 cases where family members were 'extremely' or 'very' satisfied with a public hospital admission their older relative experienced in their last 3 months of life.

RESULTS

Participants' accounts of good care aligned with Dewar and Nolan's relation-centred compassionate care model: (1) a relationship based on empathy; (2) effective interactions between patients/families and staff; (3) contextualised knowledge of the patient/family; and (4) patients/families being active participants in care. We extended the model to the bicultural context of Aotearoa, New Zealand.

CONCLUSION

We identify concrete actions that clinicians working in acute hospitals can integrate into their practice to deliver end-of-life care with which families are highly satisfied. Further research is required to support the implementation of the relation-centred compassionate care model within hospitals, with suitable adaptations for local context, and explore the subsequent impact on patients, families and staff.

Preferences Regarding and Communication About End-of-Life Care Among Older Iranian-American Adults

Using a cross-sectional study, this article addresses end-of-life (EOL) care for older Iranian-American adults. The purposes are twofold: (a) to explore participants’ preferences for home or hospital care in the event they face EOL conditions and (b) to learn how participants prefer to communicate these preferences. Results showed that about half of the 130 participants had communicated their EOL care preferences through written documents and/or verbal discussions. A set of factors predicted the preferences (χ2(9) = 17.42, p < .042) and communications (χ2(9) = 19.54, p = .021). Regression models indicated that higher scores of social support ( p = .013) and greater numbers of cohabitants ( p = .021) were associated with a preference for home care, and experience of a loved one’s death was associated with participants being willing to communicate their preferences for type of care ( p = .015). This study can bridge the gap between culturally diverse older adults’ preferences and types of EOL care they ultimately receive.

Impact of the Macmillan specialist Care at Home service: a mixed methods evaluation across six sites

Background

The Midhurst Macmillan Specialist Palliative Care at Home Service was founded in 2006 to improve community-based palliative care provision. Principal components include; early referral; home-based clinical interventions; close partnership working; and flexible teamwork. Following a successful introduction, the model was implemented in six further sites across England. This article reports a mixed methods evaluation of the implementation across these ‘Innovation Centres’. The evaluation aimed to assess the process and impact on staff, patients and carers of providing Macmillan Specialist Care at Home services across the six sites.

Methods

The study was set within a Realist Evaluation framework and used a longitudinal, mixed methods research design. Data collection over 15 months (2014–2016) included: Quantitative outcome measures - Palliative Performance Scale [PPS] and Palliative Prognostic Index [PPI] (n = 2711); Integrated Palliative Outcome Scales [IPOS] (n = 1157); Carers Support Needs Assessment Tool [CSNAT] (n = 241); Views of Informal Carers –Evaluation of Services [VOICES-SF] (n = 102); a custom-designed Service Data Tool [SDT] that gathered prospective data from each site (n = 88). Qualitative data methods included: focus groups with project team and staff (n = 32 groups with n = 190 participants), and, volunteers (n = 6 groups with n = 32 participants). Quantitative data were analysed using SPPS Vs. 21 and qualitative data was examined via thematic analysis.

Results

Comparison of findings across the six sites revealed the impact of their unique configurations on outcomes, compounded by variations in stage and mode of implementation. PPS, PPI and IPOS data revealed disparity in early referral criteria, complicated by contrasting interpretations of palliative care. The qualitative analysis, CSNAT and VOICES-SF data confirmed the value of the Macmillan model of care but uptake of specialist home-based clinical interventions was limited. The Macmillan brand engendered patient and carer confidence, bringing added value to existing services. Significant findings included better co-ordination of palliative care through project management and a single referral point and multi-disciplinary teamwork including leadership from consultants in palliative medicine, the role of health care assistants in rapid referral, and volunteer support.

Conclusions

Macmillan Specialist Care at Home increases patient choice about place of death and enhances the quality of end of life experience. Clarification of key components is advocated to aid consistency of implementation across different sites and support future evaluative work.

Electronic supplementary material

The online version of this article (10.1186/s12904-018-0281-9) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

AIM

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

DESIGN

Nationwide, retrospective cohort study using register data.

SETTING/PARTICIPANTS

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

RESULTS

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

CONCLUSION

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

Frailty affects the initial treatment response and time to recovery of mobility in acutely ill older adults admitted to hospital

Objectives

to investigate how frailty and mobility impairment affect recovery of balance and mobility in acutely ill older patients.

Design

secondary analysis of cohort study.

Setting

general and geriatric medicine inpatient units, QEII Health Sciences Centre, Dalhousie University, Canada.

Subjects

four hundred and nine older adults (mean age = 81 ± 7 standard deviation, 64% women).

Methods

we constructed a frailty index based on a comprehensive geriatric assessment (FI-CGA), at baseline (2 weeks before admission; mean 0.31 ± 0.10), and on admission (mean 0.40 ± 0.10), and recorded Hierarchical Assessment of Balance and Mobility (HABAM) scores daily. Recovery was measured as the difference in HABAM scores between discharge and admission.

Results

the odds of no or incomplete recovery increased by 1.06 (95% confidence interval: 1.01-1.11) for each 0.1 increment in the baseline FI-CGA. Recovery odds were similarly dependent on age, but independent of baseline HABAM scores. Recovery time was related to Day 1 HABAM scores, initial treatment response and change in the FI-CGA from baseline to admission (r = 0.35, P < 0.001). Recovery time was independent of age. Patients whose mobility improved within 48 h (n = 113; 28%) showed greater improvement and quicker recovery.

Conclusions

frailer patients are at a greater risk of incomplete or lengthier recovery from impaired mobility and balance. Tracking mobility and balance might help providers, patients and families understand the course of acute illness in older adults.

Pathways after inpatient admission in very advanced age: A Portuguese nationwide study

INTRODUCTION

Oldest old patients often have complex and multiple medical conditions, which are associated with higher rates of use of healthcare services, and a higher risk of experiencing adverse outcomes, such as mortality. This study investigated (a) the in-hospital mortality rate and predictors in patients aged 80+; (b) the destination patients have after hospital discharge.

METHODS

Nationwide study. All inpatient admissions by individuals aged 80 years and older between 2011 and 2014 in Portugal were considered. Exploratory descriptive analyses of data regarding in-hospital mortality and destination after discharge were performed; multivariate logistic regression analyses were conducted to identify predictors of in-hospital mortality.

RESULTS

A total of 614,807 episodes of hospital admissions were analysed. A mortality rate of 15.4% was observed. In the majority of episodes, patients returned home (78.6%). Increased age, male gender, increased length of stay, unplanned attendance, medical DRG type, increased severity of illness and mortality risk, and comorbidities were significant predictors of in-hospital mortality.

DISCUSSION

This study strengthens the importance of implementing health policies specifically to the oldest old, namely with the promotion of the use of primary care services. That would expectably concur to a better management of the most common medical conditions in this population, and a decrease in hospital unplanned attendances.