Insights into hospitalisation of advanced cancer patients: a study of medical records

A thematic analysis of hospital medical records of patients with advanced illness experiencing incarceration in the last 3 months of life

BACKGROUND

The constraining prison culture is not, for the most part, conducive to the provision of palliative care for people in prison.

AIM

This study aimed to explore patterns of palliative and end-of-life care provision for hospitalised prison patients.

DESIGN

A retrospective qualitative review of hospital medical records to explore the quality of end-of-life care provision for patients experiencing incarceration who died within hospital. Qualitative inductive analysis of record extracts of each patients final 3-months of life was undertaken.

SETTING/PARTICIPANTS

An Australian metropolitan hospital responsible for providing secondary and tertiary health services for people experiencing incarceration. This study included a systematic sample of male patients experiencing incarceration who died in hospital between 2009 and 2019.

RESULTS

Medical record extracts of 15 male patients revealed two broad themes: (1) barriers to equitable access to palliative care for incarcerated hospitalised patients; and (2) factors that facilitated quality end-of-life care for patients and families. Barriers included: tensions between balancing risk and humanity; and limited agency over place and death. Conversely, early recognition of deterioration and anticipated dying provided patients and families opportunity to focus on end-of-life goals.

CONCLUSIONS

Institutional influences of security and control challenged the provision of equitable end-of-life care for people experiencing incarceration. Further research is required to inform, and incorporate, best approaches to identifying patient wishes and advance planning into care within, or despite, the constrains of incarceration. Policy reform and a coordinated, best practice approach to the management of end-of-life care for people experiencing incarceration is needed.

Prognostic decision-making about imminent death within multidisciplinary teams: a scoping review

OBJECTIVE

To summarise evidence on how multidisciplinary team (MDTs) make decisions about identification of imminently dying patients.

DESIGN

Scoping review.

SETTING

Any clinical setting providing care for imminently dying patients, excluding studies conducted solely in acute care settings.

DATA SOURCES

The databases AMED, CINAHL, Embase, MEDLINE, PsychINFO and Web of Science were searched from inception to May 2021.Included studies presented original study data written in English and reported on the process or content of MDT discussions about identifying imminently dying adult patients.

RESULTS

40 studies were included in the review. Studies were primarily conducted using interviews and qualitative analysis of themes.MDT members involved in decision-making were usually doctors and nurses. Some decisions focused on professionals recognising that patients were dying, other decisions focused on initiating specific end-of-life care pathways or clarifying care goals. Most decisions provided evidence for a partial collaborative approach, with information-sharing being more common than joint decision-making. Issues with decision-making included disagreement between staff members and the fact that doctors were often regarded as final or sole decision-makers.

CONCLUSIONS

Prognostic decision-making was often not the main focus of included studies. Based on review findings, research explicitly focusing on MDT prognostication by analysing team discussions is needed. The role of allied and other types of healthcare professionals in prognostication needs further investigation as well. A focus on specialist palliative care settings is also necessary.

Causes of Death and End-of-Life Care in Patients With Intracranial High-Grade Gliomas: A Retrospective Observational Study

BACKGROUND AND OBJECTIVES

To understand patterns of care and circumstances surrounding end of life in patients with intracranial gliomas.

METHODS

We retrospectively analyzed end-of-life circumstances in patients with intracranial high-grade gliomas at Columbia University Irving Medical Center who died from January 2014 through February 2019, including cause of death, location of death, and implementation of comfort measures and resuscitative efforts.

RESULTS

There were 152 patients (95 men, 57 women; median age at death 61.5 years, range 24-87 years) who died from 1/2014-2/2019 with adequate data surrounding end-of-life circumstances. Clinical tumor progression (n=117, 77.0%) was the most common cause of death with all patients transitioned to comfort measures. Other causes included, but were not limited to, infection (19, 12.5%); intratumoral hemorrhage (5, 3.3%); seizures (8, 5.3%); cerebral edema (4, 2.6%); pulmonary embolism (4, 2.6%); autonomic failure (2, 1.3%); and hemorrhagic shock (2, 1.3%). Multiple mortal events were identified in 10 (8.5%). Seventy-three patients (48.0%) died at home with hospice. Other locations were inpatient hospice (40, 26.3%); acute care hospital (34, 22.4%) including 27 (17.8%) with and 7 (4.6%) without comfort measures; skilled nursing facility (4, 3.3%) including 3 (2.0%) with and 1 (0.7%) without comfort measures; or religious facility (1, 0.7%) with comfort measures. Acute cardiac and/or pulmonary resuscitation was performed in 20 patients (13.2%).

DISCUSSION

Clinical tumor progression was the most common (77.0%) cause of death followed by infection (12.5%). Hospice or comfort measures were ultimately implemented in 94.7% of patients, though resuscitation was performed in 13.2%. Improved understanding of circumstances surrounding death, frequency of use of hospice services, and frequency of resuscitative efforts in patients with gliomas may allow physicians to more accurately discuss end-of-life expectations with patients and caregivers, facilitating informed care planning.

Decision-Making about the Place of Death for Cancer Patients: A Concept Analysis

Objective:

The objective of the study was to conduct a concept analysis of “decision-making about the place of death for cancer patients” to develop a theoretical definition of the concept and identify its attributes, antecedents, and outcomes.

Methods:

The Rodgers' evolutionary model of concept analysis was used. A literature search for papers published from 2000 to 2017 was conducted using the keywords: “cancer,” “place,” “death,” and “decision-making” for the search of the electronic databases.

Results:

Thirty articles were selected for this analysis. As a result, five attributes, six antecedents, and five consequences were extracted. [options to choose as a place of death], [wishes of the patients themselves], [consideration of the burden on the family], [open discussions with other persons concerned], and [best choice according to circumstances] are considered to be the characteristics in the decision-making about the place of death for cancer patients.

Conclusions:

This concept is defined as “The best choice according to circumstances of the cancer patients among different options for a place of death, resulting from a careful evaluation of the wishes of these patients and the burden on the family, as well as through open discussions with other persons concerned.” Nurses need to assist patients discuss deaths with important others, such as family members, in making decisions about the place of death. Further studies are necessary to elucidate the details of the categories and relationships shown in the attributes in this study, investigating the actual conditions of the patients and their families.

Utilising Media and Text-Based Sources

An often-underestimated, valuable source of naturally occurring data is that of media sources, such as television programmes, documentaries, newspapers, and magazines. Often in traditional textbooks these are positioned as secondary sources. We argue that they can be considered primary data, as well as naturally occurring data. This type of naturally occurring data is of interest for qualitative research, and in this chapter, we focus on the use of policy documents, medical notes, health guidelines, as well as other data sources such as police transcripts, court transcripts, and social care reports whereby health is invoked, to illustrate the value of analysing texts that occur naturally in the field of health.

High Degree of Satisfaction With the Support Given by Multidisciplinary Palliative Home Care Teams in the County of Stockholm

Objective:

At the initiative of Stockholm County Council, a survey was performed by an independent investigator to evaluate satisfaction among patients and their families with the advanced palliative home care teams in the county of Stockholm. The survey was performed in 2010 and compiled in 2011. The aim was to evaluate the impressions of patients and their families of the support given by the palliative home care teams in the Stockholm area and to evaluate the management of symptom control, availability, continuity, confidence, and quality of communication.

Methods:

A questionnaire was sent to 1424 patients and 329 family members to evaluate the views of the users of the home care service.

Results:

The response rate was 78% among both patients and their families or other caregivers. The proportion of positive and very positive responses among those who needed the specific help of the team was as follows: information about the service 86%, availability around the clock 96%, influence and feeling of shared responsibility 88%, and possibility of family members to have supportive discussions 95%. Eighty-three percent of patients experienced total pain relief and 99% total or partial relief. The corresponding figures for anxiety were 77% and 97% and for other symptom reliefs 79% and 98%, respectively. These figures were comparable to a smaller survey in 2014 and were high compared to the results from other medical services using similar questionnaires.

Significance of the Results:

A high quality of care is possible to achieve within palliative home care services.

Frequency and Predictors of Acute Hospitalization Before Death in Patients With Glioblastoma

CONTEXT

Glioblastoma (GBM) is a devastating and incurable neuro-oncologic disease, and issues related to the end of life are almost invariably a matter of "when," not a matter of "if." Optimizing symptom management and quality of life in later stages of disease is of the utmost priority.

OBJECTIVES

To examine the frequency of and factors associated with late acute hospital admission before death in patients with GBM.

METHODS

Case-control study comparing patients with GBM admitted to the hospital within one month of death to those without late hospital admission.

RESULTS

Of 385 GBM patients followed to death at Memorial Sloan Kettering Cancer Center, 164 (42.6%) were admitted within a month of death, most frequently (140, or 85%) to manage neurologic decline. Of these, 56 (34%) had intensive care unit care during this admission and 22 (13%), 18 (11%), and 2 (1%) received mechanical ventilation, enteral feeding tubes, or cardiopulmonary resuscitation, respectively. In multivariable analysis, in-hospital chaplaincy consultation, and participation in a therapeutic clinical trial, both at any time in the GBM disease course, were significantly associated with late hospital admission.

CONCLUSIONS

Late hospitalization is frequent in GBM and often involves intensive care unit care in the management of clinical events that are part of the GBM dying process. Patients with a tendency to use religious support and those enrolled in clinical trials may be at greater risk for late hospitalization. Dedicated prospective study is needed to determine predictors of late hospitalization and to examine the impact of late acute medical care on quality of life in GBM.