Predictors of Quality of Life in Elderly Hospice Patients with Cancer

Differences in end-of-life care patterns between types of hospice used for cancer patients: a retrospective cohort study

BACKGROUND

In response to the rapid aging population and increasing number of cancer patients, discussions on dignified end-of-life (EoL) decisions are active around the world. Therefore, this study aimed to identify the differences in EoL care patterns between types of hospice used for cancer patients.

METHODS

In this population-based cohort study, the Korean National Health Insurance Service cohort data containing all registered cancer patients who died between 2017 and 2021 were used. A total of 408,964 individuals were eligible for analysis. The variable of interest, the type of hospice used in the 6 months before death, was classified as follows: (1) Non-hospice users; (2) Hospital-based hospice single users; (3) Home-based hospice single users; (4) Combined hospice users. The outcomes were set as patterns of care, including intense care and supportive care. To identify differences in care patterns between hospice types, a generalized linear model with zero-inflated negative binomial distribution was applied.

RESULTS

Hospice enrollment was associated with less intense care and more supportive care near death. Notably, those who used combined hospice care had the lowest probability and frequency of receiving intense care (aOR: 0.18, 95% CI: 0.17-0.19, aRR: 0.47, 95% CI: 0.44-0.49), while home-based hospice single users had the highest probability and frequency of receiving supportive care (Prescription for narcotic analgesics, aOR: 2.95, 95% CI: 2.69-3.23, aRR: 1.45, 95% CI: 1.41-1.49; Mental health care, aOR: 3.40, 95% CI: 3.13-3.69, aRR: 1.35, 95% CI: 1.31-1.39).

CONCLUSION

Our findings suggest that although intense care for life-sustaining decreases with hospice enrollment, QoL at the EoL actually improves with appropriate supportive care. This study is meaningful in that it not only offers valuable insight into hospice care for terminally ill patients, but also provides policy implications for the introduction of patient-centered community-based hospice services.

Using an adaptive network-based fuzzy inference system for prediction of successful aging: a comparison with common machine learning algorithms

INTRODUCTION

The global society is currently facing a rise in the elderly population. The concept of successful aging (SA) appeared in the gerontological literature to overcome the challenges and problems of population aging. SA is a subjective and multidimensional concept with many ambiguities regarding its meaning or measuring. This study aimed to propose an intelligent predictive model to predict SA.

METHODS

In this retrospective study, the data of 784 elderly people were used to develop and validate machine learning (ML) methods. Data pre-processing was first performed. First, an adaptive neuro-fuzzy inference system (ANFIS) was proposed to predict SA. Then, the predictive performance of the proposed model was compared with three ML algorithms, including multilayer perceptron (MLP) neural network, support vector machine (SVM), and random forest (RF) based on accuracy, sensitivity, precision, and F-score metrics.

RESULTS

The findings indicated that the ANFIS model with gauss2mf built-in membership function (MF) outperformed the other models with accuracy, sensitivity, precision, and F-score of 91.57%, 95.18%, 92.31%, and 92.94%, respectively.

CONCLUSIONS

The predictive performance of ANFIS is more efficient than the other ML models in SA prediction. The development of a decision support system (DSS) using our prediction model can provide healthcare administrators and policymakers with a reliable and responsive tool to improve elderly outcomes.

Fatigue-related symptom clusters and functional status of older adults in hospice

BACKGROUND

Fatigue is frequently co-existing with other symptoms and is highly prevalent among patients with cancer and geriatric population. There was a lack of knowledge that focus on fatigue clusters in older adults with cancer in hospice care.

OBJECTIVES

To identify fatigue-related symptom clusters in older adult hospice patients and discover to what extent fatigue-related symptom clusters predict functional status while controlling for depression.

METHOD

This was a cross-sectional study in a sample of 519 older adult hospice patients with cancer, who completed the Memorial Symptom Assessment Scale, the Center for Epidemiological Studies Depression, Boston Short Form Scale, and the Palliative Performance Scale. Data from a multi-center symptom trial were extracted for this secondary analysis using exploratory factor analysis and hierarchical multiple regression analysis.

RESULTS

Data from 519 patients (78 ± 7 years) with terminal cancer who received hospice care under home healthcare services revealed that 39% of the participants experienced fatigue-related symptom clusters (lack of energy, feeling drowsy, and lack of appetite). The fatigue cluster was significantly associated positively with depression (r = 0.253, p < 0.01), and negatively with functional status (r = -0.117, p < 0.01) and was a strong predictor of participants' low functional status. Furthermore, depression made a significant contribution to this predictive relationship.

CONCLUSION

Older adult hospice patients with cancer experienced various concurrent symptoms. The fatigue-specific symptom cluster was identified significantly associated with depression and predicted functional status. Fatigue should be routinely monitored in older adults, especially among hospice cancer patients, to help reduce psychological distress and prevent functional decline.

The Mutual Effects of Perceived Spiritual Needs on Quality of Life in Patients With Advanced Cancer and Family Caregivers

Perceived spiritual needs may increase when patients with advanced cancer and their family caregivers are confronted with the challenges of physical and psychological distress. Given the intertwined relationships between patients and family caregivers, their interdependence should be considered to understand how perceived spiritual needs affect the quality of life of their own and of their partner. This study used the Actor-Partner Interdependence Model as the conceptual model to investigate the mutual effects of perceived spiritual needs on the quality of life in patients with advanced cancer and their family caregivers after being admitted to hospice. This cross-sectional study used the baseline data of a large clinical trial and identified that patients with cancer and their family caregivers perceived similar spiritual needs associated with the community and outlook needs and had fewer unmet spiritual needs. After controlling for partner effects, perceived outlook needs shown in patients significantly predicted their own functional well-being and social/spiritual well-being. Outlook and community needs perceived by family caregivers also significantly predicted their own mental health. Although partner effects were not shown as expected, the findings provide insight into the mutuality of spirituality and demonstrate the necessity of providing timely and ongoing spiritual assessment and care.

Hospice Care Experiences Among Cancer Patients and Their Caregivers

BACKGROUND

Little is known about the current quality of care for hospice cancer patients and how it varies across hospice programs in the USA.

OBJECTIVE

To examine hospice care experiences among decedents with a primary cancer diagnosis and their family caregivers, comparing quality across settings of hospice care.

DESIGN

We analyzed data from the Consumer Assessment of Healthcare Providers and Systems Hospice Survey (32% response rate). Top-box outcomes (0-100) were calculated overall and by care setting, adjusting for survey mode and patient case mix.

PARTICIPANTS

Two hundred seventeen thousand five hundred ninety-six caregiver respondents whose family member had a primary cancer diagnosis and died in 2017 or 2018 while receiving hospice care from 2,890 hospices nationwide.

MAIN MEASURES

Outcomes (0-100 scale) included 8 National Quality Forum-endorsed quality measures, as well as responses to 4 survey questions assessing whether needs were met for specific symptoms (pain, dyspnea, constipation, anxiety/sadness).

KEY RESULTS

Quality measure scores ranged from 74.9 (Getting Hospice Care Training measure) to 89.5 (Treating Family Member with Respect measure). The overall score for Getting Help for Symptoms was 75.1 with item scores within this measure ranging from 60.6 (getting needed help for feelings of anxiety or sadness) to 84.5 (getting needed help for pain). Measure scores varied significantly across settings and differences were large in magnitude, with caregivers of decedents who received care in a nursing home (NH) or assisted living facility (ALF) setting consistently reporting poorer quality of care.

CONCLUSIONS

Important opportunities exist to improve hospice care for symptom palliation and providing training for caregivers when their family members are at home or in an ALF setting. Efforts to improve care for cancer patients in the NH and ALF setting are especially needed.

Quality of life determinants in older patients with cancer: Results from a French prospective monocenter cohort

OBJECTIVES

The aim of this study is to describe determinants of quality of life (QOL) quoted by vulnerable older patients with cancer and compare them with domains included in cancer-specific QOL questionnaires.

MATERIAL AND METHODS

This prospective, monocenter, observational study was performed in a French university hospital. Cancer patients Patients with cancer aged over 74 years were recruited when referred for an out-patient geriatric evaluation (n = 102). After geriatric assessment, they were invited to respond to open-ended questions, Q1: "For you, what is most important to have a good QOL?" Q2: "What could improve your QOL?" Q3: "What could worsen your QOL?" A Delphi process was conducted to categorize patient responses according to content analysis.

RESULTS

The most frequently patient-reported determinants for high quality of life were maintaining close ties with family/friends or social relations, autonomy for decision and mobility without depending on others, being in good health, not suffering from pain and the absence of problems concerning relatives. Global health status, physical functioning/mobility, social functioning and worries about others were the more frequently mentioned QOL domains related to the EORTC QLQ-C30 and ELD14 questionnaires. Some determinants of QOL were not linked to pre-defined domains, some others without a 100% consensus after the Delphi process, illustrating the subjectivity of QOL analysis by a single practitioner.

CONCLUSION

Patient interview with open-ended questions provides valuable supplementary information to QOL questionnaires, in order to personalize health related (cancer treatment, pain management…) and global (maintenance of autonomy and family/social relations…) assessment and intervention.

Indian Society for Study of Pain, Cancer Pain Special Interest Group Guidelines on Palliative Care Aspects in Cancer Pain Management

The Indian Society for Study of Pain (ISSP), Cancer Pain Special Interest Group guidelines on palliative care aspects in cancer pain in adults provide a structured, stepwise approach which will help to improve the management of cancer pain and to provide the patients with a minimally acceptable quality of life. The guidelines have been developed based on the available literature and evidence, to suit the needs, patient population, and situations in India. A questionnaire based on the key elements of each sub draft addressing certain inconclusive areas where evidence was lacking was made available on the ISSP website and circulated by E-mail to all the ISSP and Indian Association of Palliative Care (IAPC) members. In a cancer care setting, approaches toward managing pain vary between ambulatory setting, home care setting, acute inpatient setting, and end-of-life care in hospice setting. We aim to expound the cancer pain management approaches in these settings. In an ambulatory palliative care setting, the WHO analgesic step ladder is used for cancer pain management. The patients with cancer pain require admission for acute inpatient palliative care unit for poorly controlled pain in ambulatory and home care settings, rapid opioid titration, titration of difficult drugs such as methadone, acute pain crisis, pain neuromodulation, and pain interventions. In a palliative home care setting, the cancer pain is usually assessed and managed by nurses and primary physicians with a limited input from the specialist physicians. In patients with cancer at the end of life, the pain should be assessed at least once a day. Moreover, physicians should be trained in assessing patients with pain who are unable to verbalize or have cognitive impairment.

The Association between ADL Ability and Quality of Life among People with Advanced Cancer

BACKGROUND

Occupational therapy and occupational science are founded on the theoretical core assumption that occupation and quality of life (QoL) are closely related. However, such theoretical core assumptions must be supported through empirically based research.

OBJECTIVE

To investigate the association between QoL and occupation, here self-reported and observed ADL abilities as a part of occupation, among people with advanced cancer, including determining whether self-reported or observed ADL ability had the stronger association with QoL.

METHODS

The study was nested in a cross-sectional study. The association between ADL ability and QoL among 108 people with advanced cancer was investigated using the ADL Interview (ADL-I), the Assessment of Motor and Process Skills (AMPS), and the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC-QLQ-C30).

RESULTS AND CONCLUSIONS

Results showed that high observed ADL motor ability was associated with high QoL. In contrast, observed ADL process ability and self-reported ADL ability were not significantly associated with QoL. Oppositely expected, observed ADL ability had a stronger association with QoL than self-reported ADL ability. Thereby, the study to some extent contributes knowledge confirming the theoretical core assumptions about the relation between occupation, here performance of ADL, and QoL.

The experience of caring for patients at the end-of-life stage in non-palliative care settings: a qualitative study

Background

More patients are dying in non-palliative care settings than in palliative care settings. How health care providers care for adult patients at the end-of-life stage in non-palliative care settings has not been adequately explored. The aim of this study was to explore the experiences of health care providers in caring for patients at the end-of-life stage in non-palliative care settings.

Methods

This is a qualitative study. Twenty-six health care providers from eight health care institutions which are based in Shanghai were interviewed individually between August 2016 and February 2017. Three levels of health care, i.e., acute care, sub-acute care, or primary care, was provided in the health care institutions. The interviews were analyzed using qualitative content analysis.

Results

Three themes emerged from the interviews: (i) Definition of the end-of-life stage: This is mainly defined based on a change in treatment. (ii) Health care at the end-of-life stage: Most patients spent their last weeks in tertiary/secondary hospitals, transferring from one location to another and receiving disease- and symptom-focused treatment. Family-dominated decision making was common when discussing treatment options. Nurses instinctively provided extra care attention to patients, but nursing care is still task-oriented. (iii) Challenges, difficulties, and the future. From the interviews, it was found that pressure from families was the main challenge faced by health care providers. Three urgent tasks before the end-of-life care can become widely available in the future were identified from the interviews, including educating the public on death, extending government support, and creating better health care environment.

Conclusion

The end-of-life care system of the future should involve health care institutions at all levels, with established mechanisms of collaboration between institutions. Care should be delivered to patients with various life-threatening diseases in both palliative and non-palliative care settings. But first, it is necessary to address the obstacles to the development of end-of-life care, which involve health care providers, patients and their families, and the health care system as a whole.

Electronic supplementary material

The online version of this article (10.1186/s12904-018-0372-7) contains supplementary material, which is available to authorized users.

Trajectory of overall health from self-report and factors contributing to health declines among cancer survivors

PURPOSE

This study aims to quantify trajectories of overall health pre- and post-diagnosis of cancer, trajectories of overall health among cancer-free individuals, and factors affecting overall health status.

METHODS

Overall health status, derived from self-rated health report, of Atherosclerosis Risk in Communities cohort participants diagnosed with incident cancer [lung (n = 400), breast (n = 522), prostate (n = 615), colorectal (n = 303)], and cancer-free participants (n = 11,634) over 19 years was examined. Overall health was evaluated in two ways: (1) overall health was assessed until death or follow-up year 19 (survivorship model) and (2) same as survivorship model except that a self-rated health value of zero was used for assessments after death to follow-up year 19 (cohort model). Mean overall health at discrete times was used to generate overall health trajectories. Differences in repeated measures of overall health were assessed using linear growth models.

RESULTS

Overall health trajectories declined dramatically within one-year of cancer diagnosis. Lung, breast, and colorectal cancer were associated with a significant decreased overall health score (β) compared to the cancer-free group (survivorship model: lung-7.00, breast-3.97, colorectal-2.12; cohort model: lung-7.63, breast-5.07, colorectal-2.30). Other predictors of decreased overall health score included low education, diabetes, cardiovascular disease, and age.

CONCLUSIONS

All incident cancer groups had declines in overall health during the first year post-diagnosis, which could be due to cancer diagnosis or intensive treatments. Targeting factors related to overall health declines could improve health outcomes for cancer patients.

Differences in the symptom experience of older oncology outpatients

CONTEXT

The relatively low number of older patients in cancer trials limits knowledge of how older adults experience symptoms associated with cancer and its treatment.

OBJECTIVES

This study evaluated for differences in the symptom experience across four older age groups (60-64, 65-69, 70-74, ≥75 years).

METHODS

Demographic, clinical, and symptom data from 330 patients aged >60 years who participated in one Australian and two U.S. studies were evaluated. The Memorial Symptom Assessment Scale was used to evaluate the occurrence, severity, frequency, and distress of 32 symptoms commonly associated with cancer and its treatment.

RESULTS

On average, regardless of the age group, patients reported 10 concurrent symptoms. The most prevalent symptoms were physical in nature. Worrying was the most common psychological symptom. For 28 (87.5%) of the 32 Memorial Symptom Assessment Scale symptoms, no age-related differences were found in symptom occurrence rates. For symptom severity ratings, an age-related trend was found for difficulty swallowing. As age increased, severity of difficulty swallowing decreased. For symptom frequency, age-related trends were found for feeling irritable and diarrhea, with both decreasing in frequency as age increased. For symptom distress, age-related trends were found for lack of energy, shortness of breath, feeling bloated, and difficulty swallowing. As age increased, these symptoms received lower average distress ratings.

CONCLUSION

Additional research is warranted to examine how age differences in symptom experience are influenced by treatment differences, aging-related changes in biological or psychological processes, or age-related response shift.

Palliative and end-of-life care research: embracing new opportunities

The past two decades have witnessed dramatic advances in palliative and end-of-life care research with increased understanding of the burden of life-limiting diseases on patients, families, clinicians, and our healthcare system; and researchers have documented palliative care interventions that improve patient and family outcomes and reduce the costs of care (Detering, Hancock, Reade, & Silvester, 2010). These advances have led to a new era of palliative and end-of-life care research and practice with widespread recognition of its accomplishments and successes. Consequently, we now have an important opportunity to reassess our recent successes and challenges and to identify the goals and benchmarks that will ensure ongoing robust advances in this now-recognized and critical scientific area. High-quality palliative and end-of-life care will be best informed by methodologically strong research efforts that generate a body of evidence with the capacity to support and direct care and effect changes in practice. It is in this context that the National Institute of Nursing Research conceptualized and led a Summit titled The Science of Compassion: Future Directions in End-of-Life and Palliative Care Research in August, 2011. In this summary article, we present brief overviews of the six articles chosen for this Special Issue of Nursing Outlook, examine their key conclusions, articulate gaps and needs, and discuss next steps in palliative and end-of-life care research through the lens of these six topics.

Pain and symptom management in palliative care and at end of life

The purpose of this review is to provide a literature update of the research published since 2004 on pain and symptom management in palliative care and at end of life. Findings suggest that pain and symptoms are inadequately assessed and managed, even at the end of life. Although not pervasive, there is evidence of racial/ethnic disparities in symptom management in palliative care and at end of life. There is a need for a broader conceptualization and measurement of pain and symptom management as multidimensional experiences. There is insufficient evidence about mechanisms underlying pain at end of life. Although there are advances in the knowledge of pain as a multidimensional experience and the many symptoms that occur sometimes with pain, gaps remain. One approach to addressing the gaps will involve assessment and management of pain and symptoms as multidimensional experiences in people receiving palliative care and at end of life.

Testing the PHQ-9 interview and observational versions (PHQ-9 OV) for MDS 3.0

OBJECTIVES

To test the feasibility and validity of the Patient Health Questionnaire-9 item interview (PHQ-9) and the newly developed Patient Health Questionnaire Observational Version (PHQ-9 OV) for screening for mood disorder in nursing home populations.

METHODS

The PHQ-9 was tested as part of the national Minimum Data Set 3.0 (MDS 3.0) evaluation study among 3822 residents scheduled for MDS 2.0 assessments. Residents from 71 community nursing homes (NHs) in eight states were randomly included in a feasibility sample (n = 3258) and a validation sample (n = 418). Each resident's ability to communicate determined whether the PHQ-9 interview or the PHQ-9 OV was initially attempted. In the validation sample, trained research nurses administered the instruments. For residents in the validation sample without severe cognitive impairment (3 MS ≥30) agreement between PHQ-9 and the modified Schedule for Affective Disorders and Schizophrenia (m-SADS) was measured with weighted kappas (κ). For residents with severe cognitive impairment (3MS <30), agreement between PHQ-9 interview or PHQ-9 OV and the Cornell Scale for Depression in Dementia (Cornell Scale) was measured using correlation coefficients. Staff impressions were obtained from an anonymous survey mailed to all MDS assessors.

RESULTS

The PHQ-9 was completed in 86% of the 3258 residents in the feasibility sample. In the validation sample, the agreement between PHQ-9 and m-SADS was very good (weighted κ = 0.69, 95% CI = 0.61-0.76), whereas agreement between MDS 2.0 and m-SADS was poor (weighted κ = 0.15, 95% CI = 0.06-0.25). Likewise, in residents with severe cognitive impairment, PHQ correlations with the criterion standard Cornell Scale were superior to the MDS 2.0 for both the PHQ-9 (0.63 vs 0.34) and the PHQ-9 OV (0.84 vs 0.28). Eighty-six percent of survey respondents reported that the PHQ-9 provided new insight into residents' mood. The average time for completing the PHQ-9 interview was 4 minutes.

DISCUSSION

Compared with the MDS 2.0 observational items, the PHQ-9 interview had greater agreement with criterion standard diagnostic assessments. For residents who could not complete the interview, the PHQ-9 OV also had greater agreement with a criterion measure for depression than did the MDS 2.0 observational items. Moreover, the majority of NH residents were able to complete the PHQ-9, and most surveyed staff reported improved assessments with the new approach.