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Spear S, Little E, Tapp A, Nancarrow C, Morey Y, Warren S, Verne J. Attitudes towards advance care planning amongst community-based older people in England. PLoS One 2024; 19:e0306810. [PMID: 39167589 PMCID: PMC11338439 DOI: 10.1371/journal.pone.0306810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 06/24/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND Advance care planning has been advocated as a way for people to have their wishes recorded and respected in relation to types of treatment and place of care. However, uptake in England remains low. AIMS To examine the views of older, well, adults towards Advance Care Plans (ACPs) and planning for end-of-life care, in order to inform national policy decisions. METHODS A mixed methods approach was adopted, involving individual and mini-group qualitative interviews (n = 76, ages 45-85), followed by a quantitative survey (n = 2294, age 55+). The quantitative sample was based on quotas in age, gender, region, socio-economic grade, and ethnicity, combined with light weighting to ensure the findings were representative of England. RESULTS Knowledge and understanding of advance care planning was low, with only 1% of survey respondents reporting they had completed an ACP for themselves. Common reasons for not putting wishes into writing were not wanting/needing to think about it now, the unpredictability of the future, trusting family/friends to make decisions, and financial resources limiting real choice. CONCLUSION Whilst advance care planning is seen as a good idea in theory by older, well, adults living in the community, there is considerable reticence in practice. This raises questions over the current, national policy position in England, on the importance of written ACPs. We propose that policy should instead focus on encouraging ongoing conversations between individuals and all those (potentially) involved in their care, about what is important to them, and on ensuring there are adequate resources in community networks and health and social care systems, to be responsive to changing needs.
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Affiliation(s)
- Sara Spear
- Faculty of Business and Law, St Mary’s University, London, England
- Bristol Business School, University of the West of England, Bristol, England
| | - Ed Little
- Bristol Business School, University of the West of England, Bristol, England
| | - Alan Tapp
- Bristol Business School, University of the West of England, Bristol, England
| | - Clive Nancarrow
- Bristol Business School, University of the West of England, Bristol, England
| | - Yvette Morey
- Bristol Business School, University of the West of England, Bristol, England
| | - Stella Warren
- Bristol Business School, University of the West of England, Bristol, England
| | - Julia Verne
- OHID, Department for Health and Social Care, London, England
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Bradshaw A, Birtwistle J, Evans CJ, Sleeman KE, Richards S, Foy R, Millares Martin P, Carder P, Allsop MJ, Twiddy M. Factors Influencing the Implementation of Digital Advance Care Planning: Qualitative Interview Study. J Med Internet Res 2024; 26:e50217. [PMID: 39151167 PMCID: PMC11364948 DOI: 10.2196/50217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/18/2023] [Accepted: 05/30/2024] [Indexed: 08/18/2024] Open
Abstract
BACKGROUND Palliative care aims to improve the quality of life for people with life-limiting illnesses. Advance care planning conversations that establish a patient's wishes and preferences for care are part of a person-centered approach. Internationally, electronic health record systems are digital interventions used to record and share patients' advance care plans across health care services and settings. They aim to provide tools that support electronic information sharing and care coordination. Within the United Kingdom, Electronic Palliative Care Coordination Systems (EPaCCS) are an example of this. Despite over a decade of policy promoting EPaCCS nationally, there has been limited implementation and consistently low levels of use by health professionals. OBJECTIVE The aim of this study is to explore the factors that influence the implementation of EPaCCS into routine clinical practice across different care services and settings in 2 major regions of England. METHODS A qualitative interview study design was used, guided by Normalization Process Theory (NPT). NPT explores factors affecting the implementation of complex interventions and consists of 4 primary components (coherence, cognitive participation, collective action, and reflexive monitoring). Health care and social care practitioners were purposively sampled based on their professional role and work setting. Individual web-based semistructured interviews were conducted. Data were analyzed using thematic framework analysis to explore issues which affected the implementation of EPaCCS across different settings at individual, team, organizational, and technical levels. RESULTS Participants (N=52) representing a range of professional roles were recruited across 6 care settings (hospice, primary care, care home, hospital, ambulatory, and community). In total, 6 themes were developed which mapped onto the 4 primary components of NPT and represented the multilevel influences affecting implementation. At an individual level, these included (1) EPaCCS providing a clear and distinct way of working and (2) collective contributions and buy-in. At a team and organizational level, these included (3) embedding EPaCCS into everyday practice and (4) championing driving implementation. At a technical level, these included (5) electronic functionality, interoperability, and access. Breakdowns in implementation at different levels led to variations in (6) confidence and trust in EPaCCS in terms of record accuracy and availability of access. CONCLUSIONS EPaCCS implementation is influenced by individual, organizational, and technical factors. Key challenges include problems with access alongside inconsistent use and engagement across care settings. EPaCCS, in their current format as digital advance care planning systems are not consistently facilitating electronic information sharing and care coordination. A redesign of EPaCCS is likely to be necessary to determine configurations for their optimal implementation across different settings and locations. This includes supporting health care practitioners to document, access, use, and share information across multiple care settings. Lessons learned are relevant to other forms of digital advance care planning approaches being developed internationally.
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Affiliation(s)
- Andy Bradshaw
- Cicely Saunders Institute, Kings College London, London, United Kingdom
| | | | - Catherine J Evans
- Cicely Saunders Institute, Kings College London, London, United Kingdom
- Sussex Community NHS Foundation Trust, Brighton, United Kingdom
| | | | - Suzanne Richards
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | | | - Paul Carder
- NHS West Yorkshire Integrated Care Board, White Rose House, Wakefield, United Kingdom
| | - Matthew J Allsop
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Maureen Twiddy
- Hull York Medical School, Institute of Clinical and Applied Health Research, Allam Medical Building, University of Hull, Hull, United Kingdom
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Wilson E, Baker A, Stockley L, Allgar V, Richfield E. Place of death in Parkinson's disease and related disorders in England and Wales: post-pandemic trends and implications for care planning. Age Ageing 2024; 53:afae048. [PMID: 38497239 DOI: 10.1093/ageing/afae048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND With growing emphasis on palliative care for neurodegenerative conditions, understanding trends in place of death helps improve quality of end-of-life care for people with Parkinson's disease and related disorders (PDRDs), focusing allocation of resources and training and identifying inequalities. OBJECTIVES Review national and regional place of death trends for people with PDRD including pre- and post-pandemic trends. METHODS Mortality data for England and Wales (March 2018 and July 2022) were analysed with summary statistics and interrupted time series, exploring place of death for those who died with PDRD, with and without coexisting dementia, with reference to all deaths in England and Wales. RESULTS Of 2,415,566 adult deaths, 56,790 included mention of PDRD. Hospital deaths were most common in people with PDRD (39.17%), followed by care homes (38.84%). People with PDRD were half as likely to die in hospice compared with the general population (2.03 vs 4.94%). Proportion of care home deaths fell significantly after March 2020 (40.6-37%, P = 0.035). Regionally, London was an outlier with a lower proportion of deaths occurring in care homes with a higher proportion of hospital deaths. CONCLUSION Place of death for people with PDRD is changing, with more hospice and home deaths. People with PDRD, particularly those with co-existent dementia, are less likely to access inpatient hospice care than the general population. Since the COVID-19 pandemic, the proportion of care home deaths has reduced significantly with an increase in home deaths, with implications for service and resource allocation.
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Affiliation(s)
- Elisabeth Wilson
- Medicine for Older People, North Bristol NHS Trust, Bristol BS105NB, UK
| | - Amy Baker
- Medical Statistics Group, Peninsula Medical School, University of Plymouth, Plymouth Science Park, Plymouth PL6 8BX, UK
| | - Lauren Stockley
- Medical Statistics Group, Peninsula Medical School, University of Plymouth, Plymouth Science Park, Plymouth PL6 8BX, UK
| | - Victoria Allgar
- Medical Statistics Group, Peninsula Medical School, University of Plymouth, Plymouth Science Park, Plymouth PL6 8BX, UK
| | - Edward Richfield
- Medicine for Older People, North Bristol NHS Trust, Bristol BS105NB, UK
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Li W, Qureshi D, Rhodes E, Imsirovic H, Isenberg SR, Tanuseputro P. Place of Death and Place of Care at the End of Life: Are They Correlated? A Retrospective Cohort Study of Ontario Decedents. J Palliat Med 2024; 27:224-230. [PMID: 37967408 DOI: 10.1089/jpm.2023.0167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
Background: Dying in nonpalliative acute care is generally considered inappropriate and avoidable. Place of death, a commonly reported big-dot indicator of end-of-life care quality, is often used as a proxy for place of care despite no empirical evidence for their correlations. Thus, we examined the correlations between place of death and place of care in the last month of life. We also investigated anecdotal claims that individuals cared in acute care often get discharged to die at home, and vice versa. Methods: We conducted a retrospective cohort study of Ontario decedents (18+) who died between January 1, 2015 and December 31, 2017. We identified individuals who died in nonpalliative acute care, palliative care unit, subacute care, long-term care (LTC), and the community. We calculated the number of days decedents spent in each setting in their last month of life, and used descriptive analyses to investigate their correlations. Results: Decedent's place of death generally correlated with their place of care in the last month of life-individuals who died in a particular setting spent more time in that setting than individuals who died elsewhere. Furthermore, 75.0% of individuals who spent more than two weeks of their last month in acute care died in acute care. Among individuals who died in the community and in LTC, 65.4% and 75.0%, respectively, spent zero days in acute care. Interpretation: We showed that place of death can be a useful high-level performance indicator, by itself and as a proxy for place of care, to gauge end-of-life quality and service provision/implementation.
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Affiliation(s)
- Wenshan Li
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Danial Qureshi
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Emily Rhodes
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Haris Imsirovic
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES uOttawa, Ottawa, Ontario, Canada
| | - Sarina R Isenberg
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Wang J, Shand J, Gomes M. End-of-life care costs and place of death across health and social care sectors. BMJ Support Palliat Care 2023:spcare-2023-004356. [PMID: 37673471 DOI: 10.1136/spcare-2023-004356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/21/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVES This study explores the relationship between end-of-life care costs and place of death across different health and social care sectors. METHODS We used a linked local government and health data of East London residents (n=4661) aged 50 or over, deceased between 2016 and 2020. Individuals who died in hospital were matched to those who died elsewhere according to a wide range of demographic, socioeconomic and health factors. We reported mean healthcare costs and 95% CIs by care sectors over the 12-month period before death. Subgroup analyses were conducted to investigate if the role of place of death differs according to long-term conditions and age. RESULTS We found that mean difference in total cost between hospital and non-hospital decedents was £4565 (95% CI £3132 to £6046). Hospital decedents were associated with higher hospital cost (£5196, £4499 to £5905), higher mental healthcare cost (£283, £78 to £892) and lower social care cost (-£838, -£1,209 to -£472), compared with individuals who died elsewhere. Subgroup analysis shows that the association between place of death and healthcare costs differs by age and long-term conditions, including cancer, mental health and cardiovascular diseases. CONCLUSION This study suggests that trajectories of end-of-life healthcare costs vary by place of death in a differential way across health and social care sectors. High hospital burden for cancer patients may be alleviated by strengthening healthcare provision in less cost-intensive settings, such as community and social care.
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Affiliation(s)
- Jiunn Wang
- Department of Applied Health Research, University College London, London, UK
| | - Jenny Shand
- UCLPartners, London, UK
- Department of Clinical, Education and Health Psychology, University College London, London, UK
| | - Manuel Gomes
- Department of Applied Health Research, University College London, London, UK
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Kramer NM, Besbris J, Hudoba C. Education in neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:259-272. [PMID: 36599512 DOI: 10.1016/b978-0-12-824535-4.00006-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The importance and value of providing palliative care for patients with neurologic disease is increasingly recognized. While palliative and neuropalliative specialists may be well-positioned to provide this care, there is a shortage of specialists to address these needs. As a result, much of the upfront palliative care will naturally be provided by the treating neurologist. It is imperative that all neurologists receive quality training in primary palliative care skills. As the subspecialty of neuropalliative care grows, the need for specialty neuropalliative education has arisen. This chapter reviews existing educational initiatives and common neuropalliative-oriented career tracks and identifies opportunities for growth along the continuum of medical education and beyond.
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Affiliation(s)
- Neha M Kramer
- Department of Internal Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago, IL, United States; Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States.
| | - Jessica Besbris
- Departments of Neurology and Supportive Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Christine Hudoba
- Department of Internal Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago, IL, United States
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Korfage IJ, Polinder S, Preston N, van Delden JJ, Geraerds SAJ, Dunleavy L, Faes K, Miccinesi G, Carreras G, Moeller Arnfeldt C, Kars MC, Lippi G, Lunder U, Mateus C, Pollock K, Deliens L, Groenvold M, van der Heide A, Rietjens JA. Healthcare use and healthcare costs for patients with advanced cancer; the international ACTION cluster-randomised trial on advance care planning. Palliat Med 2022; 37:707-718. [PMID: 36515362 DOI: 10.1177/02692163221142950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Advance care planning supports patients to reflect on and discuss preferences for future treatment and care. Studies of the impact of advance care planning on healthcare use and healthcare costs are scarce. AIM To determine the impact on healthcare use and costs of an advance care planning intervention across six European countries. DESIGN Cluster-randomised trial, registered as ISRCTN63110516, of advance care planning conversations supported by certified facilitators. SETTING/PARTICIPANTS Patients with advanced lung or colorectal cancer from 23 hospitals in Belgium, Denmark, Italy, the Netherlands, Slovenia and the UK. Data on healthcare use were collected from hospital medical files during 12 months after inclusion. RESULTS Patients with a good performance status were underrepresented in the intervention group (p< 0.001). Intervention and control patients spent on average 9 versus 8 days in hospital (p = 0.07) and the average number of X-rays was 1.9 in both groups. Fewer intervention than control patients received systemic cancer treatment; 79% versus 89%, respectively (p< 0.001). Total average costs of hospital care during 12 months follow-up were €32,700 for intervention versus €40,700 for control patients (p = 0.04 with bootstrap analyses). Multivariable multilevel models showed that lower average costs of care in the intervention group related to differences between study groups in country, religion and WHO-status. No effect of the intervention on differences in costs between study groups was observed (p = 0.3). CONCLUSIONS Lower care costs as observed in the intervention group were mainly related to patients' characteristics. A definite impact of the intervention itself could not be established.
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Affiliation(s)
- Ida J Korfage
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nancy Preston
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - Johannes Jm van Delden
- Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Sandra A Jlm Geraerds
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lesley Dunleavy
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - Kristof Faes
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Guido Miccinesi
- Clinical Epidemiology, Oncological network, prevention and research Institute (ISPRO), Florence, Italy
| | - Giulia Carreras
- Clinical Epidemiology, Oncological network, prevention and research Institute (ISPRO), Florence, Italy
| | - Caroline Moeller Arnfeldt
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Palliative Medicine, The Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | - Marijke C Kars
- Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | | | - Urska Lunder
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Ceu Mateus
- Division of Health Research, Lancaster University, Lancaster, UK
| | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Mogens Groenvold
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Palliative Medicine, The Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Judith Ac Rietjens
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Owen L, Steel A, Goffe K, Pleming J, Sampson EL. A multidisciplinary simulation programme to improve advance care planning skills and engagement across primary and secondary care. Clin Med (Lond) 2022; 22:51-57. [PMID: 35078794 PMCID: PMC8813010 DOI: 10.7861/clinmed.2021-0240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND In the context of an ageing population, many healthcare professionals have limited experience and confidence in having necessary advance care planning (ACP) conversations. METHODS We conducted nine half-day simulation sessions, using professional actors. One-hundred and thirty-two participants attended from multidisciplinary backgrounds across primary and secondary care. RESULTS Following the course, 90.2% felt confident or very confident initiating conversations, compared with 14.4% beforehand. Understanding of when ACP is appropriate also increased from 70% to 100%. Post-course, 98% of participants stated that they would be more likely to initiate an ACP. Three months later, 86% had a sustained change in practice. All participants said they would recommend this simulation course and multidisciplinary approach. CONCLUSION Multidisciplinary simulation training is an effective way to teach ACP to doctors, nurses and allied healthcare professionals. The simulation was shown to improve participant understanding, confidence and reduce barriers to discussions, both immediately and 3 months later.
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Affiliation(s)
| | | | | | - Joanna Pleming
- , stroke and general internal medicine, Barnet Hospital, London, UK
| | - Elizabeth L Sampson
- consultant liaison psychiatrist, North Middlesex University Hospital, London, UK and clinical professor in dementia and palliative care, University College London, London, UK
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Allsop MJ, Chumbley K, Birtwistle J, Bennett MI, Pocock L. Building on sand: digital technologies for care coordination and advance care planning. BMJ Support Palliat Care 2021; 12:194-197. [PMID: 34876456 DOI: 10.1136/bmjspcare-2021-003304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/21/2021] [Indexed: 11/03/2022]
Abstract
Approaches using digital technologies to support advance care planning (ACP) and care coordination are being used in palliative and end of life care. While providing opportunities to facilitate increases in the completeness, sharing and availability of care plans, the evidence base underpinning their use remains limited. We outline an approach that continues to be developed in England; Electronic Palliative Care Coordination Systems (EPaCCS). Stages governing their optimal use are outlined alongside unanswered questions with relevance across technology-mediated approaches to ACP. Research has a critical role in determining if technology-mediated approaches to ACP, such as EPaCCS, could be useful tools to support the delivery of care for patients with chronic and progressive illnesses.
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Affiliation(s)
- Matthew John Allsop
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Karen Chumbley
- North East Essex Health and Wellbeing Alliance, Colchester, UK
| | - Jacqueline Birtwistle
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Lucy Pocock
- Centre for Academic Primary Care, University of Bristol Medical School, Bristol, UK
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Nicholas R, Nicholas E, Hannides M, Gautam V, Friede T, Koffman J. Influence of individual, illness and environmental factors on place of death among people with neurodegenerative diseases: a retrospective, observational, comparative cohort study. BMJ Support Palliat Care 2021:bmjspcare-2021-003105. [PMID: 34489324 DOI: 10.1136/bmjspcare-2021-003105] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/11/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND In long-term neurological conditions, location of death is poorly understood but is seen as a marker of quality of dying. OBJECTIVE To examine individual, illness and environmental factors on place of death among people with multiple sclerosis (MS) and Parkinson's disease (PD) in isolation or in combination and compare them with people without either condition. METHODS Retrospective, observational, comparative cohort study of 582 people with MS, 579 people with PD and 95 controls from UK Multiple Sclerosis and Parkinson's Disease Tissue Bank. A subset of people with MS and PD were selected for analysis of individual clinical encounters 2 years before death and further subset of all groups for analysis of impact of advance care planning (ACP) and recognition of dying. RESULTS People with MS died more often (50.8%) in hospital than those with PD (35.3%). Examining individual clinical encounters over 2 years (4931 encounters) identified increased contact with services 12 months before death (F(1, 58)=69.71, p<0.0001) but was not associated with non-hospital deaths (F(1, 58)=1.001, p=0.321). The presence of ACPs and recognition of dying were high among people with MS and PD and both associated with a non-hospital death. ACPs were more likely to prevent hospital deaths when initiated by general practitioners (GPs) compared with other professional groups (χ2=68.77, p=0.0007). CONCLUSIONS For people with MS and PD, ACPs contribute to reducing dying in hospital. ACPs appear to be most effective when facilitated by GPs underlining the importance of primary care involvement in delivering holistic care at the end of life.
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Affiliation(s)
- Richard Nicholas
- UK Multiple Sclerosis Tissue Bank, Imperial College London, London, UK
| | - Emma Nicholas
- UK Multiple Sclerosis Tissue Bank, Imperial College London, London, UK
| | - Mike Hannides
- UK Multiple Sclerosis Tissue Bank, Imperial College London, London, UK
| | - Vishal Gautam
- UK Multiple Sclerosis Tissue Bank, Imperial College London, London, UK
| | - Tim Friede
- Department of Medical Statistics, University Medical Center, University of Göttingen, Göttingen, Germany
| | - Jonathan Koffman
- Department of Palliative Care, Policy and Rehabiltation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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11
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Efstathiou N, Lock A, Ahmed S, Parkes L, Davies T, Law S. A realist evaluation of a "single point of contact" end-of-life care service. J Health Organ Manag 2021; ahead-of-print. [PMID: 32436670 DOI: 10.1108/jhom-07-2019-0218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Following the development of a service that consisted of a "single point of contact" to coordinate end-of-life care (EoLC), including EoLC facilitators and an urgent response team, we aimed to explore whether the provision of coordinated EoLC would support patients being cared or dying in their preferred place and avoid unwanted hospital admissions. DESIGN/METHODOLOGY/APPROACH Using a realist evaluation approach, the authors examined "what worked for whom, how, in what circumstances and why". Multiple data were collected, including activity/performance indicators, observations of management meetings, documents, satisfaction survey and 30 interviews with service providers and users. FINDINGS Advance care planning (ACP) increased through the first three years of the service (from 45% to 83%) and on average 74% of patients achieved preferred place of death. More than 70% of patients avoided an emergency or unplanned hospital admission in their last month of life. The mechanisms and context identified as driving forces of the service included: 7/7 single point of contact; coordinating services across providers; recruiting and developing the workforce; understanding and clarifying new roles; and managing expectations. RESEARCH LIMITATIONS/IMPLICATIONS This was a service evaluation and the outcomes are related to the specific context and mechanisms. However, findings can be transferable to similar settings. PRACTICAL IMPLICATIONS "Single point of contact" services that offer coordinated EoLC can contribute in supporting people to be cared and die in their preferred place. ORIGINALITY/VALUE This paper provides an evaluation of a novel approach to EoLC and creates a set of hypotheses that could be further tested in similar services in the future.
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Affiliation(s)
- Nikolaos Efstathiou
- School of Nursing, College of Medical and Dental Sciences, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Anna Lock
- Connected Palliative Care, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Suha Ahmed
- Connected Palliative Care, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Linda Parkes
- Connected Palliative Care, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Tammy Davies
- Connected Palliative Care, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Susan Law
- Connected Palliative Care, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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Bauer A, Dixon J, Knapp M, Wittenberg R. Exploring the cost-effectiveness of advance care planning (by taking a family carer perspective): Findings of an economic modelling study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2021; 29:967-981. [PMID: 32783319 DOI: 10.1111/hsc.13131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/15/2020] [Accepted: 07/21/2020] [Indexed: 06/11/2023]
Abstract
Advance care planning is considered an important part of high-quality end-of-life care. Its cost-effectiveness is currently unknown. In this study, we explore the cost-effectiveness of a strategy, in which advance care planning is offered systematically to older people at the end-of-life compared with standard care. We conducted decision-analytic modelling. The perspective was health and social care and the time horizon was 1 year. Outcomes included were quality-adjusted life years as they referred to the surviving carers. Data sources included published studies, national statistics and expert views. Average total cost in the advance care planning versus standard care group was £3,739 versus £3,069. The quality-adjusted life year gain to carers was 0.03 for the intervention in comparison with the standard care group. Based on carer's health-related quality-of-life, the average cost per quality-adjusted life year was £18,965. The probability that the intervention was cost-effective was 55% (70%) at a cost per quality-adjusted life year threshold of £20,000 (£30,000). Conducting cost-effectiveness analysis for advance care planning is challenging due to uncertainties in practice and research, such as a lack of agreement on how advance care planning should be provided and by whom (which influences its costs), and about relevant beneficiary groups (which influences its outcomes). However, even when assuming relatively high costs for the delivery of advance care planning and only one beneficiary group, namely, family carers, our analysis showed that advance care planning was probably cost-effective.
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Affiliation(s)
- Annette Bauer
- Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, London, UK
| | - Josie Dixon
- Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, London, UK
| | - Martin Knapp
- Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, London, UK
| | - Raphael Wittenberg
- Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, London, UK
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Kelly M, O'Brien KM, Hannigan A. Using administrative health data for palliative and end of life care research in Ireland: potential and challenges. HRB Open Res 2021; 4:17. [PMID: 33842831 PMCID: PMC8014706 DOI: 10.12688/hrbopenres.13215.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 11/20/2022] Open
Abstract
Background: This study aims to examine the potential of currently available administrative health and social care data for palliative and end-of-life care (PEoLC) research in Ireland. Objectives include to i) identify data sources for PEoLC research ii) describe the challenges and opportunities of using these and iii) evaluate the impact of recent health system reforms and changes to data protection laws. Methods: The 2017 Health Information and Quality Authority catalogue of health and social care datasets was cross-referenced with a recognised list of diseases with associated palliative care needs. Criteria to assess the datasets included population coverage, data collected, data dictionary and data model availability, and mechanisms for data access. Results: Nine datasets with potential for PEoLC research were identified, including death certificate data, hospital episode data, pharmacy claims data, one national survey, four disease registries (cancer, cystic fibrosis, motor neurone and interstitial lung disease) and a national renal transplant registry. The
ad hoc development of the health system in Ireland has resulted in i) a fragmented information infrastructure resulting in gaps in data collections particularly in the primary and community care sector where much palliative care is delivered, ii) ill-defined data governance arrangements across service providers, many of whom are not part of the publically funded health service and iii) systemic and temporal issues that affect data quality. Initiatives to improve data collections include introduction of i) patient unique identifiers, ii) health entity identifiers and iii) integration of the Eircode postcodes. Recently enacted general data protection and health research regulations will clarify legal and ethical requirements for data use. Conclusions: Ongoing reform initiatives and recent changes to data privacy laws combined with detailed knowledge of the datasets, appropriate permissions, and good study design will facilitate future use of administrative health and social care data for PEoLC research in Ireland.
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Affiliation(s)
- Maria Kelly
- National Cancer Registry Ireland, Building 6800, Cork Airport Business Park Kinsale Road, Cork, T12 CDF7, Ireland.,School of Medicine, University of Limerick, Limerick, V94 T9PX, Ireland
| | - Katie M O'Brien
- National Cancer Registry Ireland, Building 6800, Cork Airport Business Park Kinsale Road, Cork, T12 CDF7, Ireland.,Department of Health, Block 1 Miesian Plaza, 50 - 58 Lower Baggot Street, Dublin, D02 XW14, Ireland
| | - Ailish Hannigan
- School of Medicine, University of Limerick, Limerick, V94 T9PX, Ireland.,Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland
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Nnate DA. Treatment withdrawal of the patient on end of life: An analysis of values, ethics and guidelines in palliative care. Nurs Open 2021; 8:1023-1029. [PMID: 33569923 PMCID: PMC8046138 DOI: 10.1002/nop2.777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 01/07/2021] [Accepted: 01/21/2021] [Indexed: 11/07/2022] Open
Abstract
AIM Family surrogate decision-making during the later stage of a patient's life may sometimes result in conflict and emotional distress among the parties involved. The present article aims to promote ethical end-of-life decision-making among healthcare professionals in a view to eliminating any misunderstanding that may arise while meeting the care needs of the patient. DESIGN A case study involving a request for treatment withdrawal by the family of a patient on end of life. METHODS This paper draws upon a scenario encountered during practice to analyse the moral commitments in delivering high-quality end-of-life care with much emphasis on pre-existing palliative care guidelines for adults. RESULTS Healthcare professionals are bound by the principle of beneficence, non-maleficence, autonomy and justice. Although the use of guidelines may be tenable, decisions often take into consideration the patient's choice and then weighed against the moral values of healthcare specialists and those required in the profession.
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Affiliation(s)
- Daniel A. Nnate
- Nursing and Community HealthSchool of Health and Life SciencesGlasgow Caledonian UniversityGlasgowUK
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15
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Rozman LM, Campolina AG, Patiño EG, de Soárez PC. Factors Associated with the Costs of Palliative Care: A Retrospective Cost Analysis at a University Cancer Hospital in Brazil. J Palliat Med 2021; 24:1481-1488. [PMID: 33656925 DOI: 10.1089/jpm.2020.0600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: There have been few studies evaluating the costs of palliative care (PC) in low- and middle-income countries (LMICs), especially for patients with cancer. Objectives: The objective of this study was to identify the sociodemographic and clinical variables that could explain the cost per day of PC for cancer in Brazil. Methods: This was a retrospective cost analysis of PC at a quaternary cancer center in São Paulo, Brazil, between January 2010 and December 2013. Factors influencing the cost per day were assessed with generalized linear models and generalized linear-mixed models in which the random effect was the site of the cancer. Results: The study included 2985 patients. The mean total cost per patient was $12,335 (standard deviation [SD] = 14,602; 95% confidence interval [CI] = 11,803 to 12,851). The mean cost per day per patient was $325.50 (SD = 246.30, 95% CI = 316.60 to 334.30). There were statistically significant differences among cancer sites in terms of the mean cost per day. Multivariate analysis revealed that the drivers of cost per day were Karnofsky performance status, the number of hospital admissions, referral to PC, and place of death. Place of death had the greatest impact on the cost per day; death in a hospital and in hospice care increased the mean cost per day by $1.56 and $1.83, respectively. Conclusion: To allocate resources effectively, PC centers in LMICs should emphasize early enrollment of patients at PC outpatient clinics, to avoid hospital readmission, as well as advance planning of the place of death.
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Affiliation(s)
- Luciana Martins Rozman
- Department of Preventive Medicine, University of São Paulo School of Medicine, São Paulo, Brazil
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16
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Cross SH, Kaufman BG, Quest TE, Warraich HJ. National Trends in Hospice Facility Deaths in the United States, 2003-2017. J Pain Symptom Manage 2021; 61:350-357. [PMID: 32858165 DOI: 10.1016/j.jpainsymman.2020.08.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 11/16/2022]
Abstract
CONTEXT Hospice facilities are increasingly preferred as a location of death, but little is known about the characteristics of patients who die in these facilities in the U.S. OBJECTIVES We sought to examine the trends and factors associated with death in a hospice facility. METHODS Retrospective cross-sectional study using mortality data for years 2003-2017 for deaths attributed to natural causes in the U.S. RESULTS The proportion of natural deaths occurring in hospice facilities increased from 0.2% in 2003 to 8.3% in 2017, resulting in nearly 1.7 million deaths during this time frame. Females had increased odds of hospice facility deaths (odds ratio [OR] = 1.04; 95% CI = 1.04, 1.05). Nonwhite race was associated with lower odds of hospice facility death (black [OR = 0.915; 95% CI = 0.890, 0.940]; Native American [OR = 0.559; 95% CI = 0.515, 0.607]; and Asian [OR = 0.655; 95% CI = 0.601, 0.713]). Being married was associated with hospice facility death (OR = 1.06; 95% CI = 1.04, 1.07). Older age was associated with increased odds of hospice facility death (85 and older [OR = 1.40; 95% CI = 1.39, 1.41]). Having at least some college education was associated with increased odds of hospice facility death (OR = 1.13; 95% CI = 1.11, 1.15). Decedents from cardiovascular disease had the lowest odds of hospice facility death (OR = 0.278; 95% CI = 0.274, 0.282). CONCLUSION Hospice facility deaths increased among all patient groups; however, striking differences exist by age, sex, race, marital status, education level, cause of death, and geography. Factors underlying these disparities should be examined.
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Affiliation(s)
- Sarah H Cross
- Sanford School of Public Policy, Duke University, Durham, North Carolina, USA.
| | - Brystana G Kaufman
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA; Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
| | - Tammie E Quest
- Department of Emergency Medicine, Emory University, Atlanta, Georgia, USA; Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
| | - Haider J Warraich
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiology Section, Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
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17
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Impact of palliative care on end-of-life care and place of death in children, adolescents, and young adults with life-limiting conditions: A systematic review. Palliat Support Care 2021; 19:488-500. [PMID: 33478607 DOI: 10.1017/s1478951520001455] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine the impact of palliative care (PC) on end-of-life (EoL) care and the place of death (PoD) in children, adolescents, and young adults with life-limiting conditions. METHOD Eight online databases (PubMed, Medline, EMBASE, Cochrane Library, CINAHL, Airiti, GARUDA Garba Rujukan Digital, and OpenGrey) from 2010 to February 5, 2020 were searched for studies investigating EoL care and the PoD for pediatric patients receiving and not receiving PC. RESULTS Of the 6,468 citations identified, 14 cohort studies and one case series were included. An evidence base of mainly adequate- and strong-quality studies shows that inpatient hospital PC, either with or without the provision of home and community PC, was found to be associated with a decrease in intensive care use and high-intensity EoL care. Conflicting evidence was found for the association between PC and hospital admissions, length of stay in hospital, resuscitation at the time of death, and the proportion of hospital and home deaths. SIGNIFICANCE OF RESULTS Current evidence suggests that specialist, multidisciplinary involvement, and continuity of PC are required to reduce the intensity of EoL care. Careful attention should be paid to the need for a longer length of stay in a medical setting late in life, and earlier EoL care discussion should take place with patients/caregivers, especially in regard to attempting resuscitation in toddlers, adolescents, and the young adult population. A lack of robust evidence has identified a gap in rigorous multisite prospective studies utilizing data collection.
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18
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Ho V, Chen C, Ho S, Hooi B, Chin LS, Merchant RA. Healthcare utilisation in the last year of life in internal medicine, young-old versus old-old. BMC Geriatr 2020; 20:495. [PMID: 33228566 PMCID: PMC7685638 DOI: 10.1186/s12877-020-01894-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 11/12/2020] [Indexed: 11/16/2022] Open
Abstract
Background With increasing cost of healthcare in our aging society, a consistent pain point is that of end-of-life care. It is particularly difficult to prognosticate in non-cancer patients, leading to more healthcare utilisation without improving quality of life. Additionally, older adults do not age homogenously. Hence, we seek to characterise healthcare utilisation in young-old and old-old at the end-of-life. Methods We conducted a single-site retrospective review of decedents under department of Advanced Internal Medicine (AIM) over a year. Young-old is defined as 65–79 years; old-old as 80 years and above. Data collected was demographic characteristics; clinical data including Charlson Comorbidity Index (CCI), FRAIL-NH and advance care planning (ACP); healthcare utilisation including days spent in hospital, hospital admissions, length of stay of terminal admission and clinic visits; and quality of end-of-life care including investigations and symptomatic control. Documentation was individually reviewed for quality of communication. Results One hundred eighty-nine older adult decedents. Old-old decedents were mostly females (63% vs. 42%, p = 0.004), higher CCI scores (7.7 vs 6.6, p = 0.007), similarly frail with lower polypharmacy (62.9% vs 71.9%, p = 0.01). ACP uptake was low in both, old-old 15.9% vs. young-old 17.5%. Poor prognosis was conveyed to family, though conversation did not result in moderating extent of care. Old-old had less healthcare utilisation. Adjusting for sex, multimorbidity and frailty, old-old decedents had 7.3 ± 3.5 less hospital days in their final year. Further adjusting for cognition and residence, old-old had 0.5 ± 0.3 less hospital admissions. When accounted for home care services, old-old spent 2.7 ± 0.8 less hospital days in their last admission. Conclusion There was high healthcare utilisation in older adults, but especially young-old. Enhanced education and goal-setting are needed in the acute care setting. ACP needs to be reinforced in acute care with further research to evaluate if it reduces unnecessary utilisation at end-of-life.
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Affiliation(s)
- Vanda Ho
- Division of Advanced Internal Medicine, Department of Medicine, National University Hospital, Singapore, Singapore.
| | - Cynthia Chen
- Saw Swee Hock School of Public Health, National University Singapore, Singapore, Singapore
| | - Sara Ho
- Division of Advanced Internal Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Benjamin Hooi
- Division of Advanced Internal Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Loo Swee Chin
- Division of Advanced Internal Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Reshma Aziz Merchant
- Division of Advanced Internal Medicine, Department of Medicine, National University Hospital, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
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20
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Malhotra C, Bundoc FG, Sim D, Jaufeerally FR, Finkelstein EA. Instability in Preference for Place of Death Among Patients With Symptoms of Advanced Heart Failure. J Am Med Dir Assoc 2020; 22:349.e29-349.e34. [PMID: 32693993 DOI: 10.1016/j.jamda.2020.05.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/11/2020] [Accepted: 05/15/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Patient preference for place of death is an important component of advance care planning (ACP). If patients' preference for place of death changes over time, this questions the value of their documented preference. We aimed to assess the extent and correlates of change in preference for place of death over time among patients with symptoms of advanced heart failure. DESIGN We conducted a secondary analysis of data from a randomized controlled trial of a formal ACP program vs usual care. SETTING AND PARTICIPANTS We interviewed 282 patients aged 21 years old and above with heart failure and New York Heart Association Classification III and IV symptoms in Singapore. Analytic sample included 200 patients interviewed at least twice. METHODS We assessed factors associated with patients' preference for place of death (home/institution/no preference) and change in their preference for place of death from previous time point (change toward home death/toward an institutional death/toward no preference/no change). These included patient demographics, quality of life (Kansas City Cardiomyopathy Questionnaire), and prognostic understanding. RESULTS In our study, 66% of patients with heart failure changed their preference for place of death at least once during the study period with no consistent pattern of change. Correct prognostic understanding at the time of survey reduced the relative risk of change in preference for place of death to home (relative risk ratio 0.49, 95% confidence interval 0.32, 0.76), whereas a higher quality of life score was associated with a lower relative risk of patients changing their preferred place of death to an institution (relative risk ratio 0.99, 95% confidence interval 0.97, 1.00) relative to no change in preference. CONCLUSIONS AND IMPLICATIONS We provide evidence of instability in patients with heart failure preference for place of death, which suggests that ACP documents should be regularly re-evaluated.
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Affiliation(s)
- Chetna Malhotra
- Lien Center for Palliative Care, Duke-NUS Medical School, Singapore.
| | | | - David Sim
- National Heart Center Singapore, Singapore
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21
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Gallagher J, Bolt T, Tamiya N. Advance care planning in the community: factors of influence. BMJ Support Palliat Care 2020; 12:bmjspcare-2020-002221. [PMID: 32513679 DOI: 10.1136/bmjspcare-2020-002221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/08/2020] [Accepted: 05/04/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES This study aims to identify factors among British community-based adults associated with advance care planning engagement. Factors are then compared among six domains of wishes: medical care, spiritual and religious needs, privacy and peace, dignified care, place of death and pain relief. METHODS Cross-sectional data were analysed from a stratified random sample of adults across Great Britain (England, Scotland and Wales) who were interviewed on their attitudes towards death and dying. Weighted multivariable logistic regression tested for associations with expressing any end-of-life wishes and then for each separate domain. RESULTS Analysis of 2042 respondents (response rate: 53.5%) revealed those less likely to have discussed their wishes were: male, younger, born in the UK, owned their residence, had no experience working in health or social care, had no chronic conditions or disabilities, had not experienced the death of a close person in the last 5 years and feel neither comfortable nor uncomfortable or uncomfortable talking about death. Additional factors among the six domains associated with having not discussed wishes include: having less and more formal education, no religious beliefs, lower household income and living with at least one other person. CONCLUSIONS This study is the first to be conducted among a sample of community-dwelling British adults and the first of its kind to compare domains of end-of-life wishes. Our findings provide an understanding of social determinants which can inform a public health approach to end-of-life care that promotes advance care planning among compassionate communities.
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Affiliation(s)
- Joshua Gallagher
- School of Global and Area Studies, University of Oxford, Oxford, UK
- Health Services Research & Development Center, University of Tsukuba, Tsukuba, Japan
| | - Timothy Bolt
- Health Services Research & Development Center, University of Tsukuba, Tsukuba, Japan
- Department of Economics, Saitama University, Saitama, Japan
| | - Nanako Tamiya
- Health Services Research & Development Center, University of Tsukuba, Tsukuba, Japan
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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22
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Archibald N, Bakal JA, Richman-Eisenstat J, Kalluri M. Early Integrated Palliative Care Bundle Impacts Location of Death in Interstitial Lung Disease: A Pilot Retrospective Study. Am J Hosp Palliat Care 2020; 38:104-113. [PMID: 32431183 DOI: 10.1177/1049909120924995] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Interstitial lung diseases (ILDs) comprise a heterogeneous group of fibrotic, progressive pulmonary diseases characterized by poor end-of-life care and hospital deaths. In 2012, we launched our Multidisciplinary Collaborative (MDC) ILD clinic to deliver integrated palliative approach throughout disease trajectory to improve care. We sought to explore the effects of palliative care and other factors on location of death (LOD) of patients with ILD. METHODS The MDC-ILD clinic implemented a palliative care bundle including advance care planning (ACP), opiates use, allied health home care engagement, and use of supplemental oxygen and early caregiver engagement in care. Data from patients with ILD who attended the clinic and died between 2012 and 2019 were used to generate scores representing the components and duration of palliative care (palliative care bundle score) and caregiver involvement (caregiver engagement score). We examined the impact of these scores on patients' LOD. RESULTS A total of 92 MDC-ILD clinic patients were included, 57 (62%) had home or hospice deaths. Patients who died at home or hospice had higher palliative care bundle scores (10.0 ± 4.0 vs 7.8 ± 3.9, P = .01) and caregiver engagement scores (1.7 ± 0.6 vs 1.3 ± 0.7, P = .01) compared to those who died in hospital. Patients were 1.13 times more likely to die at home or hospice following a 1-point increase in palliative care bundle score (95% CI: 1.01-1.29, P = .04) and 2.38 times more likely following a 1-point increase in caregiver engagement score (95% CI: 1.17-5.15, P = .02). CONCLUSIONS Home and hospice deaths are feasible in ILD. Early initiation of palliative care bundle components such as ACP discussions, symptom self-management, caregiver engagement, and close collaboration with allied health home care supports can promote adherence to patient preference for home or hospice deaths.
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Affiliation(s)
- Nathan Archibald
- Department of Physiology, 98623University of Alberta, Edmonton, Alberta, Canada
| | - Jeffrey A Bakal
- Provincial Research Data Services, 3146Alberta Health Services, Edmonton, Alberta, Canada
| | - Janice Richman-Eisenstat
- Division of Pulmonary Medicine, Department of Medicine, 12357University of Alberta, Edmonton, Alberta, Canada.,3146Alberta Health Services, Edmonton, Alberta, Canada
| | - Meena Kalluri
- Division of Pulmonary Medicine, Department of Medicine, 12357University of Alberta, Edmonton, Alberta, Canada.,3146Alberta Health Services, Edmonton, Alberta, Canada
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Franklin AE, Rhee J, Raymond B, Clayton JM. Incorporating an advance care planning screening tool into routine health assessments with older people. Aust J Prim Health 2020; 26:240-246. [PMID: 32327028 DOI: 10.1071/py19195] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/16/2020] [Indexed: 11/23/2022]
Abstract
General practice is arguably the ideal setting to initiate advance care planning (ACP), but there are many barriers. This pilot study was designed to assess the feasibility, acceptability and perceived utility of a nurse-facilitated screening interview to initiate ACP with older patients in general practice. Patients were recruited from four general practices in Sydney, Australia. General practice nurses administered the ACP screening interview during routine health assessments. Patients and nurses completed a follow-up questionnaire consisting of questions with Likert responses, as well as open-ended questions. Descriptive statistics and content analysis were used to analyse the data. Twenty-four patients participated; 17 completed the follow-up questionnaire. All patients found the ACP screening interview useful and most felt it would encourage them to discuss their wishes further with their family and general practitioner. Several patients were prompted to consider legally appointing their preferred substitute decision-maker. All six participating nurses found the screening interview tool useful for initiating discussions about ACP and substitute decision-making. This nurse facilitated screening tool provides a simple, acceptable and feasible approach to introducing ACP to older general practice patients during routine health assessments.
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Affiliation(s)
- Abigail E Franklin
- Palliative and Supportive Care Service, HammondCare, Greenwich Hospital, Sydney, NSW 2065, Australia
| | - Joel Rhee
- School of Medicine, University of Wollongong, Australia and General Practitioner, Centre for Positive Ageing and Care, HammondCare, Hammondville, Sydney, NSW 2170, Australia
| | - Bronwyn Raymond
- Centre for Learning and Research in Palliative Care, HammondCare, Greenwich Hospital, Sydney, NSW 2065, Australia
| | - Josephine M Clayton
- Palliative and Supportive Care Service, HammondCare, Greenwich Hospital, Sydney, NSW 2065, Australia; and Centre for Learning and Research in Palliative Care, HammondCare, Greenwich Hospital, Sydney, NSW 2065, Australia; and Northern Clinical School and Kolling Institute, The University of Sydney, Sydney, NSW 2065, Australia; and Corresponding author.
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24
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Knight T, Malyon A, Fritz Z, Subbe C, Cooksley T, Holland M, Lasserson D. Advance care planning in patients referred to hospital for acute medical care: Results of a national day of care survey. EClinicalMedicine 2020; 19:100235. [PMID: 32055788 PMCID: PMC7005412 DOI: 10.1016/j.eclinm.2019.12.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 11/24/2019] [Accepted: 12/04/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) is a voluntary process of discussion about future care between an individual and their care provider. ACP is a key focus of national policy as a means to improve patient centered care at the end-of-life. Despite a wide held belief that ACP is beneficial, uptake is sporadic with considerable variation depending on age, ethnicity, location and disease group. METHODS This study looked to establish the prevalence of ACP on initial presentation to hospital with a medical emergency within The Society for Acute Medicine Benchmarking Audit (SAMBA18). 123 acute hospitals from across the UK collected data during a day of care survey. The presence of ACP and the presence of 'Do Not Attempt Cardiopulmonary Resuscitation' orders were recorded separately. FINDINGS Among 6072 patients presenting with an acute medical emergency, 290 patients (4.8%) had an ACP that was available for the admitting medical team. The prevalence of ACP increased incrementally with age, in patients less than 80 years old the prevalence was 2·9% (95% CI 2·7-3·1) compared with 9·5% (95% CI 9·1-10·0%) in patients aged over 80. In the patients aged over 90 the prevalence of ACP was 12·6% (95% CI 9·8-16·0). ACP was present in 23·3% (95% CI 21.8-24.8%) of patients admitted from institutional care compared with 3·5% (95% CI 3·3-3·7) of patients admitted from home. The prevalence of ACP was 7.1% (95% CI 6·6-7·6) amongst patients re-admitted to the hospital within the previous 30 days. INTERPRETATION Very few patients have an ACP that is available to admitting medical teams during an unscheduled hospital admission. Even among patients with advanced age, and who have recently been in hospital, the prevalence of available ACP remains low, in spite of national guidance. Further interventions are needed to ensure that patients' wishes for care are known by providers of acute medical care.
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Affiliation(s)
- Thomas Knight
- Institute of Applied Health Research, University of Birmingham, United Kingdom
- Corresponding author.
| | - Alexandra Malyon
- Cambridge University Hospital NHS Foundation Trust, United Kingdom
| | - Zoe Fritz
- University of Cambridge, United Kingdom
| | - Chris Subbe
- School of Medical Sciences, Bangor University, United Kingdom
| | - Tim Cooksley
- Manchester University NHS Foundation Trust, United Kingdom
| | - Mark Holland
- School of Health and Social Care, University of Bolton, United Kingdom
| | - Daniel Lasserson
- Institute of Applied Health Research, University of Birmingham, United Kingdom
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Hospital and Patient Characteristics Regarding the Place of Death of Hospitalized Impending Death Patients: A Multilevel Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16234609. [PMID: 31757082 PMCID: PMC6926854 DOI: 10.3390/ijerph16234609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/15/2019] [Accepted: 11/16/2019] [Indexed: 11/30/2022]
Abstract
Objectives: To explore the influence of hospital and patient characteristics on deaths at home among inpatients facing impending death. Method: In this historical cohort study, 95,626 inpatients facing impending death from 362 hospitals in 2011 were recruited. The dependent variable was the place of death. The independent variables were the characteristics of the hospitals and the patients. A two-level hierarchical generalized linear model was used. Results: In total, 41.06% of subjects died at home. The hospital characteristics contributed to 29.25% of the total variation of the place of death. Private hospitals (odds ratio [OR] = 1.32, 95% confidence interval [CI] = 1.00–1.75), patients >65 years old (OR = 1.48, 95% CI. = 1.42–1.54), married (OR = 3.15, 95% CI. = 2.93–3.40) or widowed (OR = 3.39, 95% CI. = 3.12–3.67), from near-poor households (OR = 5.16, 95% CI. = 4.57–5.84), having diabetes mellitus (OR = 1.79, 95% CI. = 1.65–1.94), and living in a subcounty (OR = 2.27, 95% CI. = 2.16–2.38) were all risk factors for a death at home. Conclusion: Both hospital and patient characteristics have an effect of deaths at home among inpatients facing impending death. The value of the inpatient mortality rate as a major index of hospital accreditation should be interpreted intrinsically with the rate of deaths at home.
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Chamberlain C, Blazeby JM. A good surgical death. Br J Surg 2019; 106:1427-1428. [DOI: 10.1002/bjs.11360] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/14/2019] [Indexed: 01/20/2023]
Affiliation(s)
- C Chamberlain
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - J M Blazeby
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Webber C, Viola R, Knott C, Peng Y, Groome PA. Community Palliative Care Initiatives to Reduce End-of-Life Hospital Utilization and In-Hospital Deaths: A Population-Based Observational Study Evaluating Two Home Care Interventions. J Pain Symptom Manage 2019; 58:181-189.e1. [PMID: 31022443 DOI: 10.1016/j.jpainsymman.2019.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/12/2019] [Accepted: 04/15/2019] [Indexed: 01/08/2023]
Abstract
CONTEXT The end-of-life period is characterized by increased hospital utilization despite patients' preferences to receive care and die at home. OBJECTIVES To evaluate the impact of interventions aimed at planning for a home death (Yellow Folder) and managing symptoms in the home (Symptom Response Kit) on place of death and hospital utilization among palliative home care patients. METHODS This was an ecologic and retrospective cohort study of palliative home care patients in southeastern Ontario from April 2009 to March 2014. Linked health administrative and clinical databases were used to identify palliative home care patients and their receipt of the interventions, hospitalizations, emergency department visits, and place of death. Bivariable and multivariable regressions were used to evaluate outcomes according to patients' receipt of intervention(s). RESULTS The proportion of patients who died in the community increased after implementation of the interventions, from 42.8% to 48.5% (P < 0.0001). Compared with patients who received neither intervention, patients who received the Yellow Folder or Symptom Response Kit had an increased likelihood of dying in the community, with the largest relative risk observed in patients who received both interventions (relative risk = 2.20, 95% confidence interval 2.05-2.36). Receipt of these interventions was only associated with reductions in hospitalization or emergency department visit rates in the six months before death. CONCLUSION Patients who received the Yellow Folder or Symptom Response Kit were more likely remain at home at the end of life. This association was stronger when these interventions were used together.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada.
| | - Raymond Viola
- Division of Palliative Medicine, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Christine Knott
- Centre for Health Services and Policy Research, Queen's University, Kingston, Ontario, Canada; ICES, Kingston, Ontario, Canada
| | - Yingwei Peng
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada; Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, Ontario, Canada
| | - Patti A Groome
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada; Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, Ontario, Canada
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Foley LM. Improving End-of-Life Care for Hospitalized Older Adults: What Can Nurses and Health Care Systems Do? J Gerontol Nurs 2019; 45:2-4. [PMID: 31237657 DOI: 10.3928/00989134-20190612-01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Skorstengaard MH, Jensen AB, Andreassen P, Brogaard T, Brendstrup E, Løkke A, Aagaard S, Wiggers H, Neergaard MA. Advance care planning and place of death, hospitalisation and actual place of death in lung, heart and cancer disease: a randomised controlled trial. BMJ Support Palliat Care 2019; 10:e37. [DOI: 10.1136/bmjspcare-2018-001677] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 02/04/2019] [Accepted: 02/20/2019] [Indexed: 11/04/2022]
Abstract
ObjectivesAdvance care planning (ACP) can be a way to meet patients’ end-of-life preferences and enhance awareness of end-of-life care. Thereby it may affect actual place of death (APOD) and decrease the rate of hospitalisations. The aim was to investigate if ACP among terminally ill patients with lung, heart and cancer diseases effects fulfilment of preferred place of death (PPOD), amount of time spent in hospital and APOD.MethodsThe study was designed as a randomised controlled trial. Patients were assessed using general and disease-specific criteria and randomised into groups: one received usual care and one received usual care plus ACP. The intervention consisted of a discussion between a healthcare professional, the patient and their relatives about preferences for end-of-life care. The discussion was documented in the hospital file.ResultsIn total, 205 patients were randomised, of which 111 died during follow-up. No significant differences in fulfilment of PPOD (35% vs 52%, p=0.221) or in amount of time spent in hospital among deceased patients (49% vs 23%, p=0.074) were found between groups. A significant difference in APOD was found favouring home death in the intervention group (17% vs 40%, p=0.013).ConclusionConcerning the primary outcome, fulfilment of PPOD, and the secondary outcome, time spent in hospital, no differences were found. A significant difference concerning APOD was found, as more patients in the intervention group died at home, compared with the usual care group.Trial registration numberNCT01944813.
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30
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Overbeek A, Polinder S, Haagsma J, Billekens P, de Nooijer K, Hammes BJ, Muliaditan D, van der Heide A, Rietjens JA, Korfage IJ. Advance Care Planning for frail older adults: Findings on costs in a cluster randomised controlled trial. Palliat Med 2019; 33:291-300. [PMID: 30269650 DOI: 10.1177/0269216318801751] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Advance Care Planning aims at improving alignment of care with patients’ preferences. This may affect costs of medical care. Aim: To determine the costs of an Advance Care Planning programme and its effects on the costs of medical care and on concordance of care with patients’ preferences. Design/settings/participants: In a cluster randomised trial, 16 residential care homes were randomly allocated to the intervention group, where frail, older participants were offered facilitated Advance Care Planning conversations or to the control group. We calculated variable costs of Advance Care Planning per participant including personnel and travel costs of facilitators. Furthermore, we assessed participants’ healthcare use during 12 months applying a broad perspective (including medical care, inpatient days in residential care homes, home care) and calculated costs of care per participant. Finally, we investigated whether treatment goals were in accordance with preferences. Analyses were conducted for 97 participants per group. Trial registration number: NTR4454. Results: Average variable Advance Care Planning costs were €76 per participant. The average costs of medical care were not significantly different between the intervention and control group (€2360 vs €2235, respectively, p = 0.36). Costs of inpatient days in residential care homes (€41,551 vs €46,533) and of home care (€14,091 vs €17,361) were not significantly different either. Concordance of care with preferences could not be assessed since treatment goals were often not recorded. Conclusion: The costs of an Advance Care Planning programme were limited. Advance Care Planning did not significantly affect the costs of medical care for frail older adults.
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Affiliation(s)
- Anouk Overbeek
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Suzanne Polinder
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Juanita Haagsma
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | | | - Kim de Nooijer
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | | | - Daniel Muliaditan
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | | | | | - Ida J Korfage
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
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31
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Lemon C, De Ridder M, Khadra M. Do Electronic Medical Records Improve Advance Directive Documentation? A Systematic Review. Am J Hosp Palliat Care 2018; 36:255-263. [PMID: 30165755 DOI: 10.1177/1049909118796191] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Documentation rates of advance directives (ADs) remain low. Using electronic medical records (EMRs) could help, but a synthesis of evidence is currently lacking. OBJECTIVES To evaluate the evidence for using EMRs in documenting ADs and its implications for overcoming challenges associated with their use. DESIGN Systematic review of articles in English, published from inception of databases to December 2017. DATA SOURCES PubMed, PsycINFO, EMBASE, and CINAHL. METHODS/MEASUREMENTS Four databases were searched from inception to December 2017. Randomized and nonrandomized quantitative studies examining the effects of EMRs on creation, storage, or use of ADs were included. All featured an advance care planning process. Evidence was evaluated using the Cochrane Collaboration's risk assessment tool. RESULTS Fifteen studies were included: 1 randomized controlled trial, 1 randomized pilot, 4 pre-post studies, 4 cross-sectional studies, 1 retrospective cohort study, 1 historical control study, 1 retrospective observational study, 1 retrospective review, and 1 evaluation of an EMR feature. Seven studies showed that EMR-based reminders, AD templates, and decision aids can improve AD documentation rates. Three demonstrated that EMR search functions, decision aids, and automatic identification software can help identify patients who have or need ADs according to certain criteria. Five showed EMRs can create documentation challenges, including locating ADs, and making some patients more likely than others to have an AD. Most studies had an unclear or high risk of bias. CONCLUSIONS Limited evidence suggests EMRs could be used to help address AD documentation challenges but may also create additional problems. Stronger evidence is needed to more conclusively determine how EMR may assist in population approaches to improving AD documentation.
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Affiliation(s)
- Christopher Lemon
- University of Notre Dame Australia, Sydney, School of Medicine, Sydney, NSW, Australia
| | - Michael De Ridder
- Institute of Biomedical Engineering and Technology (BMET), The University of Sydney, Australia.,Nepean Telehealth Technology Centre, Sydney Medical School Nepean, The University of Sydney, Australia
| | - Mohamed Khadra
- Nepean Telehealth Technology Centre, Sydney Medical School Nepean, The University of Sydney, Australia.,Discipline of Surgery, Sydney Medical School Nepean, The University of Sydney, Australia
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32
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Danielsen BV, Sand AM, Rosland JH, Førland O. Experiences and challenges of home care nurses and general practitioners in home-based palliative care - a qualitative study. BMC Palliat Care 2018; 17:95. [PMID: 30021583 PMCID: PMC6052702 DOI: 10.1186/s12904-018-0350-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 07/11/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Norway has one of the lowest home death rates in Europe. However, it is the health authorities´ ambition to increase this by facilitating palliative care at home. The aim of this study was to achieve more insight, through home care nurses and general practitioners, of conditions that facilitate or hamper more time at home and more home deaths for patients with terminal disease and short life expectancy. METHODS We used a qualitative research design with four focus groups with a total of 19 participants, of either home care nurses or general practitioners, using semi-structured question guides. The data were processed by systematic text condensation and encompassed thematic analysis of meaning and content of data across cases, which included four steps of analysis. RESULTS Three main themes were identified: 1) The importance of a good start for the patient and family with five sub-themes, 2) 'Passing the baton' - the importance of collaboration across the health system with four sub-themes, and 3) Avoiding new hospitalization by establishing collaboration and competence within primary health care with four sub-themes. CONCLUSIONS This study demonstrates that optimum palliative care at home depends on close collaboration and dialogue between the patient, family, home care nurses and general practitioner. It suggests the need for safer discharge routines and planning when hospitals transfer patients with terminal disease to their homes. A good start for the patient and family, where the initial interdisciplinary collaboration meeting takes place in the patient's home, is crucial for a good result. The general practitioners' perception of their 'disconnection' during hospitalization and prior to discharge has the potential to reduce patient safety. The family seems to be fundamental in gaining more time at home for the patient and supporting the patient to eventually die at home. Home-based palliative care demands experience and competence as well as regular supportive mentoring.
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Affiliation(s)
- Britt Viola Danielsen
- Department of Health and Caring Sciences, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, P.O. Box 7030, N-5020, Bergen, Norway.
| | - Anne Marit Sand
- Department of Health and Caring Sciences, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, P.O. Box 7030, N-5020, Bergen, Norway
| | - Jan Henrik Rosland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Sunniva Centre for Palliative Care, Haraldsplass Deaconess Hospital Bergen, Bergen, Norway
| | - Oddvar Førland
- Centre for Care Research - Western Norway, Western Norway University of Applied Sciences, Bergen, Norway.,Faculty of Health Studies, VID Specialized University, Bergen, Norway
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Kok M, van der Werff GFM, Geerling JI, Ruivenkamp J, Groothoff W, van der Velden AWG, Thoma M, Talsma J, Costongs LGP, Gans ROB, de Graeff P, Reyners AKL. Feasibility of hospital-initiated non-facilitator assisted advance care planning documentation for patients with palliative care needs. BMC Palliat Care 2018; 17:79. [PMID: 29793477 PMCID: PMC5967098 DOI: 10.1186/s12904-018-0331-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/08/2018] [Indexed: 01/23/2023] Open
Abstract
Background Advance Care Planning (ACP) and its documentation, accessible to healthcare professionals regardless of where patients are staying, can improve palliative care. ACP is usually performed by trained facilitators. However, ACP conversations would be more tailored to a patient’s specific situation if held by a patient’s clinical healthcare team. This study assesses the feasibility of ACP by a patient’s clinical healthcare team, and analyses the documented information including current and future problems within the palliative care domains. Methods This multicentre study was conducted at the three Groningen Palliative Care Network hospitals in the Netherlands. Patients discharged from hospital with a terminal care indication received an ACP document from clinical staff (non-palliative care trained staff at hospitals I and II; specialist palliative care nurses at hospital III) after they had held ACP conversations. An anonymised copy of this ACP document was analysed. Documentation rates of patient and contact details were investigated, and documentation of current and future problems were analysed both quantitatively and qualitatively. Results One hundred sixty ACP documents were received between April 2013 and December 2014, with numbers increasing for each consecutive 3-month time period. Advance directives were frequently documented (82%). Documentation rates of current problems in the social (24%), psychological (27%) and spiritual (16%) domains were low compared to physical problems (85%) at hospital I and II, but consistently high (> 85%) at hospital III. Of 545 documented anticipated problems, 92% were physical or care related in nature, 2% social, 5% psychological, and < 1% spiritual. Half of the anticipated non-physical problems originated from hospital III. Conclusions Hospital-initiated ACP documentation by a patient’s clinical healthcare team is feasible: the number of documents received per time period increased throughout the study period, and overall, documentation rates were high. Nonetheless, symptom documentation predominantly regards physical symptoms. With the involvement of specialist palliative care nurses, psychological and spiritual problems are addressed more frequently. Whether palliative care education for non-palliative care experts will improve identification and documentation of non-physical problems remains to be investigated. Electronic supplementary material The online version of this article (10.1186/s12904-018-0331-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maaike Kok
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, 9700 RB, The Netherlands.,Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, 9700 RB, The Netherlands
| | | | - Jenske I Geerling
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, 9700 RB, The Netherlands.,Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, 9700 RB, The Netherlands
| | - Jaap Ruivenkamp
- Ommelander Ziekenhuis Groningen, Palliative Care Team, Jachtlaan 50, Delfzijl, 9670 RA, The Netherlands
| | - Wies Groothoff
- Ommelander Ziekenhuis Groningen, Palliative Care Team, Jachtlaan 50, Delfzijl, 9670 RA, The Netherlands
| | - Annette W G van der Velden
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, 9700 RB, The Netherlands.,Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, 9700 RB, The Netherlands.,Martini Hospital, Palliative Care Team, Van Swietenplein 1, Groningen, 9700 RM, The Netherlands
| | - Monique Thoma
- TSN Care Groningen, Dokter Stolteweg 60-66, Zwolle, 8002 LB, The Netherlands
| | - Jaap Talsma
- Academic General Practice, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, 9700 RB, The Netherlands
| | - Louk G P Costongs
- Zonnehuisgroep Noord, Izarstraat 1, Zuidhorn, 9800 AB, The Netherlands
| | - Reinold O B Gans
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, 9700 RB, The Netherlands
| | - Pauline de Graeff
- University of Groningen, University Medical Center Groningen, Department of Internal Medicine, University Center of Geriatric Medicine, Groningen, 9700 RB, The Netherlands
| | - Anna K L Reyners
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, 9700 RB, The Netherlands. .,Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, 9700 RB, The Netherlands.
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Chidiac C. The evidence of early specialist palliative care on patient and caregiver outcomes. Int J Palliat Nurs 2018; 24:230-237. [DOI: 10.12968/ijpn.2018.24.5.230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Claude Chidiac
- Lecturer in Palliative Care, Saint Francis Hospice, Romford, UK and Course Director MSc Palliative and End of Life Care, School of Health and Social Care, London South Bank University, UK
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Bond WF, Kim M, Franciskovich CM, Weinberg JE, Svendsen JD, Fehr LS, Funk A, Sawicki R, Asche CV. Advance Care Planning in an Accountable Care Organization Is Associated with Increased Advanced Directive Documentation and Decreased Costs. J Palliat Med 2018; 21:489-502. [PMID: 29206564 PMCID: PMC5867515 DOI: 10.1089/jpm.2017.0566] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) documents patient wishes and increases awareness of palliative care options. OBJECTIVE To study the association of outpatient ACP with advanced directive documentation, utilization, and costs of care. DESIGN This was a case-control study of cases with ACP who died matched 1:1 with controls. We used 12 months of data pre-ACP/prematch and predeath. We compared rates of documentation with logit model regression and conducted a difference-in-difference analysis using generalized linear models for utilization and costs. SETTING/SUBJECTS Medicare beneficiaries attributed to a large rural-suburban-small metro multisite accountable care organization from January 2013 to April 2016, with cross reference to ACP facilitator logs to find cases. MEASUREMENTS The presence of advance directive forms was verified by chart review. Cost analysis included all utilization and costs billed to Medicare. RESULTS We matched 325 cases and 325 controls (51.1% female and 48.9% male, mean age 81). 320/325 (98.5%) ACP versus 243/325 (74.8%) of controls had a Healthcare Power of Attorney (odds ratio [OR] 21.6, 95% CI 8.6-54.1) and 172/325(52.9%) ACP versus 145/325 (44.6%) controls had Practitioner Orders for Life Sustaining Treatment (OR 1.40, 95% CI 1.02-1.90) post-ACP/postmatch. Adjusted results showed ACP cases had fewer inpatient admissions (-0.37 admissions, 95% CI -0.66 to -0.08), and inpatient days (-3.66 days, 95% CI -6.23 to -1.09), with no differences in hospice, hospice days, skilled nursing facility use, home health use, 30-day readmissions, or emergency department visits. Adjusted costs were $9,500 lower in the ACP group (95% CI -$16,207 to -$2,793). CONCLUSIONS ACP increases documentation and was associated with a reduction in overall costs driven primarily by a reduction in inpatient utilization. Our data set was limited by small numbers of minorities and cancer patients.
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Affiliation(s)
- William F. Bond
- Jump Simulation, OSF HealthCare, Peoria, Illinois
- Department of Emergency Medicine, OSF HealthCare, Peoria, Illinois
- Department of Emergency Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois
| | - Minchul Kim
- Center for Outcomes Research, University of Illinois College of Medicine at Peoria, Peoria, Illinois
- Department of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois
| | | | | | | | - Linda S. Fehr
- Division of Supportive Care, OSF HealthCare, Peoria, Illinois
| | - Amy Funk
- College of Nursing, Illinois Wesleyan University, Bloomington, Illinois
| | - Robert Sawicki
- Division of Supportive Care, OSF HealthCare, Peoria, Illinois
| | - Carl V. Asche
- Center for Outcomes Research, University of Illinois College of Medicine at Peoria, Peoria, Illinois
- Department of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois
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36
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Broadhurst HL, Droney J, Callender T, Shaw A, Riley J. Advance care planning: the impact of Ceiling of Treatment plans in patients with Coordinate My Care. BMJ Support Palliat Care 2018; 9:267-270. [PMID: 29572344 DOI: 10.1136/bmjspcare-2017-001414] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 03/01/2018] [Accepted: 03/01/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The aim of this evaluation is to describe the components and results of urgent care planning in Coordinate My Care (CMC), a digital clinical service for patients with life-limiting illness, for use if a patient is unable to make or express choices. Ceiling of treatment (CoT) plans were created detailing where the patient would like to receive their care and how aggressive medical interventions should be. METHODS A retrospective service evaluation was completed of all CMC records created between December 2015 and September 2016 (n=6854). CMC records were divided into two cohorts: those with a CoT plan and those without. The factors associated with these cohorts were reviewed including age, diagnosis, resuscitation status and preferences for place of death (PPD). Analysis of the non-mandatory free text section was carried out. RESULTS Two-thirds of patients had recorded decisions about CoT. Regardless of which CoT option was chosen, for most patients, PPD was home or care home. Patients with a CoT plan were more likely to have a documented resuscitation status. Patients with a CoT were more likely to die in their PPD (82%vs71%, OR 1.79, p<0.0001). A higher proportion of patients with a CoT decision died outside hospital. CONCLUSION This analysis demonstrates that a substantial proportion of patients are willing to engage in urgent care planning. Three facets of urgent care planning identified include PPD, CoT and resuscitation status.
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Affiliation(s)
| | - Joanne Droney
- Symptom Control and Palliative Care Department, Royal Marsden Hospital, London, UK
| | - Tom Callender
- Symptom Control and Palliative Care Department, Royal Marsden Hospital, London, UK
| | - Amanda Shaw
- Coordinate My Care, Coordinate My Care, London, UK
| | - Julia Riley
- Symptom Control and Palliative Care Department, Royal Marsden Hospital, London, UK.,Coordinate My Care, Coordinate My Care, London, UK.,Institute of Global Health Innovation, Imperial College London, London, UK
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37
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Myers J, Cosby R, Gzik D, Harle I, Harrold D, Incardona N, Walton T. Provider Tools for Advance Care Planning and Goals of Care Discussions: A Systematic Review. Am J Hosp Palliat Care 2018. [PMID: 29529884 DOI: 10.1177/1049909118760303] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Advance care planning and goals of care discussions involve the exploration of what is most important to a person, including their values and beliefs in preparation for health-care decision-making. Advance care planning conversations focus on planning for future health care, ensuring that an incapable person's wishes are known and can guide the person's substitute decision maker for future decision-making. Goals of care discussions focus on preparing for current decision-making by ensuring the person's goals guide this process. AIM To provide evidence regarding tools and/or practices available for use by health-care providers to effectively facilitate advance care planning conversations and/or goals of care discussions. DATA SOURCES A systematic review was conducted focusing on guidelines, randomized trials, comparative studies, and noncomparative studies. Databases searched included MEDLINE, EMBASE, and the proceedings of the International Advance Care Planning Conference and the American Society of Clinical Oncology Palliative Care Symposium. CONCLUSIONS Although several studies report positive findings, there is a lack of consistent patient outcome evidence to support any one clinical tool for use in advance care planning or goals of care discussions. Effective advance care planning conversations at both the population and the individual level require provider education and communication skill development, standardized and accessible documentation, quality improvement initiatives, and system-wide coordination to impact the population level. There is a need for research focused on goals of care discussions, to clarify the purpose and expected outcomes of these discussions, and to clearly differentiate goals of care from advance care planning.
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Affiliation(s)
- Jeff Myers
- 1 Sinai-Bridgepoint Palliative Care Unit, Toronto, Ontario, Canada
| | - Roxanne Cosby
- 2 Program in Evidence-Based Care, McMaster University, Hamilton, Canada
| | - Danusia Gzik
- 3 North Simcoe Muskoka Regional Cancer Program, Cancer Care Ontario, Barrie, Canada
| | - Ingrid Harle
- 4 Department of Medicine, Queen's University, Kingston, Canada.,5 Department of Oncology, Queen's University, Kingston, Canada
| | - Deb Harrold
- 3 North Simcoe Muskoka Regional Cancer Program, Cancer Care Ontario, Barrie, Canada
| | - Nadia Incardona
- 6 Michael Garron Hospital, Toronto East Health Network, Ontario, Canada.,7 Department of Family & Community Medicine, University of Toronto, Toronto, Canada
| | - Tara Walton
- 8 Ontario Palliative Care Network Secretariat, Toronto, Canada
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Wahid AS, Sayma M, Jamshaid S, Kerwat D, Oyewole F, Saleh D, Ahmed A, Cox B, Perry C, Payne S. Barriers and facilitators influencing death at home: A meta-ethnography. Palliat Med 2018; 32:314-328. [PMID: 28604232 DOI: 10.1177/0269216317713427] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In many countries, achieving a home death represents a successful outcome from both a patient welfare and commissioning viewpoint. Significant variation exists in the proportion of home deaths achieved internationally, with many countries unable to meet the wishes of a large number of patients. This review builds on previous literature investigating factors influencing home death, synthesising qualitative research to supplement evidence that quantitative research in this field may have been unable to reach. AIM To identify and understand the barriers and facilitators influencing death at home. DESIGN Meta-ethnography. DATA SOURCES The review adhered to the PRISMA guidelines. A systematic literature search was conducted using five databases: PubMed, EMBASE, Ovid, CINAHL and PsycINFO. Databases were searched from 2006 to 2016. Empirical, UK-based qualitative studies were included for analysis. RESULTS A total of 38 articles were included for analysis. Seven overarching barriers were identified: lack of knowledge, skills and support among informal carers and healthcare professionals; informal carer and family burden; recognising death; inadequacy of processes such as advance care planning and discharge; as well as inherent patient difficulties, either due to the condition or social circumstances. Four overarching facilitators were observed: support for patients and healthcare professionals, skilled staff, coordination and effective communication. CONCLUSION Future policies and clinical practice should develop measures to empower informal carers as well as emphasise earlier commencement of advance care planning. Best practice discharge should be recommended in addition to addressing remaining inequity to enable non-cancer patients greater access to palliative care services.
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Affiliation(s)
- Abdul Samad Wahid
- 1 Faculty of Medicine, Imperial College London, London, UK.,2 Imperial College Business School, London, UK
| | - Meelad Sayma
- 2 Imperial College Business School, London, UK.,3 Peninsula College of Medicine & Dentistry, Plymouth, UK
| | - Shiraz Jamshaid
- 1 Faculty of Medicine, Imperial College London, London, UK.,2 Imperial College Business School, London, UK
| | - Doa'a Kerwat
- 2 Imperial College Business School, London, UK.,4 Bart's and the London School of Medicine and Dentistry, London, UK
| | - Folashade Oyewole
- 1 Faculty of Medicine, Imperial College London, London, UK.,2 Imperial College Business School, London, UK
| | - Dina Saleh
- 1 Faculty of Medicine, Imperial College London, London, UK.,2 Imperial College Business School, London, UK
| | - Aaniya Ahmed
- 1 Faculty of Medicine, Imperial College London, London, UK.,2 Imperial College Business School, London, UK
| | - Benita Cox
- 2 Imperial College Business School, London, UK
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The impact of early palliative care on the quality of care during the last days of life: what does the evidence say? Curr Opin Support Palliat Care 2018; 10:310-315. [PMID: 27635766 DOI: 10.1097/spc.0000000000000240] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to critically appraise the existing evidence on 'early palliative care' (EPC), discuss its relationship with advance care planning, and to reflect on the impact of EPC on the quality of care provided during the last days of life. RECENT FINDINGS There are indicators that EPC may help to avoid aggressive treatment, shorten hospital stay, improve overall quality of life, and to see more frequently dying and death at the preferred place of care. SUMMARY The evidence from randomized controlled trials supports the integration of palliative care early in the disease trajectory. However, in terms of outcomes and quality indicators for care in the last days of life, evidence is still lacking. Predominantly, when it comes to the outcomes which may be more difficult to assess, such as spiritual aspects, or the social network, for which more comprehensive information is needed. These outcomes should not be neglected in palliative care studies, particularly when they can provide meaningful information about patient and family adjustment, and focus on psychosocial aspects rather than physical symptom control.
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Anstey M, Watts N, Orford N, Seppelt IM, Mitchell I. Does anyone ever expect to die? Anaesth Intensive Care 2017; 45:466-468. [PMID: 28673216 DOI: 10.1177/0310057x1704500409] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patients who come to the intensive care unit are amongst the sickest patients in our hospitals. Patients can be admitted to the intensive care unit unexpectedly (following accidents or sudden onset of illness) or as unplanned but not necessarily truly 'unexpected' admissions. These patients often have significant underlying chronic health issues, including metastatic cancer, advanced cardiac, respiratory, renal, or hepatic failure, or frailty, with a high likelihood of death in the ensuing months. Using the Australian and New Zealand Intensive Care Society Clinical Trials Group Point Prevalence Program, a prospective single-day observational study across 46 Australian hospitals in 2014 and 2015, we found that less than 9% of intensive care unit patients (51/577) had an advance directive available. From these results, we provide two suggestions to increase intensive care's understanding of patients' end-of-life wishes. First, systematically target 'high risk of dying' patient groups for goals of care conversations in the outpatient setting. Such groups include those where one would not be 'surprised' if they died within a year. Second, as a society, more conversations about end-of-life wishes are needed.
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Affiliation(s)
- Mhr Anstey
- Intensivist, Intensive Care Unit, Sir Charles Gairdner Hospital, Adjunct Researcher, Curtin University School of Public Health, Perth, Western Australia
| | - N Watts
- Post Doctoral Research Fellow, Critical Care and Trauma Division, The George Institute for Global Health, Sydney, New South Wales
| | - N Orford
- Intensive Care Specialist, Intensive Care, University Hospital, Geelong, Victoria
| | - I M Seppelt
- Senior Staff Specialist, Intensive Care, Nepean Hospital, Critical Care and Trauma Division, The George Institute for Global Health, Sydney, New South Wales
| | - I Mitchell
- Director, Intensive Care Unit, Canberra Hospital, Associate Professor, ANU Medical School, Canberra, Australian Capital Territory
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Malyon AC, Forman JR, Fuld JP, Fritz Z. Discussion and documentation of future care: a before-and-after study examining the impact of an alternative approach to recording treatment decisions on advance care planning in an acute hospital. BMJ Support Palliat Care 2017; 10:e12. [PMID: 28864448 DOI: 10.1136/bmjspcare-2016-001101] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 02/08/2017] [Accepted: 05/15/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine whether discussion and documentation of decisions about future care was improved following the introduction of a new approach to recording treatment decisions: the Universal Form of Treatment Options (UFTO). METHODS Retrospective review of the medical records of patients who died within 90 days of admission to oncology or respiratory medicine wards over two 3-month periods, preimplementation and postimplementation of the UFTO. A sample size of 70 per group was required to provide 80% power to observe a change from 15% to 35% in discussion or documentation of advance care planning (ACP), using a two-sided test at the 5% significance level. RESULTS On the oncology ward, introduction of the UFTO was associated with a statistically significant increase in cardiopulmonary resuscitation decisions documented for patients (pre-UFTO 52% to post-UFTO 77%, p=0.01) and an increase in discussions regarding ACP (pre-UFTO 27%, post-UFTO 49%, p=0.03). There were no demonstrable changes in practice on the respiratory ward. Only one patient came into hospital with a formal ACP document. CONCLUSIONS Despite patients' proximity to the end-of-life, there was limited documentation of ACP and almost no evidence of formalised ACP. The introduction of the UFTO was associated with a change in practice on the oncology ward but this was not observed for respiratory patients. A new approach to recording treatment decisions may contribute to improving discussion and documentation about future care but further work is needed to ensure that all patients' preferences for treatment and care at the end-of-life are known.
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Affiliation(s)
- Alexandra C Malyon
- Acute Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Julia R Forman
- Applied Statistics and Epidemiology, Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jonathan P Fuld
- Respiratory and Acute Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Zoë Fritz
- Acute Medicine, Cambridge University Hospitals NHS Foundation Trust and Warwick University, UK
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42
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Advance care planning and end-of-life care for patients with hematologic malignancies who die after hematopoietic cell transplant. Bone Marrow Transplant 2017; 52:929-931. [PMID: 28287642 DOI: 10.1038/bmt.2017.41] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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43
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Hounsome L, Verne J, Woodhams S. End of life care for urological cancer patients. JOURNAL OF CLINICAL UROLOGY 2017. [DOI: 10.1177/2051415816664273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Each year around 15,000 men and 2900 women die from a urological cancer. The trajectory at end of life can be long and progressive or punctuated by acute events. Nonetheless those who die from urological cancer share some certain common disease manifestations that necessitate input from secondary care. Methods: All records of people dying from a urological cancer in 2004–2013 were extracted from Office for National Statistics and National Cancer Registration and Analysis Service databases. Records were linked to hospital episode statistics to analyse patterns of admitted patient care, outpatient attendances and emergency department attendances. Results: There has been a progressive decline in the proportion of deaths in hospital, from 47% to 35% of deaths. There has been a notable increase in care home deaths, which have risen from 13% to 19% of deaths and overtaken deaths in a hospice. Despite an only modest rise in total deaths from urological cancers (15,573 per year 2004–2006; 16,921 per year 2011–2013) there has been a much larger increase in secondary care activity in the last year of life. The largest change was for outpatient attendances, where the mean number increased from 3.0 to 13.6 per person. Conclusion: Differences in age at death may account for some of the differences in place of death. Those dying at an older age will be more likely to require care for comorbidities or frailty, and hence be in a care home already. The large increase in outpatient activity could reflect attempts to manage more end of life care without hospital admissions. Yet inpatient activity has increased more quickly than the number of deaths. The increase in outpatient activity may instead be due to developments in treatment for advanced cancer, and prostate cancer in particular, being offered to patients close to the end of life.
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Affiliation(s)
- Luke Hounsome
- National Cancer Intelligence Network, Public Health England, UK
| | - Julia Verne
- National Cancer Intelligence Network, Public Health England, UK
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44
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Home-based specialized palliative care in patients with advanced cancer: A systematic review. Palliat Support Care 2016; 14:713-724. [DOI: 10.1017/s147895151600050x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AbstractObjective:Due to an urgent need for specialized palliative care (SPC) for patients with advanced cancer, an overview of available information on organization and outcomes of home-based SPC would be valuable. Our systematic review aims to give an overview of available information on the organization and outcomes of home-based SPC for patients with advanced cancer. Outcomes related to place of death, survival time, quality of life, performance status, and symptom management are included.Method:A PICO process search strategy consisting of terms related to cancer, palliation, and home care was employed. The search was conducted in PubMed, EMBASE, and Cochrane from January 1, 2000, to January 27, 2015. A hand search of the reference lists of the included studies was also performed.Results:A total of 5 articles (out of 2080 abstracts) were selected for analysis. Three additional studies were added by the hand search. Six observational and two interventional studies were evaluated. In all of these studies, the description of the SPC service was limited to the composition of the staff—no other organizational aspects were detailed. From 44 to 90% of the patients receiving home-based SPC died at home. Studies including survival and quality of life had divergent outcomes, and overall performance status did not improve. However, symptom control did improve over time.Significance of results:There is a lack of controlled clinical trials and organizational descriptions regarding home-based SPC for patients with advanced cancer, resulting in poor information and a lack of evidence. Generally, home-based SPC seems to have some positive effect on pain and dyspnea, but more high-quality studies are required.
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Dixon J, King D, Knapp M. Advance care planning in England: Is there an association with place of death? Secondary analysis of data from the National Survey of Bereaved People. BMJ Support Palliat Care 2016; 9:316-325. [PMID: 27312056 PMCID: PMC6817703 DOI: 10.1136/bmjspcare-2015-000971] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 01/10/2016] [Accepted: 03/30/2016] [Indexed: 12/31/2022]
Abstract
Objectives To explore whether advance care planning is associated with place of death in England, as well as with sufficiency of support to care for a dying person at home, overall quality of care and pain management. Methods We undertook secondary analysis of data from the National Survey of Bereaved People, 2013, based on a stratified random sample of 49 607 people selected from 150 111 eligible registered deaths (n=22 661, 46% response rate). The indicator of advance care planning used was having expressed a preference for place of death and this being recorded by healthcare staff. Analysis was conducted using logistic regression models. Results Decedents with a recorded preference for place of death had significantly greater odds of dying at home rather than in hospital (OR 6.25; 99% CI 5.56 to 7.14) and in a care home rather than in hospital (OR 2.70; 99% CI 2.33 to 3.13). They also had significantly greater odds of receiving sufficient support to be cared for and to die at home, of receiving ‘outstanding’ or ‘excellent’ care, and of having pain relieved ‘completely, all the time’ while being cared for at home. Conclusions Advance care planning was found to be strongly associated with lower rates of hospital death and a range of quality outcomes. These findings provide support for the emphasis on advance care planning in end of life care policy in England, while also suggesting the need for further research to better understand the mechanisms underlying these relationships.
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Affiliation(s)
- Josie Dixon
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science, London, UK
| | - Derek King
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science, London, UK
| | - Martin Knapp
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science, London, UK
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46
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Davies A, Todd J, Bailey F, Gregory A, Waghorn M. Good concordance between patients and their non-professional carers about factors associated with a ‘good death’ and other important end-of-life decisions. BMJ Support Palliat Care 2016; 9:340-345. [DOI: 10.1136/bmjspcare-2015-001085] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 04/12/2016] [Accepted: 04/27/2016] [Indexed: 11/04/2022]
Abstract
ObjectivesThe aim of this study was to investigate concordance between patients and non-professional carers about factors associated with a ‘good death’ and other end-of-life decisions.MethodsPatients completed a questionnaire about end-of-life care issues, and were asked to rank the importance of factors linked to a ‘good death’. Carers also completed a questionnaire about end-of-life care issues relating to the patient, and whether or not they agreed with those choices (ie, medical treatments, PPD). Carers were also asked to rank the importance of factors linked to a ‘good death’ to the patient, and to them personally at that point in time.ResultsOnly 69% of patients stated they had discussed their preferences for end-of-life care with their respective carer. The rankings were similar for the patient and the carer's views of what was important for the patient, although the patients ranked ‘to be involved in decisions about my care’ as less important than the carers, while the carers ranked ‘to have sorted out my personal affairs’ as less important than the patients.ConclusionsWhen discussions around end-of-life choices do occur, carers generally appear to agree with the patients' preferences around end-of-life treatment, and preferred place of death.
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Okamoto Y, Fukui S, Yoshiuchi K, Ishikawa T. Do Symptoms among Home Palliative Care Patients with Advanced Cancer Decide the Place of Death? Focusing on the Presence or Absence of Symptoms during Home Care. J Palliat Med 2016; 19:488-95. [DOI: 10.1089/jpm.2015.0184] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Yuko Okamoto
- Department of Community Health Nursing, Graduate School of Nursing, Japanese Red Cross University, Tokyo, Japan
| | - Sakiko Fukui
- Department of Community Health Nursing, Graduate School of Nursing, Japanese Red Cross University, Tokyo, Japan
| | - Kazuhiro Yoshiuchi
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takako Ishikawa
- Department of Community Health Nursing, Graduate School of Nursing, Japanese Red Cross University, Tokyo, Japan
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Gágyor I, Himmel W, Pierau A, Chenot JF. Dying at home or in the hospital? An observational study in German general practice. Eur J Gen Pract 2016; 22:9-15. [DOI: 10.3109/13814788.2015.1117604] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Dixon J, Matosevic T, Knapp M. The economic evidence for advance care planning: Systematic review of evidence. Palliat Med 2015; 29:869-84. [PMID: 26060176 DOI: 10.1177/0269216315586659] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Advance care planning is a process of discussion and review concerning future care in the event of losing capacity. Aimed at improving the appropriateness and quality of care, it is also often considered a means of making better use of healthcare resources at the end of life. AIM To review and summarise economic evidence on advance care planning. DESIGN A systematic review of the academic literature. DATA SOURCES We searched for English language, peer-reviewed journal articles, 1990-2014, using relevant research databases: PubMed, ProQuest, CINAHL Plus with Full Text; EconLit, PsycINFO, SocINDEX with Full Text and International Bibliography of the Social Sciences. Empirical studies using statistical methods in which advance care planning and costs are variables were included. RESULTS There are no published cost-effectiveness studies. Included studies focus on healthcare savings, usually associated with reduced demand for hospital care. Advance care planning appears to be associated with healthcare savings for some people in some circumstances, such as people living with dementia in the community, people in nursing homes or in areas with high end-of-life care spending. There is no evidence that advance care planning is likely to be more expensive. CONCLUSION There is need for clearer articulation of the likely mechanisms by which advance care planning can lead to reduced care costs or improved cost-effectiveness, particularly for people who retain capacity. There is also a need to consider wider costs, including the costs of advance care planning facilitation or interventions and the costs of substitute health, social and informal care. Economic outcomes need to be considered in the context of quality benefits.
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Affiliation(s)
- Josie Dixon
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science (LSE), London, UK
| | - Tihana Matosevic
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science (LSE), London, UK
| | - Martin Knapp
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science (LSE), London, UK
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Abstract
Background Older people living in care homes often have limited life expectancy. Practitioners and policymakers are increasingly questioning the appropriateness of many acute hospital admissions and the quality of end-of-life care provided in care homes. Aim To describe care home residents’ trajectories to death and care provision in their final weeks of life. Design and setting Prospective study of residents in six residential care homes in three sociodemographically varied English localities: Hertfordshire, Essex, and Cambridgeshire. Method Case note reviews and interviews with residents, care home staff, and healthcare professionals. Results Twenty-three out of 121 recruited residents died during the study period. Four trajectories to death were identified: ‘anticipated dying’ with an identifiable end-of-life care period and death in the care home (n = 9); ‘unexpected dying’ with death in the care home that was not anticipated and often sudden (n = 3); ‘uncertain dying’ with a period of diagnostic uncertainty or difficult symptom management leading to hospital admission and inpatient death (n = 7); and ‘unpredictable dying’ with an unexpected event leading to hospital admission and inpatient death (n = 4). End-of-life care tools were rarely used. Most residents who had had one or more acute hospital admission were still alive at the end of the study. Conclusion For some care home residents there was an identifiable period when they were approaching the end-of-life and planned care was put in place. For others, death came unexpectedly or during a period of considerable uncertainty, with care largely unplanned and reactive to events.
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