Risk Factors for All-Cause Mortality in Patients Diagnosed with Advanced Heart Failure: A Scoping Review

Introduction: Identifying the evolving needs of patients with advanced heart failure (AdHF) and triaging those at high risk of death can facilitate timely referrals to palliative care and advance patient-centered individualized care. There are limited models specific for patients with end-stage HF. We aim to identify risk factors associated with up to three-year all-cause mortality (ACM) and describe prognostic models developed or validated in AdHF populations. Methods: Frameworks proposed by Arksey, O'Malley, and Levac were adopted for this scoping review. We searched the Medline, EMBASE, PubMed, CINAHL, Cochrane library, Web of Science and gray literature databases for articles published between January 2010 and September 2020. Primary studies that included adults aged ≥ 18 years, diagnosed with AdHF defined as New York Heart Association class III/IV, American Heart Association/American College of Cardiology Stage D, end-stage HF, and assessed for risk factors associated with up to three-year ACM using multivariate analysis were included. Studies were appraised using the Quality of Prognostic Studies tool. Data were analyzed using a narrative synthesis approach. Results: We reviewed 167 risk factors that were associated with up to three-year ACM and prognostic models specific to AdHF patients across 65 articles with low-to-moderate bias. Studies were mostly based in Western and/or European cohorts (n = 60), in the acute care setting (n = 56), and derived from clinical trials (n = 40). Risk factors were grouped into six domains. Variables related to cardiovascular and overall health were frequently assessed. Ten prognostic models developed/validated on AdHF patients displayed acceptable model performance [area under the curve (AUC) range: 0.71-0.81]. Among the ten models, the model for end-stage-liver disease (MELD-XI) and acute decompensated HF with N-terminal pro b-type natriuretic peptide (ADHF/proBNP) model attained the highest discriminatory performance against short-term ACM (AUC: 0.81). Conclusions: To enable timely referrals to palliative care interventions, further research is required to develop or validate prognostic models that consider the evolving landscape of AdHF management.

Physiotherapy in palliative medicine: patient and caregiver wellness

OBJECTIVES

Despite the demonstrated efficacy of physiotherapy in palliative care programmes, there are scarce data of its real-life impact on patients' and caregivers' wellness and stress. Our aim was to assess effectiveness of a 30-day physiotherapy programme in psychological wellness and health-related quality of life (HRQoL) of patients with advanced chronic diseases or cancer and in their caregivers' stress.

METHODS

Quasiexperimental before-after study applying personalised kinesitherapy, exercise with curative effects, respiratory physiotherapy, therapeutic massages and ergotherapy. Psychological wellness, HRQoL and caregiver's strain outcomes were measured.

RESULTS

207 patients (60% men, with a mean age of 73.6±12 years) were included; 129 (62.3%) with advanced cancer, and the remaining 78 with advanced chronic diseases. Psychological wellness (Emotional Stress Detection Tool decreased from 12.4±3 to 11±3; p<0.0001), caregiver's strain (Caregiver Strain Index decreased from 8.5±3.2 to 7.9±3.5; p<0.0001) and HRQoL (WHO-BREF physical health domain increased from 8.3±2.6 to 9.4±2.9; p<0.0001) showed a significant improvement after the physiotherapy programme. Global satisfaction with the physiotherapy intervention was also high (Client Satisfaction Questionnaire-8 of 28.3±3.3 points).

CONCLUSIONS

A personalised physiotherapy programme incorporated to integral palliative care improved psychological wellness, HRQoL and caregivers' strain of patients with advanced chronic diseases and cancer.

Care Disruptions and End-Of-Life Care Experiences Among Home-Based Primary Care Patients During the COVID-19 Pandemic in New York City: A Retrospective Chart Review

Background: Research on deaths during COVID-19 has largely focused on hospitals and nursing homes. Less is known about medically complex patients receiving care in the community. We examined care disruptions and end-of-life experiences of homebound patients receiving home-based primary care (HBPC) in New York City during the initial 2020 COVID-19 surge. Methods: We conducted a retrospective chart review of patients enrolled in Mount Sinai Visiting Doctors who died between March 1-June 30, 2020. We collected patient sociodemographic and clinical data and analyzed care disruptions and end-of-life experiences using clinical notes, informed by thematic and narrative analysis. Results: Among 1300 homebound patients, 112 (9%) died during the study period. Patients who died were more likely to be older, non-Hispanic white, and have dementia than those who survived. Thirty percent of decedents had confirmed or probable COVID-19. Fifty-eight (52%) were referred to hospice and 50 enrolled. Seventy-three percent died at home. We identified multiple intersecting disruptions in family caregiving, paid caregiving, medical supplies and services, and hospice care, as well as hospital avoidance, complicating EOL experiences. The HBPC team responded by providing clinical, logistical and emotional support to patients and families. Conclusion: Despite substantial care disruptions, the majority of patients in our study died at home with support from their HBPC team as the practice worked to manage care disruptions. Our findings suggest HBPC's multi-disciplinary, team-based model may be uniquely suited to meet the needs of the most medically and socially vulnerable older adults at end of life during public health emergencies.

A comparison of end-of-life care patterns between older patients with both cancer and Alzheimer's disease and related dementias versus those with only cancer

INTRODUCTION

Aggressive end-of-life (EOL) care that is not aligned with the preferences of persons with cancer has negative impacts on their quality of life. Alzheimer's disease and related dementias (ADRD) could potentially complicate EOL care planning among persons with cancer. Little is known about the aggressive EOL care patterns among Medicare beneficiaries with both cancer and ADRD.

MATERIALS AND METHODS

A matched retrospective cohort was created using the 2004 to 2016 Surveillance, Epidemiology, End Results-Medicare (SEER-Medicare) data differentiated by beneficiaries' ADRD status. Beneficiaries with breast, lung, colorectal, or prostate cancer who died between January 1, 2005 and December 31, 2016, were included. Six existing domains of aggressive EOL care and one overall indicator were derived. The major predictor was having ADRD comorbidity; other covariates included sex, marital status, census tract poverty indicator, race/ethnicity, metro status, geographic location, Charlson Comorbidity Index (CCI), survival time, cancer site, and histology stage. Multivariable logistic regression models were deployed to estimate the odds of receiving aggressive EOL care.

RESULTS

The study sample was 135,380 people after the one-to-one propensity score matching. The prevalence of aggressive EOL care utilization was slightly lower in beneficiaries with both cancer and ADRD when compared to beneficiaries with cancer only (54% vs. 58%, p < 0.0001). Beneficiaries with both cancer and ADRD were less likely to receive aggressive EOL care (AOR: 0.88, 95% CI: 0.86, 0.90) versus beneficiaries with cancer only. From the multivariable logistic regression model, certain beneficiaries' characteristics were associated with higher odds of receiving aggressive EOL care, such as: beneficiaries belonging to a racial/ethnic minority, a shorter survival time, and a higher CCI score.

DISCUSSION

The combined presence of ADRD and cancer was associated with lower odds of receiving aggressive EOL care compared to the presence of only cancer; however, the prevalence difference between the cohorts was not huge. Future studies could conduct in-depth evaluations of the ADRD's influence on the EOL care utilization.

'End of life': a concept analysis

BACKGROUND

The concept of end of life (EOL), as in the term end-of-life care, is used synonymously in both palliative and terminal care. Practitioners and researchers both require a clearer specification of the end-of-life concept to be able to provide appropriate care in this phase of life and to conduct robust research on a well-described theoretical basis.

AIMS

The aim of this study was to critically analyse the end-of-life concept and its associated terminology.

METHOD

A concept analysis was performed by applying Rodgers' evolutionary concept analysis method.

FINDINGS

Time remaining, clinical status/physical symptoms, psychosocial symptoms and dignity were identified as the main attributes of the concept. Transition into the end-of-life phase and its recognition were identified as antecedents. This study demonstrates that end-of-life care emerged following the application of the 'end-of-life concept' to clinical practice.

CONCLUSION

The early recognition of the end-of-life phase seems to be crucial to ensuring an individual has well-managed symptoms and a dignified death.

Awareness of Imminent Death: Results From a Mixed Methods Study of Israeli Family Caregivers' Perceptions of Their Awareness and That of the Patients for Whom They Cared

We studied levels of awareness of impending death in older patients and their family caregivers. Using a mixed methods approach, we interviewed 70 family caregivers in Israel. Of the caregivers, 64% reported having been aware of the impending death, 33% were unaware, and 3% uncertain. Caregivers reported their perception that 36% of patients were aware, 27% unaware, and for 37% they were uncertain about the patient's awareness. Mechanisms that increased caregivers' awareness were specific diagnosis, significant deterioration in health, preparation by a health professional, or patient preparations for death. This study clarifies processes which aid awareness, and the relationship between awareness and actual preparation for dying.

Potential determinants of unfavourable healthcare utilisation trajectories during the last year of life of people with incident Alzheimer Disease or Related Syndromes: a nationwide cohort study using administrative data

BACKGROUND

people approaching the end-of-life frequently face inappropriate care. With Alzheimer Disease or Related Syndromes (ADRS), end-of-life is characterised by progressive decline, but this period remains difficult to identify. This leads to a lack of anticipation and sometimes with unfavourable healthcare utilisation trajectories (HUTs).

OBJECTIVE

to quantify unfavourable HUTs during the last year of life and identify their potential determinants in both community and nursing-home settings.

DESIGN

nationwide cohort study using administrative database.

SETTING

French community and nursing-home residents.

SUBJECTS

incident ADRS people identified in 2012, who died up to 31 December 2017.

METHODS

we used multidimensional clustering to identify 15 clusters of HUTs, using 11 longitudinal healthcare dimensions during the last year of life. Clusters were qualitatively assessed by pluri-disciplinary experts as favourable or unfavourable HUTs. Individual and contextual potential determinants of unfavourable HUTs were studied by setting using logistic random-effect regression models.

RESULTS

62,243 individuals died before 31 December 2017; 46.8% faced unfavourable end-of-life HUTs: 55.2% in the community and 31.8% in nursing-homes. Individual potential determinants were identified: younger age, male gender, ADRS identification through hospitalisation, shorter survival, life-limiting comorbidities, psychiatric disorders, acute hospitalisations and polypharmacy. In the community, deprivation and autonomy were identified as potential determinants. Contextual potential determinants raised mostly in the community, such as low nurse or physiotherapist accessibilities.

CONCLUSIONS

Nearly half of people with ADRS faced unfavourable HUTs during their last year of life. Individual potential determinants should help anticipate advance care planning and palliative care needs assessment. Contextual potential determinants suggest geographical disparities and health inequalities.

Regrets of family caregivers in Israel about the end of life of deceased relatives

Objective: We aimed to clarify the content of different types of regrets or lack of regret, and the frequency of feeling regret among family caregivers who assisted their relatives during their end of life stage.Method: Seventy primary informal caregivers in Israel were interviewed (17 spouses, 52 children, and 1 cousin) concerning their regret about the end of life of their deceased relative, including a general question about regret and questions about regret concerning life-sustaining treatments. After calculating the frequency of regrets and lack of regret, we conducted a qualitative analysis, using a thematic approach to identify themes and interpret data.Results: A majority of caregivers (63%) expressed regret and about 20% expressed ambivalence involving both regret and denial of regret. Regrets pertained to care given, suffering experienced, and the caregiver's behavior towards, and relationship with the deceased, including missing opportunities to express love and caring toward relatives. Caregivers viewed almost 30% of 75 administered life-sustaining procedures as misguided. Most regrets involved inaction, such as not communicating sufficiently, or not fighting for better care.Conclusion: This article provides a comprehensive description of EoL regrets, and helps clarify the complexity of regrets, lack of regrets, and ambivalence concerning regrets, though the study is limited to one country. Analysis suggests the need for public education concerning the EoL process, and for changes within the health care system to improve communication, to improve understanding of the needs of the terminally ill, and to provide more instruction to family caregivers to help them understand EoL.

Assessing the Will to Live: A Scoping Review

CONTEXT

The will to live (WTL) is an important factor to consider in the context of providing resource-oriented palliative care. Until now, there has been no major review of the existing research on this subject.

OBJECTIVES

The primary objective of this study is to summarize the state of research concerning instruments that assess the WTL. The secondary objective is to explore the theoretical models and psychometric properties of these instruments, in studies where these instruments were initially presented. The tertiary objective is to identify, among all studies where these instruments have been used, the intensity of the WTL, and factors associated with it.

METHODS

We conducted a scoping review, including studies that were designed to assess the WTL among participants in all settings. Records were systematically searched from seven bibliographic databases with no date limitations up to August 2020.

RESULTS

Of the 3078 records screened, 281 were examined in detail and 111 were included in the synthesis. A total of 25 different instruments quantitatively assessing the WTL are presented. Most are single-question tools and rate intensity. The underlying concepts and psychometric properties are incompletely explained. Lack of crossreferencing is apparent. The intensity of the WTL is high, even among people with significant health impairment, and is frequently associated with different factors, such as resilience and quality of life.

CONCLUSION

A considerable yet unconnected body of studies assesses the WTL. Its assessment in clinical routine could promote resource-oriented and patient-centered care.

Optimism and longevity beyond age 85

BACKGROUND

Optimism is associated with health benefits and improved survival among adults aged >65. Whether or not optimism beyond age 85 continues to confer survival benefits is poorly documented. We examine the hypothesis that being optimistic at ages 85 and 90 is associated with improved survival.

METHODS

The Jerusalem Longitudinal Study (1990-2020) assessed comorbidity, depression, cognition, social and functional status, and 5-year mortality among a representative community sample, born 1920-1921, at age 85 (n=1096) and age 90 (n=533). Overall optimism (Op-Total) was measured using a validated 7-item score from the Scale of Subjective Wellbeing for Older Persons. The four questions concerning positive future expectations (Op-Future) and three questions concerning positive experiences (Op-Happy) were also analyzed separately. We determined unadjusted mortality Hazards Ratios, and also adjusted for gender, financial difficulty, marital status, educational status, ADL dependence, physical activity, diabetes mellitus, hypertension, ischemic heart disease, cognitive impairment and depression.

RESULTS

Between ages 85-90 and 90-95 years, 33.2% (364/1096) and 44.3% (236/533) people died respectively. All mean optimism scores declined from age 85 to 90, with males significantly more optimistic than females throughout. All measures of optimism (Op-Total, Op-Future, Op-Happy) at age 85 and 90 were significantly associated with improved 5-year survival from age 85-90 and 90-95 respectively, in both unadjusted and adjusted models. Findings remained unchanged after separately excluding depressed subjects, cognitively impaired subjects, and subjects dying within 6 months from baseline.

CONCLUSIONS

These finding support the hypothesis that being optimistic continues to confer a survival benefit irrespective of advancing age.

Effects of Psychosocial Interventions and Caregiving Stress on Cardiovascular Biomarkers in Family Dementia Caregivers: The UCSD Pleasant Events Program (PEP) Randomized Controlled Trial

BACKGROUND

This study examined whether biological mechanisms linking dementia caregiving with an increased risk of coronary heart disease can be modified by psychosocial interventions and which caregivers might benefit the most from an intervention.

METHODS

Spousal dementia caregivers were randomized to 12-week treatment with either a behavioral activation intervention (ie, Pleasant Events Program [PEP]; n = 60), or an active control Information and Support (IS; n = 63) condition. Indicators of caregiving stress were assessed pretreatment and circulating cardiovascular biomarkers were measured pre- and posttreatment.

RESULTS

There were no significant changes in biomarker levels from pre- to posttreatment both by treatment condition and across all caregivers. Regardless of the treatment condition, exploratory regression analysis revealed that caregivers were more likely to show significant decreases in C-reactive protein (CRP) and D-dimer when their spouse had severe functional impairment; in interleukin (IL)-6 and CRP when they had greater distress due to care recipient's problem behaviors; in tumor necrosis factor (TNF)-α when they had higher levels of negative affect; and in IL-6, CRP, TNF-α, and D-dimer when they had higher personal mastery. Within the PEP group, caregivers with higher negative affect and those with higher positive affect were more likely to show a reduction in von Willebrand factor and D-dimer, respectively. Within the IS group, caregivers whose spouse had severe functional impairment were more likely to show a decrease in IL-6.

CONCLUSIONS

Unlike the average caregiver, caregivers high in burden/distress and resources might benefit from psychosocial interventions to improve cardiovascular risk, although these observations need confirmation.

Prevalence of Treatment Burden in the Last Three Years of Life

Background: Little is known about the experience of treatment burden, or the difficulties that arise when the treatment workload overwhelms one's ability to take on treatment activities, at the end of life. Objective: We first assessed rates of treatment burden experienced by all older adults in the last three years of life. Among the subset of our sample who had multiple chronic conditions (MCCs), we determined correlates of treatment burden with sociodemographic, health, and caregiving factors. Design: We conducted a cross-sectional study using nationally representative data from the National Health and Aging Trends Study (NHATS). Setting/Subjects: Our sample included 356 adults, aged 65 years and older, who died within three years of completing the 2012 NHATS Treatment Burden Questionnaire. Our MCC cohort included only those in our sample with two or more chronic conditions. Measurements: Our measure of treatment burden included reports of difficulty in managing treatment activities, delays in treatments, or feeling that physicians asked for too much. We built a composite measure to identify burden if participants reported that at least one item occurred sometimes or often. Results: Forty-three percent of older adults in their last three years of life experienced treatment burden. Among individuals with MCCs, bivariate analysis found that treatment burden was associated with being a racial minority and having depression, anxiety, and a cancer diagnosis. These associations were not statistically significant in a multivariable model. Conclusion: Treatment burden is a common experience among older adults regardless of sociodemographic, clinical, and caregiving factors.

After providing end of life care to relatives, what care options do family caregivers prefer for themselves?

Objectives

We examined how caregivers who had cared for a relative at end of life (EoL) wished to be cared for in the event that they experienced advanced dementia or physical disability in the future, and what factors influenced their preferences for EoL care.

Methods

In this mixed-methods study, 83 participants, recruited from multiple sources in Israel, were interviewed concerning socio-demographic factors, health status, past experience with EoL, preference for extension of life vs. quality of life (QoL), willingness to be dependent on others, and preferences for EoL care.

Results

In case of advanced dementia, 58% preferred euthanasia or suicide; around a third chose those for physical disability. Care by family members was the least desired form of care in the advanced dementia scenario, although more desirable than institutional care in the physical disability scenario. QoL was rated as the highest factor impacting preferences for EoL care. Men demonstrated a higher preference than women for extension of life over QoL.

Conclusion

Our study points to the need for society to consider solutions to the request of participants to reject the type of EoL experienced by their relatives. Those solutions include investing in improving the quality of life at the end of life, and offering alternatives such as euthanasia, which a large proportion of our participants found ethically and medically appropriate within the current system of care in the event of severe physical disability, and more so in the event of advanced dementia.

Family caregiver perceptions of end of life in persons with and without dementia

BACKGROUND

We compare the End of Life [EoL] period, the period of decline to death, for persons with dementia [PwD] to those without dementia, examining the duration and number of stages, and their precipitating events.

METHODS

In this cross-sectional study, 70 primary caregivers of decedents were interviewed. Frequencies were compared using the McNemar statistical test.

RESULTS

PwD were more likely to be female and older, compared to those without dementia. For PwD, the reported duration of the EoL period was significantly longer, involved more stages, and included a longer first stage. Precipitating events for EoL were more likely to include cognitive decline for PwD, but for those without, more likely to involve a new medical diagnosis or decline in health status.

DISCUSSION

End of Life as the final stage of development differs significantly between the two populations in length and other parameters. This has considerable implications for the experiences of PwD.

Perception of a "good death" in Thai patients with cancer and their relatives

Background

Understanding the perceptions regarding what constitutes a "good death" among cancer patients and their families could help healthcare teams to ensure proper palliative and supportive care.

Objectives

To demonstrate and compare the wishes cancer patients and the perceptions of their relatives regarding end-of-life care, and to identify factors associated with patients' preferences regarding place of death.

Methods

A sample of cancer patients and their relatives who attended the Srinagarind Hospital (Thailand) oncology clinic or day chemotherapy from September 2017 to August 2018 were enrolled. Questionnaires were given to the participants, in which the patients were asked to respond based on their own end-of-life preferences, and relatives were asked to imagine how the patients would respond to the questions.

Results

One hundred eighty pairs of patients and relatives were recruited. Respondents in both groups placed importance on place of death, relationship with family, physical and psychological comfort, and relationship with the medical staff. Both groups generally agreed with the statements on the questionnaire (10/13 statements). Relatives underestimated the preferences of the patients in 3 areas: "not being a burden to others," "preparation for death," and "physical and psychological comfort." Being married (adjusted odds ratio (AOD) 6.4, 95%confidence interval (CI) 1.1,36.5), having had more than 6 years of education (AOD 6.5, 95%CI 1.8,23.7), having lung cancer compared to colon cancer (AOD 12, 95%CI 1.2,118.7), duration after cancer diagnosis (AOD 0.9, 95%CI 0.93,0.99), previous hospital admission (AOD 5.7, 95%CI 1.5,21.2), and life satisfaction (AOD 17.6, 95%CI 2.9,104.9) were factors associated with preference for home death.

Conclusion

Thai cancer patients and their relatives indicated similar preferences with regard to what constitutes a good death and patients' wishes for their end-of-life period. However, the patients' relatives underestimated the importance patients placed on statements in three domains. Factors that influenced a preference for a home death were identified.

Does Caregiving Strain Increase as Patients With and Without Dementia Approach the End of Life?

CONTEXT

Family caregivers play critical and demanding roles in the care of persons with dementia through the end of life.

OBJECTIVES

The objective of this study was to determine whether caregiving strain increases for dementia caregivers as older adults approach the end of life, and secondarily, whether this association differs for nondementia caregivers.

METHODS

Participants included a nationally representative sample of community-living older adults receiving help with self-care or indoor mobility and their primary caregivers (3422 dyads). Older adults' death within 12 months of survey was assessed from linked Medicare enrollment files. Multivariable logistic regression was used to assess the association between dementia and end-of-life status and a composite measure of caregiving strain (range: 0-9, using a cut point of 5 to define "high" strain) after comprehensively adjusting for other older adult and caregiver factors.

RESULTS

The prevalence of dementia in our sample was 30.1%; 13.2% of the sample died within 12 months. The proportion of caregivers who experienced high strain ranged from a low of 13.5% among nondementia, non-end-of-life caregivers to a high of 35.0% among dementia caregivers of older adults who died within 12 months. Among dementia caregivers, the odds of high caregiving strain were nearly twice as high (aOR = 1.94, 95% CI: 1.10-3.45) for those who were assisting older adults nearing end of life. Among nondementia caregivers, providing care near the end of life was not associated with high strain.

CONCLUSION

Increased strain toward the end of life is particularly notable for dementia caregivers. Interventions are needed to address the needs of this population.

Minimum Data Set Changes in Health, End-Stage Disease and Symptoms and Signs Scale: A Revised Measure to Predict Mortality in Nursing Home Residents

OBJECTIVES

To revise the Minimum Data Set (MDS) Changes in Health, End-stage disease and Symptoms and Signs (CHESS) scale, an MDS 2.0-based measure widely used to predict mortality in institutional settings, in response to the release of MDS 3.0.

DESIGN

Development of a predictive scale using observational data from the MDS and Medicare Master Beneficiary Summary File.

SETTING

All Centers for Medicare and Medicaid Services (CMS)-certified nursing homes in the United States.

PARTICIPANTS

Development cohort of 1.3 million Medicare beneficiaries newly admitted to a CMS-certified nursing home during 2012. Primary validation cohort of 1.2 million Medicare recipients who were newly admitted to a CMS-certified nursing home during 2013.

MEASUREMENTS

Items from the MDS 3.0 assessments identified as likely to predict mortality. Death information was obtained from the Medicare Master Beneficiary Summary File.

RESULTS

MDS-CHESS 3.0 scores ranges from 0 (most stable) to 5 (least stable). Ninety-two percent of the primary validation sample with a CHESS scale score of 5 and 15% with a CHESS scale of 0 died within 1 year. The risk of dying was 1.63 times as great (95% CI=1.628-1.638) for each unit increase in CHESS scale score. The MDS-CHESS 3.0 is also strongly related to hospitalization within 30 days and successful discharge to the community. The scale predicted death in long-stay residents at 30 days (C=0.759, 95% confidence interval (CI)=0.756-0.761), 60 days (C=0.716, 95% CI=0.714-0.718) and 1 year (C=0.655, 95% CI=0.654-0.657).

CONCLUSION

The MDS-CHESS 3.0 predicts mortality in newly admitted and long-stay nursing home populations. The additional relationship to hospitalizations and successful discharges to community increases the utility of this scale as a potential risk adjustment tool.