Patient choice regarding place of death

Using A Quality Framework to Assess Rural Palliative Care

Introduction: High-quality palliative care may remain out of reach for rural people who are dying. The purpose of this study was to explore the opportunities and issues affecting the provision of high-quality palliative care from the perspective of nurses employed in two rural health regions. Method: Using an interpretive descriptive design, focus groups and in-depth individual interviews of 44 nurses were conducted. Results: Descriptions of challenges and opportunities fell into three themes: effectiveness and safety, patient-cen-tredness, and efficiency and timeliness. Patient-cen-tredness was seen as a major strength of rural palliative care. Major challenges included provision of adequate symptom management and support of home deaths. The scarcity of health human resources and the negative impact these shortages had on all dimensions of palliative care quality consistently underpinned the discussions. Conclusion: Implementing outcome measurements related to symptom management and home deaths may be a critical foundation for enhancing the quality of rural palliative care.

Preference for place of death in Germany

BACKGROUND

Dying in the preferred place is considered a key requirement for a "good death." The aims of our study were to explore preferred places of death of deceased people and their bereaved relatives in Rhineland-Palatinate (Germany). We further wanted to assess the congruence between preferred and actual place of death.

METHODS

The cross-sectional study was based on a random sample of 5000 inhabitants of Rhineland-Palatinate (Germany) who died between May 25 and August 24, 2008. Relatives of these deceased persons were interviewed by a written survey.

RESULTS

After removing duplicates, 4967 questionnaires were sent out, 3832 delivered, and 1378 completed, yielding a response rate of 36.0%. Regarding the deceased, 93.8% wanted to die at home, 0.7% in a hospital, 2.8% in palliative care, 2.4% in a nursing home, and 0.3% elsewhere. The figures for the relatives were 80.7%, 4.3%, 7.5%, 7.1%, and 0.5%, respectively. Of the deceased 58.9% and of the relatives 59.1% had their wish fulfilled. Logistic regression analysis revealed that living in a rural municipality (adjusted odds ratio [aOR]: 1.88; 95% confidence interval [CI]: 1.02-3.43), rural town (aOR: 2.30; 95% CI: 1.17-4.49) or small town (aOR: 1.95; 95% CI: 1.04-3.68), having a nonworking relative (aOR: 1.79; 95% CI: 1.16-2.76), and living together with a relative (aOR: 2.28; 95% CI:1.57-3.32) increases the probability to die in the preferred place.

DISCUSSION

Because the availability of a relative was the most important factor to die in the preferred place, relatives of dying people should be supported in providing informal care. The introduction of palliative home care teams should allow more people to die in their preferred place by easing the burden of informal carers.

Factors influencing place of death in Germany

CONTEXT

Knowledge about factors influencing the place of death may be very useful for the planning of public health strategies to improve the situation of terminally ill patients.

OBJECTIVES

The aim of our study was to determine where people died in the German federal state of Rhineland-Palatinate in 2008. We further wanted to detect which factors had an influence on the place of death.

METHODS

Our cross-sectional survey was based on a random sample of 5000 inhabitants of Rhineland-Palatinate who had died between May 25, 2008 and August 24, 2008. Relatives of these randomly drawn deceased persons were interviewed by means of a written survey.

RESULTS

After removing duplicates, 4967 questionnaires were sent out. In total, 3832 questionnaires were delivered and 1378 completed, leading to a response rate of 36.0%. Of this group, 38.2% of the deceased died at home, 39.3% in a hospital, 13.4% in a nursing home, 7.5% in a palliative care facility, and 1.6% elsewhere. Suffering from cancer (adjusted odds ratio [AOR]: 1.30; 95% confidence interval [CI]: 1.01-1.68), social support (AOR being married: 1.33; 95% CI: 1.04-1.70; AOR having a nonworking relative: 1.71; 95% CI: 1.28-2.29), a high care level (AOR Care Level II: 2.79; 95% CI: 2.06-3.79, AOR Care Level III: 4.96; 95% CI: 3.40-7.24), and living in a rural municipality (AOR: 1.36; 95% CI: 1.01-1.84) were major factors favoring home death compared with institutional death.

CONCLUSION

Compared with other European countries, home death is still a frequent event in the federal state of Rhineland-Palatinate. Regional health policy should consider the actual distribution of place of death and corresponding predicting factors when establishing specialized palliative care home services as designed by recent German health legislation.

GPs' awareness of patients' preference for place of death

BACKGROUND

Being able to die in one's place of choice is an indicator of the quality of end-of-life care. GPs may play a key role in exploring and honouring patients' preferences for place of death.

AIM

To examine how often GPs are informed about patients' preferred place of death, by whom and for which patients, and to study the expressed preferred place of death and how often patients die at their preferred place.

DESIGN OF STUDY

One-year nationwide mortality retrospective study.

SETTING

Sentinel Network of GPs in Belgium, 2006.

METHOD

GPs' weekly registration of all deaths (patients aged =1 year).

RESULTS

A total of 798 non-sudden deaths were reported. GPs were informed of patients' preferred place of death in 46% of cases. GPs obtained this information directly from patients in 63%. GP awareness was positively associated with patients not being hospitalised in the last 3 months of life (odds ratio [OR] = 3.9; 95% confidence interval [CI] = 2.8 to 5.6), involvement of informal caregivers (OR = 3.3; 95% CI = 1.8 to 6.1), use of a multidisciplinary palliative care team (OR = 2.5; 95% CI = 1.8 to 3.5), and with presence of more than seven contacts between GP and patient or family in the last 3 months of life (OR = 3.0; 95% CI = 2.2 to 4.3). In instances where GPs were informed, more than half of patients (58%) preferred to die at home. Overall, 80% of patients died at their preferred place.

CONCLUSION

GPs are often unaware of their patients' preference for place of death. However, if GPs are informed, patients often die at their preferred location. Several healthcare characteristics might contribute to this and to a higher level of GP awareness.

[Patient-controlled analgesia (PCA) in outpatients with cancer pain. Analysis of 1,692 treatment days]

INTRODUCTION

In the home-care setting, cancer pain patients in need of parenteral analgesia have to be switched to patient-controlled analgesia using portable pumps. But there is a paucity on data on the logistic requirements or the success rate of such a cost-intensive therapy performed by specialized home-care services.

METHODS

In a retrospective study we analyzed data on care intensity, logistics and outcome of 46 consecutive palliative cancer patients with patient-controlled analgesia (PCA) in a home-care setting.

RESULTS

On days 1, 2, and 3 of PCA the switch to parenteral analgesia resulted in a significant increase of the median daily opioid dose in comparison to the dose just prior to PCA. Concurrently, pain scores were significantly reduced. The median duration of PCA was 25 days (range 2-189 days). On average, each patient was seen by the home-care team every 7.4 days. The median duration of the home visits was 60 min (range, 10-190 min). Of the visits 20% were unscheduled, most of these visits being due to problems regarding analgesia. Most patients died at home. Insufficient analgesia required prefinal hospitalization in only a single case.

CONCLUSION

If the indications are correct, intravenous PCA for palliative cancer pain patients results in higher opioid consumption and better pain control. Home-care PCA requires a lot of human and financial resources, but pain-related hospitalization can be prevented.