Congruence between preferred and actual place of care and death among Danish cancer patients

Barriers and facilitators for place of death: A scoping review

OBJECTIVES

Many factors influence where people die, but most people prefer to die at home. Investigating the factors affecting death at different locations can enhance end-of-life care and enable more people to die at their preferred place. The aim was to investigate barriers and facilitators affecting place of death and compare facilitators and barriers across different places of death.

METHODS

A scoping review registered on Open Science Framework was conducted in accordance with the guidelines for Scoping Reviews (PRISMA-ScR). An electronic search of literature was undertaken in MEDLINE, EMBASE, PUBMED, PsycINFO, and CINAHL covering the years January 2013-December 2023. Studies were included if they described barriers and/or facilitators for place of death among adults.

RESULTS

This review identified 517 studies, and 95 of these were included in the review. The review identified the following themes. Illness factors: disease type, dying trajectory, treatment, symptoms, and safe environment. Individual factors: sex, age, ethnicity, preferences, and for environmental factors the following were identified: healthcare inputs, education and employment, social support, economy, and place of residence.

SIGNIFICANCE OF RESULTS

The factors influencing place of death are complex and some have a cumulative impact affecting where people die. These factors are mostly rooted in structural aspects and make hospital death more likely for vulnerable groups, who are also less likely to receive palliative care and advanced care planning. Disease type and social support further impact the location of death. Future research is needed regarding vulnerable groups and their preferences for place of death.

Prospective Study of Preferred Versus Actual Place of Death Among Swedish Palliative Cancer Patients

Background: The place of death of cancer patients is an important aspect of end-of-life care. However, little research has been conducted regarding factors that may influence the preferred and actual place of death in cancer patients and whether the patients die at their preferred place of death. In this study, we aimed to investigate the preferred and actual place of death for palliative cancer patients, and factors influencing these variables. Methods: Patients diagnosed with cancer and admitted to a palliative care team across three Swedish cities between 2019 and 2022 were asked for participation. Participants completed a questionnaire capturing sociodemographic data and preferred place of death. Further data regarding age, sex, and cancer type were collated at inclusion, and the actual place of death recorded for those deceased by 5-May-2023. Results: The study included 242 patients. A majority (79%) wanted to die at home which was the actual death location for 76% of the patients. When the place-of-death decision was made by the patient alone, 75% chose home, compared to 96% when decided jointly with relatives-a statistically significant variation (p = 0.0037). For the patients who wanted to die at home, 80% actually died at home, with insignificant disparities among subgroups. Conclusions: Most palliative cancer patients in this Swedish cohort preferred and achieved death at home. Involving relatives in decision-making may influence the preferred place of death, however larger studies are needed to comprehensively assess factors affecting the preferred and actual place of death in different subgroups of patients.

Factors associated with emergency admission for people dying from cancer in Northern Ireland: an observational data linkage study

BACKGROUND

Many people living with cancer are admitted as an emergency, some just prior to diagnosis and others in their last year of life. Factors associated with accessing emergency care for people dying of cancer are complex and not well understood. This can make it difficult to have the resources and staffing in place to best care for individuals in their last year of life and their families.

METHODS

This study uses routinely collected administrative data from people who died of cancer in N. Ireland (NI) during 2015 and explores how personal characteristics (e.g., gender, age) and disease related factors (e.g., tumour site, cancer stage at initial diagnosis) were associated with having an emergency admission to hospital in the last year and the last 28 days of their lives, using multivariate logistic regression.

RESULTS

Almost three in four people had at least one emergency admission in the last year of life, and over one in three had an emergency admission the last 28 days of life. Patterns were similar for both time outcomes with males, people with haematological, lung or brain cancers, younger persons, those diagnosed with late-stage cancer, and people diagnosed close to time of death, being significantly more likely to have an emergency admission. While there was no significant association between deprivation and emergency admission rates, those living in urban areas were more likely to have an emergency admission in their last month of life compared to rural dwellers. Late diagnosis was evident with 538 people (12.8% of all deaths from cancer) being diagnosed within one month of death and 1242 (29%) within 3 months of death.

CONCLUSION

The high level of emergency admissions points to gaps in routine end-of-life care, and the need for additional training for hospital staff including frontline emergency department (ED) staff who are often the 'gatekeepers' to emergency inpatient care for people living with cancer. The levels of late diagnosis indicate a need for increased population awareness of cancer symptoms and system change to promote earlier diagnosis.

Preferred versus Actual Place of Care and Factors Associated with Home Discharge among Korean Patients with Advanced Cancer: A Retrospective Cohort Study

Respecting the preference for a place of care is essential for advance care planning in patients with advanced cancer. This retrospective study included adult patients with cancer referred to an inpatient palliative care consultation team at a tertiary acute care hospital in South Korea between April 2019 and December 2020. Patients' preference for place of care and demographic and clinical factors were recorded, and the actual discharge locations were categorized as home or non-home. Patients discharged home but with unintended hospital visits within 2 months were also investigated. Of the 891 patients referred to the palliative care consultation team, 210 (23.6%) preferred to be discharged home. Among them, 113 (53.8%) were discharged home. No significant differences were found between patients who preferred home discharge and those who did not. Home discharge was higher among female patients (p = 0.04) and lower in those with poor oral intake (p < 0.001) or dyspnea (p = 0.02). Of the 113 patients discharged home, 37 (32.8%) had unintended hospital visits within 2 months. Approximately one-quarter of hospitalized patients with advanced cancer preferred to be discharged home, but only half of them received the home discharge. To meet patients' preferences for end-of-life care, individual care planning considering relevant factors is necessary.

The 'good death' in Mainland China - A Scoping Review

Background

Since the mid 80'ies, the western palliative care philosophy has influenced the development of palliative care in mainland China. However, it has caused several challenges.

Objective

To explore the understanding of the 'good death' among authorities, professionals, patients, and their relatives in end-of-life care settings in mainland China.

Design

Scoping review. The PRISMA-ScR checklist was used. The study is not registered.

Settings

End-of-life care settings, Mainland China.

Participants

Authorities, healthcare professionals, adult patients, and general population in mainland China.

Method

Literature searches were performed through Medline, CINAHL, PsycInfo, and Web of Sciences from 2001-2021, last search 21.4.2021. Inclusion criteria were: Empirical research studies investigating 'good death' or political documents about 'good death', perspectives from authorities, professionals, patients, and/or relatives, and studies following the Declaration of Helsinki. Exclusion criteria were: Literature reviews, languages other than English and Chinese, editorials, letters, comments, and children's death/dying.The analysis consisted of analysing the data including a descriptive numerical summary analysis and a qualitative thematic analysis.

Results

Nineteen articles and two political documents were included. The 19 studies were carried out from 2003-2020, with data collected from 1999 to 2019. The political documents were written in 2012 and 2017, respectively. The thematic analysis resulted in three themes: 'Medicalisation of death', 'Communication about death - a clash between two philosophies', and 'Dying and death were socially dependent'. The medicalisation of death meant the understanding of the 'good death' primarily focused on physical symptoms and treatments. The good death was understood as painless and symptom-free, where all symptoms could be measured and assessed. Dignity and shared decision-making were connected to the understanding of the 'good death'. However, the contents of the 'good death' varied across the different actors. The understanding of the 'good death' in mainland China was a negotiation between Chinese traditional philosophy and contemporary western medicine practice. There was a tension between openness and silence about death, which reflected the importance of death education. The understanding of the 'good death' consisted partly of a timely and practical preparation for the death and afterlife, partly of a matter of social and financial issues.

Conclusions

There seemed to be a clash between two different cultures in the understanding of a good death in Mainland China, where western philosophy seemed to rule the political medical actors while traditional Chinese philosophy seemed to rule parts of the population.

The quality of end-of-life care for Danish cancer patients who have received non-specialized palliative care: a national survey using the Danish version of VOICES-SF

PURPOSE

About half of Danish patients dying from cancer have never been in contact with specialized palliative care. Non-specialized palliative care in Denmark, i.e., somatic hospital departments, community nurses, and general practitioners, has rarely been described or evaluated. We aim to assess how non-specialized palliative care was evaluated by bereaved spouses, and to test whether distress when completing the questionnaire and ratings of aspects of end-of-life care was associated with satisfaction with place of death and overall quality of end-of-life care.

METHODS

Bereaved spouses of 792 cancer patients who had received non-specialized palliative care were invited to answer the Views of Informal Carers-Evaluation of Services-Short Form (VOICES-SF) and the Hospital Anxiety and Depression Scale (HADS) 3-9 months after the patient's death.

RESULTS

A total of 280 (36%) of invited spouses participated. In the last 3 months of the patient's life, the quality of all services taken together was rated as good, excellent, or outstanding in 70% of the cases. Satisfaction was associated with respondent's current distress (p = 0.0004). Eighty percent of bereaved spouses believed that the patient had died in the right place. Satisfaction with place of death was associated with place of death (p = 0.012) and the respondent's current distress (p = 0.0016).

CONCLUSION

Satisfaction with place of death and overall quality of services was generally high but was rated lower by spouses reporting higher levels of distress when completing the questionnaire. Distress should be taken into account whenever services are evaluated by bereaved relatives.

Preferred place of death and end-of-life care for adult cancer patients in Iran: A cross-sectional study

Background

More than 50,000 deaths in terms of cancer occur annually in Iranian hospitals. Determining the preferred place of end-of-life care and death for cancer patients in Iran is a quality marker for good end-of-life care and good death. The purpose of this study was to determine the preferred place of end-of-life care and death in cancer patients.

Method

In 2021, the current descriptive cross-sectional investigation was carried out. Using the convenience sample approach, patients were chosen from three Tehran referral hospitals (the capital of Iran). A researcher-made questionnaire with three parts for demographic data, clinical features, and two questions on the choice of the desired location for end-of-life care and the death of cancer patients served as the data collecting instrument. Data were analyzed using SPSS software version 18. The relationship between the two variables preferred place for end-of-life care and death and other variables was investigated using chi-square, Fisher exact test, and multiple logistic regression.

Result

The mean age of patients participating in the study was 50.21 ± 13.91. Three hundred ninety (69.6%) of the patients chose home, and 170 (30.4%) patients chose the hospital as the preferred place of end-of-life care. Choosing the home as a preferred place for end-of-life care had a significant relationship with type of care (OR = .613 [95% CI: 0.383–0.982], P = .042), level of education (OR = 2.61 [95% CI: 1.29–5.24], P = 0.007), type of cancer (OR = 1.70 [1.01–2.89], P = .049), and income level (Mediate: (OR: 3.27 (1.49, 7.14), P = .003) and Low: (OR: 3.38 (1.52–7.52), P = .003). Also, 415 (75.2%) patients chose home and 137 (24.8%) patients chose hospital as their preferred place of death. Choosing the home as a preferred place of death had a significant relationship with marriage (OR = 1.62 [95% CI: 1.02–2.57], P = .039) and time to diagnostic disease less than 6 months (OR = 1.62 [95% CI: 0.265–0.765], P = .002).

Conclusion

The findings of the current research indicate that the majority of cancer patients selected their homes as the preferred location for end-of-life care and final disposition. Researchers advise paying more attention to patients’ wishes near the end of life in light of the findings of the current study. This will be achieved by strengthening the home care system using creating appropriate infrastructure, insurance coverage, designing executive instructions, and integration of palliative care in home care services.

Finding their place - general practitioners' experiences with palliative care-a Norwegian qualitative study

BACKGROUND

Modern palliative care focuses on enabling patients to spend their remaining time at home, and dying comfortably at home, for those patients who want it. Compared to many European countries, few die at home in Norway. General practitioners' (GPs') involvement in palliative care may increase patients' time at home and achievements of home death. Norwegian GPs are perceived as missing in this work. The aim of this study is to explore GPs' experiences in palliative care regarding their involvement in this work, how they define their role, and what they think they realistically can contribute towards palliative patients.

METHODS

We performed focus group interviews with GPs, following a semi-structured interview guide. We included four focus groups with a total of 25 GPs. Interviews were recorded and transcribed verbatim. We performed qualitative analysis on these interviews, inspired by interpretative phenomenological analysis.

RESULTS

Strengths of the GP in the provision of palliative care consisted of characteristics of general practice and skills they relied on, such as general medical knowledge, being coordinator of care, and having a personal and longitudinal knowledge of the patient and a family perspective. They generally had positive attitudes but differing views about their formal role, which was described along three positions towards palliative care: the highly involved, the weakly involved, and the uninvolved GP.

CONCLUSION

GPs have evident strengths that could be important in the provision of palliative care. They rely on general medical knowledge and need specialist support. They had no consensus about their role in palliative care. Multiple factors interact in complex ways to determine how the GPs perceive their role and how involved they are in palliative care. GPs may possess skills and knowledge complementary to the specialized skills of palliative care team physicians. Specialized teams with extensive outreach activities should be aware of the potential they have for both enabling and deskilling GPs.

Levels and Determinants of Place-Of-Death Congruence in Palliative Patients: A Systematic Review

Introduction: Congruence, understood as the agreement between the patient's preferred place of death and their actual place of death, is emerging as one of the main variables indicating the quality of end-of-life care. The aim of this research was to conduct a systematic literature review on levels and determinants of congruence in palliative patients over the period 2010-2021. Method: A systematic review of the literature in the databases of PubMed, Scopus, Web of Science, PsycINFO, CINAHL, Cuiden, the Cochrane Library, CSIC Indexes, and IBECS. Information was extracted on research characteristics, congruence, and associated factors. Results: A total of 30 studies were identified, mainly of retrospective observational design. The congruence values varied substantially between the various studies, ranging from 21 to 100%. The main predictors of congruence include illness-related factors (functional status, treatments and diagnosis), individual factors (age, gender, marital status, and end of life preferences), and environmental factors (place of residence, availability of health, and palliative care services). Conclusion: This review, in comparison with previous studies, shows that treatment-related factors such as physical pain control, marital status, having a non-working relative, age, discussing preferred place of death with a healthcare professional, and caregiver's preference have been associated with higher levels of congruence. Depending on the study, other factors have been associated with either higher or lower congruence, such as the patient's diagnosis, gender, or place of residence. This information is useful for designing interventions aimed towards greater congruence at the end of life.

Patients' preferred place of death: patients are willing to consider their preferences, but someone has to ask them

Background

end-of-life care is not always in line with end-of-life preferences, so patients do not always die at their preferred place of death (PPD). This study aims to identify factors associated with patients’ PPD and changes in PPD.

Methods

we prospectively collected data on PPD at four time points within 6 months from 230 acutely hospitalised older patients who were part of the control group in a stepped-wedge randomised controlled trial. Associations between patient characteristics and preferences were calculated using multivariable (multinomial) logistic regression analysis.

Results

the mean age of participants was 80.7 years. 47.8% of the patients had no PPD at hospital admission. Patients previously admitted to hospital preferred to die at home (home versus no preference: odds ratio [OR] 2.38, 95% confidence interval [CI] 1.15–4.92; home versus healthcare facility: OR 3.25, 95% CI 1.15–9.16). Patients with more chronic diseases preferred the healthcare facility as their PPD (healthcare facility versus no preference: OR 1.33, 95% CI 1.09–1.61; healthcare facility versus home: OR 1.21, 95% CI 1.00–1.47). 32 of 65 patients changed their preference during follow-up, and most of these had no PPD at hospital admission (home versus no preference: OR 0.005, 95% CI ≤0.001–0.095) and poorer self-rated well-being (OR 1.82, 95% CI 1.07–3.08).

Conclusions

almost half of the patients had no PPD at baseline. Previous hospital admission, having more chronic diseases and living alone are associated with having a PPD. Introducing PPD could make older people aware of PPD and facilitate optimal palliative care.

Symptom Prevalence and Place of Death Preference in Advanced Cancer Patients: Factors Associated With the Achievement of Home Death

Objectives:

Achievement of patients’ preferred place of death is recognized as a component of a good death. This study aimed to investigate the symptom burden in advanced cancer patients, achievement of their place of death preferences and factors associated with home death.

Methods:

In this retrospective review of 287 patient deaths, we examined patients’ symptom prevalence, preferred and actual place of death and achievement of their place of death preferences using descriptive statistics. Associations between patient factors, home death preference and actual home death were further analyzed using multivariate logistic regression.

Results:

The most prevalent symptoms were weakness, pain and poor appetite, with a mean of 5.77(SD: 2.37) symptoms per patient. The median interval from palliative care referral to death was 21 (IQR: 74) days. Of the 253 patients with documented place of death preference, 132 (52.1%) preferred home death, 111(43.9%) preferred hospital death, 1 (0.4%) preferred to die at a temple and 9(3.6%) expressed no preference. Overall, 221 of 241(91.7%) patients with known actual place of death achieved their preference. Older patients were more likely to prefer home death (OR 1.021; 95% CI 1.004-1.039, p = 0.018) and die at home (OR 1.023; 95% CI 1.005-1.041, p = 0.014). Gender, marital status, cancer diagnosis and symptoms were not associated with preference for or actual home death.

Conclusion:

Despite a high symptom burden, most patients preferred and achieved a home death. Late palliative care referral and difficult symptom management contributed to failure to fulfill home death preference. Preference for home death should be considered when managing terminally ill geriatric patients.

Health care utilization at end of life among patients with lung or pancreatic cancer. Comparison between two Swedish cohorts

Objectives

The purpose was to analyze trends in intensity of care at End-of-life (EOL), in two cohorts of patients with lung or pancreatic cancer.

Setting

We used population-based registry data on health care utilization to describe proportions and intensity of care at EOL comparing the two cohorts (deceased in the years of 2010 and 2017 respectively) in the region of Stockholm, Sweden.

Primary and secondary outcomes

Main outcomes were intensity of care during the last 30 days of life; systemic anticancer treatment (SACT), emergency department (ED) visits, length of stay (LOS) > 14 days, intensive care (ICU), death at acute care hospital and lack of referral to specialized palliative care (SPC) at home. The secondary outcomes were outpatient visits, place of death and hospitalizations, as well as radiotherapy and major surgery.

A multivariable logistic regression analysis was used for associations. A moderation variable was added to assess for the effect of SPC at home between the cohorts.

Results

Intensity of care at EOL increased over time between the cohorts, especially use of SACT, increased with 10%, p<0.001, (n = 102/754 = 14% to n = 236/972 = 24%), ED visits with 7%, p<0.001, (n = 25/754 = 3% to n = 100/972 = 10%) and ICU care, 2%, p = 0.04, (n = 12/754 = 2% to n = 38/972 = 4%). High intensity of care at EOL were more likely among patients with lung cancer. The difference in use of SACT between the years, was moderated by SPC, with an increase of SACT, unstandardized coefficient β; 0.87, SE = 0.27, p = 0.001, as well as the difference between the years in death at acute care hospitals, that decreased (β = 0.69, SE = 0.26, p = 0.007).

Conclusion

These findings underscore an increase of several aspects regarding intensity of care at EOL, and a need for further exploration of the optimal organization of EOL care. Our results indicate fragmentation of care and a need to better organize and coordinate care for vulnerable patients.

What Variables Contribute to the Achievement of a Preferred Home Death for Cancer Patients in Receipt of Home-Based Palliative Care in Canada?

BACKGROUND

Home is often deemed to be the preferred place of death for most patients. Knowing the factors related to the actualization of a preferred home death may yield evidence to enhance the organization and delivery of healthcare services.

OBJECTIVE

The objectives of this study were to measure the congruence between a preferred and actualized home death among cancer patients in receipt of home-based palliative care in Canada and explore predictors of actualizing a preferred home death.

METHODS

A longitudinal prospective cohort design was conducted. A total of 290 caregivers were interviewed biweekly over the course of patients' palliative care trajectory between July 2010 and August 2012. Cross-tabulations and multivariate analyses were used in the analysis.

RESULTS

Home was the most preferred place of death, and 68% of patients who had voiced a preference for home death had their wish fulfilled. Care context variables, such as living with others and the intensity of home-based nursing visits and hours of care provided by personal support workers (PSW), contributed to actualizing a preferred home death. The intensity of emergency department visits was associated with a lower likelihood of achieving a preferred home death.

CONCLUSIONS

Higher intensity of home-based nursing visits and hours of PSW care contribute to the actualization of a preferred home death.

IMPLICATIONS FOR PRACTICE

This study has implications for policy decision-makers and healthcare managers. Improving and expanding the provision of home-based PSW and nursing services in palliative home care programs may help patients to actualize a preferred home death.

The Compliance of End-of-Life Care Preferences Among Older Adults and Its Facilitators and Barriers: A Scoping Review

OBJECTIVES

To explore the compliance of end-of-life (EOL) care preferences, and the facilitators and barriers of promoting quality of EOL care among older adults.

DESIGN

A scoping review was used to identify key themes in the compliance of EOL care preferences among older adults.

SETTING AND PARTICIPANTS

Studies published between 2009 and 2020 were identified from the Medline and Cochrane libraries. Eligible articles containing components related to the compliance of EOL care preferences among older adults were selected.

MEASURES

The eligible articles were thematically synthesized. Factors that affected the compliance of EOL care preferences among older adults were identified from the key components.

RESULTS

In total, 35 articles were included to identify the key components in the compliance of EOL care preferences: (1) supportive policy, (2) supportive environment, (3) cultural characteristics, (4) advance care planning (ACP), (5) the concordance of EOL care preferences between patients and surrogate decision makers, (6) prognosis awareness, and (7) patient's health status and the type of disease. Facilitators for the compliance of EOL care preferences included enactment of relevant policy, sufficient care institutions, the utilization of ACP, and poor health status. Barriers included lack of supportive policy, different culture, and low utilization of ACP.

CONCLUSIONS/IMPLICATIONS

The compliance of EOL care preferences was low among older adults. The compliance of EOL care preferences can be improved through relevant policy development and the utilization of ACP.

Palliative care in general practice; a questionnaire study on the GPs role and guideline implementation in Norway

Background

Patients in need of palliative care often want to reside at home. Providing palliative care requires resources and a high level of competence in primary care. The Norwegian guideline for palliative care points to the central role of the regular general practitioner (RGP), specifying a high expected level of competence. Guideline implementation is known to be challenging in primary care. This study investigates adherence to the guideline, the RGPs experience with, and view of their role in palliative care.

Methods

A questionnaire was distributed, by post, to all 246 RGPs in a Norwegian county. Themes of the questionnaire focused on experience with palliative and terminal care, the use of recommended work methods from the guideline, communication with partners, self-reported role in palliative care and confidence in providing palliative care. Data were analyzed descriptively, using SPSS.

Results

Each RGP had few patients needing palliative care, and limited experience with terminal care at home. Limited experience challenged RGPs possibilities to maintain knowledge about palliative care. Their clinical approach was not in agreement with the guideline, but most of them saw themselves as central, and were confident in the provision of palliative care. Rural RGPs saw themselves as more central in this work than their urban colleagues.

Conclusions

This study demonstrated low adherence of the RGPs, to the Norwegian guideline for palliative care. Guideline requirements may not correspond with the methods of general practice, making them difficult to adopt. The RGPs seemed to have too few clinical cases over time to maintain skills at a complex and specialized level. Yet, there seems to be a great potential for the RGP, with the inherent specialist skills of the general practitioner, to be a key worker in the palliative care trajectory.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01426-8.

[Mortality and use of healthcare resources in elderly patients in Seville: Differences between institutionalised patients and those included in a home care program]

OBJECTIVES

Society is ageing, and as a consequence, the population with increased frailty and comorbidity is growing. The aim is to analyse the mortality and its potential factors, as well as the use of healthcare resources in elderly patients, and to study the differences between institutionalised patients and those included in a home care program.

MATERIALS AND METHODS

An observational, longitudinal and prospective cohort study was conducted in Seville during 2016. The study subjects consisted of 1314 elderly patients (1061 institutionalised and 253 at home). The variables studied included mortality and its potential factors, and the use of healthcare resources.

RESULTS

No differences were found in mortality between institutionalised and home care program patients (RR=1.044; 95% CI; 0.74-1.46; P=.799). The leading cause of death was circulatory diseases followed by respiratory diseases. Among the factors explaining the mortality, it is important to highlight: age, dependency and admissions in the hospital or the emergency department. The patient's functional independence is associated with a higher survival rate. Differences were found between both groups in the number of calls to the Critical Care and Emergency Services (P=.022) or the primary care doctor (P<.001) and in the hospital admissions (P<.001), the first 2differences being higher in home care program patients, and the latter in institutionalised patients.

CONCLUSIONS

There are no differences between groups either in the mortality or in the cause of death. Age, functional dependency and admissions in the hospital are factors which explain the mortality. The use of healthcare resources is higher in patients at home.

Hospitalisation at the end of life among cancer and non-cancer patients in Denmark: a nationwide register-based cohort study

OBJECTIVES

End-of-life hospitalisations may not be associated with improved quality of life. Studies indicate differences in end-of-life care for cancer and non-cancer patients; however, data on hospital utilisation are sparse. This study aimed to compare end-of-life hospitalisation and place of death among patients dying from cancer, heart failure or chronic obstructive pulmonary disease (COPD).

DESIGN

A nationwide register-based cohort study.

SETTING

Data on all in-hospital admissions obtained from nationwide Danish medical registries.

PARTICIPANTS

All decedents dying from cancer, heart failure or COPD disease in Denmark between 2006 and 2015.

OUTCOME MEASURES

Data on all in-hospital admissions within 6 months and 30 days before death as well as place of death. Comparisons were made according to cause of death while adjusting for age, sex, comorbidity, partner status and residential region.

RESULTS

Among 154 235 decedents, the median total bed days in hospital within 6 months before death was 19 days for cancer patients, 10 days for patients with heart failure and 11 days for patients with COPD. Within 30 days before death, this was 9 days for cancer patients, and 6 days for patients with heart failure and COPD. Compared with cancer patients, the adjusted relative bed day use was 0.65 (95% CI, 0.63 to 0.68) for heart failure patients and 0.68 (95% CI, 0.66 to 0.69) for patients with COPD within 6 months before death. Correspondingly, this was 0.65 (95% CI, 0.63 to 0.68) and 0.70 (95% CI, 0.68 to 0.71) within 30 days before death.Patients had almost the same risk of dying in hospital independently of death cause (46.2% to 56.0%).

CONCLUSION

Patients with cancer, heart failure and COPD all spent considerable part of their end of life in hospital. Hospital use was highest among cancer patients; however, absolute differences were small.

Aims, actions and advance care planning by district nurses providing palliative care: an ethnographic observational study

District nurses are core providers of palliative care, yet little is known about the way that they provide care to people at home. This study aimed to investigate the role and practice of the district nurse in palliative care provision. This was an ethnographic study, with non-participant observation of district nurse-palliative care patient encounters, and post-observation interviews. District nurse teams from three geographical areas in northwest England participated. Data were analysed iteratively, facilitated by the use of NVivo, using techniques of constant comparison. Some 17 encounters were observed, with 23 post-observation interviews (11 with district nurses, 12 with patients/carers). Core themes were 'planning for the future' and 'caring in the moment'. District nurses described how they provided and planned future care, but observations showed that this care focused on physical symptom management. District nurses engaged in friendly relationship building, which allows detailed management of symptomatology, but with little evidence of advance care planning.

Congruence between Preferred and Actual Place of Death for Those in Receipt of Home-Based Palliative Care

Background: Understanding the factors that affect the congruence between preferred and actual place of death may help providers offer clients customized end-of-life care settings. Little is known about this congruence for cancer patients in receipt of home-based palliative care. Objectives: This study aims to determine the congruence between preferred and actual place of death among cancer patients in home-based palliative care programs. Design: A longitudinal prospective cohort study was conducted. Congruence between preferred and actual place of death was measured. Both univariate and multivariate analyses were used to assess the determinants of achieving a preferred place of death. From July 2010 to August 2012, a total of 290 caregivers were interviewed biweekly over the course of their palliative care trajectory from entry to the program and death. Results: The overall congruence between preferred and actual place of death was 71.72%. Home was the most preferred place of death. The intensity of home-based nursing visits and hours of care from personal support workers (PSWs) increased the likelihood of achieving death in a preferred setting. Conclusions: The provision of care by home-based nurse visits and PSWs contributed to achieving a greater congruence between preferred and actual place of death. This finding highlights the importance of formal care providers in signaling and executing the preferences of clients in receipt of home-based palliative care.

Advance care planning for patients and their relatives

BACKGROUND

Advance care planning (ACP) has been suggested to improve the quality of life (QoL) and mental wellbeing in severely ill patients and their relatives.

AIM

To investigate the effects of ACP among patients with lung, heart and cancer diseases with an estimated life-span of up to 12 months.

METHODS

Patients and relatives were randomised into two groups: one receiving usual care and one receiving ACP and usual care. Themes from the ACP discussion were documented in patients' electronic medical file. Participants completed self-reported questionnaires four to five weeks after randomisation.

FINDINGS

In total, 141 patients and 127 relatives participated. No significant differences were found according to outcomes. However, patients with non-malignant diseases had the highest level of anxiety and depression; these patients seemed to benefit the most from ACP, though not showing statistically significant results.

CONCLUSION

No significant effects of ACP among patients with lung, heart, and cancer diseases and their relatives regarding HRQoL, anxiety, depression, and satisfaction with healthcare were found.

Asking terminally ill patients about their preferences concerning place of care and death

BACKGROUND

Asking patients with palliative care needs about their end-of-life (EoL) preferences is widely acknowledged as an important aspect of EoL care. However, the issue of how to ask patients these questions has not been fully explored. Most prior studies in this area do not differentiate between patients' pragmatic preferences and ideal preferences, and between preferences concerning place of care (PoC) and place of death (PoD).

AIM

The aim of this study was to examine possible differences between pragmatic and ideal preferences of terminally ill patients, as well as differences between asking patients about preferences concerning PoC and PoD.

METHODS

Structured interviews were performed with terminally ill cancer patients at inclusion and a follow-up questionnaire was completed 1 month later. Answers were compared using kappa (k) statistics and Pearson's c²-test.

RESULTS

Among 96 cancer patients, agreement between pragmatic and ideal preferences was statistically significantly different (p=<0.001). Agreement between preferences for PoC and PoD was high (k:0.76-0.85).

CONCLUSION

Differences exist between pragmatic and ideal EoL preferences, whereas preferences for PoC and PoD were found to be similar. These findings highlight the importance of the phrasing of questions when uncovering patients' preferences for EoL care.

A Tripartite Model of Community Attitudes to Palliative Care

Background:

Despite a growth in palliative care services, access and referral patterns are inconsistent and only a minority of people who would benefit from such care receive it. Use of palliative care is also affected by community attitudes toward palliative care. As such, determining community attitudes toward palliative care is crucial. We also need to determine what predicts attitudes in order to provide appropriate information and education.

Objectives:

The 2 research questions were: (1) What are community attitudes toward palliative care? and (2) what are the determinants of community attitudes toward palliative care?

Design:

A tripartite model of attitudes was used, which articulates attitudes as comprising knowledge and experience, emotions, and beliefs. A cross-sectional descriptive survey was used.

Participants:

A community sample of 180 participants completed the survey.

Results:

The average attitude and belief responses were very positive, the average emotions responses were somewhat positive. The sample had good knowledge of palliative care. Lowest knowledge scores were reported for the items: “Euthanasia is not part of palliative care,” “Palliative care does not prolong or shorten life,” and “Specialist palliative care is only available in hospitals.” After controlling place of birth and age, it was found that beliefs, emotions, and knowledge each accounted for a significant proportion of unique variance in attitude toward palliative care. Each variable had a positive relationship with attitude.

Conclusion:

Beliefs, emotions, and knowledge all need to be incorporated into palliative care community education programs.

Advance care planning and place of death, hospitalisation and actual place of death in lung, heart and cancer disease: a randomised controlled trial

Objectives

Advance 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.

Methods

The 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.

Results

In 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).

Conclusion

Concerning 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 number

NCT01944813.

[A retrospective study about the influence of an emergency information form on the place of death of palliative care patients]

In palliative medicine planning in advance is important for critical care situations. It is highly significant to make useful and by the patient and his relatives desired decisions. These concern transport in a situation of crisis and the venue of death (either death at home or transfer to a hospital).In this study the effect of a new Emergency Information Form about the place of death was examined. The used Emergency Information Form enabled the patient to express a wish on transfer in the case of crisis in advance and communicate this wish to the Emergency system.A total of 858 patients, taken care of by the mobile palliative-team Hartberg/Weiz/Vorau in the period from 2010 to 2015, were included in the study. The Intervention group-the patients for whom an Emergency Information Form was established-counted 38 patients. Data analysis was retrospective, pseudo anonymized and external.The 4 most important results were:1) The Emergency Information Form increased the probability for the intervention group to die at home (intervention group: 72.2%, controll group 1: 53.0%, controll group 2: 56.6%).2) Important in this change was, that the opinion of the patients was considered. The decision made in the Emergency Information Form correlated with a high significance (p = 0.01) with the actual place of death.3) Furthermore, it came clear that the Emergency Information Form was a useful tool to handle the utilization of special facilities. Within the intervention group young patients (with a lot of symptoms) died in a special facility more often than old patients. These, rather geriatric people, were mostly brought to a general hospital.4) There was no significant relation between the duration of care and the probability that an Emergency Information Form was established (p = 0.63). However, there was a high significance between the number of home visits and the probability that an Emergency Information Form was written (p = 0.02).Due to the fact that there was a small intervention group restricted to only one palliative team further studies could help to make clear advises for palliative teams regarding scope, duration and frequency of home-visits. Thus the term "care continuity" could be concretized in the guidelines.The study brought forward that numerous (and short) contacts with the patient were more convenient than less but long home-visits in order to fulfil the patients wish concerning his place of death.

Factors Associated with Fulfilling the Preference for Dying at Home among Cancer Patients: The role of General Practitioners

Aim: This study aimed to explore clinical and care-related factors associated with fulfilling cancer patients’ preference for home death across four countries: Belgium (BE), the Netherlands (NL), Italy (IT), and Spain (ES). Methods: A mortality follow-back study was undertaken from 2009 to 2011 via representative networks of general practitioners (GPs). The study included all patients aged 18 and over who had died of cancer and whose home death preference and place of death were known by the GP. Factors associated with meeting home death preference were tested using multivariable logistic regressions. Results: Among 2,048 deceased patients, preferred and actual place of death was known in 42.6 percent of cases. Home death preference met ranged from 65.5 to 90.9 percent. Country-specific factors included older age in BE, and decisionmaking capacity and being female in the NL GPs’ provision of palliative care was positively associated with meeting home death preference. Odds ratios (ORs) were: BE: 9.9 (95 percent confidence interval [CI] 3.7–26.6); NL: 9.7 (2.4–39.9); and IT: 2.6 (1.2–5.5). ORs for Spain are not shown because a multivariate model was not performed. Conclusion: Those who develop policy to facilitate home death need to examine available resources for primary end-of-life care.

But: Cette étude avait pour objectif d'examiner les facteurs cliniques associés aux demandes des patients désirant mourir à la maison. Cette re-cherche s'étendait sur quatre pays soit la Belgique, les Pays-Bas, l'Italie, et l'Espagne. Méthode: Par l'inter-médaire des réseaux représentatifs d'omnipraticiens, nous avons pu faire un suivi rétrospectif des mortalités survenues durant les années 2009, 2010, et 2011. Cette étude comprenait les patients agés de 18 ans et plus morts du cancer et dont les médecins connaissaient tout autant les volontés de pouvoir mourir à la maison que l'endroit où les patients étaient morts. Les facteurs correspondants aux préférences des patients ont été validés à l'aide de la méthode statistique de regression logistique à variables multiples. Résultats: Parmi les 2 048 personnes décédées on connaissait, chez 42,6 pourcent d'entre elles, la préférence et l'endroit de la mort. Le choix de mourir à domicile variait de 65,5 pourcent à 90,9 pourcent. Les facteurs spécifiques à certains pays étaient l'âge avancé pour la Belgique et, pour les Pays-Bas, la capacité décisionnelle et le fait d'être de sexe feminin. La prestation des soins palliatifs par les omnipraticiens est associée de façon positive au choix de mourir à la maison. Les rapports de probabilités étaient les suivants: Belgique: 9,9 [95 pourcent d'intervalle de fiabilité (3,7–26,6)], Pays-Bas: 9,7 (2,4–39,9) et l'Italie: 2,6 (1,2–5,5). Les facteurs de probabilité pour l'Espagne ne sont pas indiqués car on n'a pas fait d'analyse selon le modèle multivariable. Conclusion: Les professionnels de la santé ayant pour tâche d'établir les politiques pour faciliter la mort à la maison doivent connnaître toutes les resources dont ils disposent dans leur communauté afin de pouvoir offrir les soins de première ligne à domicile.

Registered nurses' provision of end-of-life care to hospitalised adults: A mixed studies review

OBJECTIVES

To describe, critically appraise and synthesise research regarding nurses' perceptions of their knowledge, skills or experiences in providing end-of-life care to hospitalised adults to help inform both future educational and practice initiatives.

DESIGN

Mixed studies review.

DATA SOURCES

MEDLINE, CINAHL, Cochrane Library, Web of Science and SCOPUS databases were searched for the years 2004-June 2018, along with journal hand-searching and reference list searching.

REVIEW METHODS

Two independent reviewers screened the titles and abstracts of studies. Data extraction and quality assessment using the Mixed Methods Appraisal Tool was conducted independently by two reviewers. Disagreements were adjudicated by a third reviewer. Study findings were synthesised thematically.

RESULTS

Nineteen studies met the inclusion criteria. Of them, ten were quantitative, eight qualitative and one mixed-method. All but one quantitative study were conducted in the United States and all but one used some form of survey. The qualitative studies were conducted in a variety of countries and all but one used some form of interview for data collection. Five themes were identified including nurse as a protecting provider, nurse as an advocate, nurse as a reflective practitioner, obstacles to providing quality end-of-life care and aids to providing quality end-of-life care.

CONCLUSIONS

Registered Nurses have aligned their end-of-life care with practice with the profession's expectations and are enacting a patient centred approach to their practice. They rely on reflective practices and on the support of others to overcome organisational, educational and emotional the challenges they to providing quality end-of-life care.

Trends in Hospital Deaths in Denmark from 1980 to 2014, at Ages 50 and Older

OBJECTIVES

To explore temporal trends and individual-level determinants of hospital deaths at ages 50 and older in Denmark from 1980 to 2014.

DESIGN

Individual-level register-based retrospective study.

SETTING

Denmark, 1980 to 2014.

PARTICIPANTS

All deaths that occurred in Denmark from 1980 to 2014 among individuals 50 years or older (N = 1 834 437), extracted from population registers.

MEASUREMENTS

A death was defined as a hospital death if the individual was admitted to the hospital as an inpatient and the date of discharge from the hospital is equal to the date of death.

RESULTS

The percentage of hospital deaths decreased in both sexes (all ages combined, men: 56% to 44%; women: 49% to 39%) and at ages 50 to 79, remained almost unchanged at ages 80 to 89, and increased in the oldest age group (90+ men: 27% to 32%; women: 18% to 24%). We observed increasing trends of hospital deaths for three groups, people 90 years and older, dying from respiratory diseases, and who had terminal hospitalizations lasting 1 to 3 days. Subanalysis of all hospital deaths according to length of the terminal hospitalizations suggests that the overall reduction of hospital deaths might be driven by a reduction in hospitalizations that were longer than 1 week. Persons who are married, have middle or high income, have a history of hospitalizations in the year before death, or die because of respiratory diseases have higher odds of dying in a hospital.

CONCLUSION

Results provide evidence that Danes 50 years and older are increasingly dying outside the hospital context. We find three age-specific patterns in the proportion of hospital deaths. Changes in healthcare and social systems implemented in Denmark during the observation period may underlie the broader reduction in hospital deaths in the country. J Am Geriatr Soc 67:471-476, 2019.

Development, modelling, and pilot testing of a complex intervention to support end-of-life care provided by Danish general practitioners

BACKGROUND

Most patients in end-of-life with life-threatening diseases prefer to be cared for and die at home. Nevertheless, the majority die in hospitals. GPs have a pivotal role in providing end-of-life care at patients' home, and their involvement in the palliative trajectory enhances the patient's possibility to stay at home. The aim of this study was to develop and pilot-test an intervention consisting of continuing medical education (CME) and electronic decision support (EDS) to support end-of-life care in general practice.

METHODS

We developed an intervention in line with the first phases of the guidelines for complex interventions drawn up by the Medical Research Council. Phase 1 involved the development of the intervention including identification of key barriers to provision of end-of-life care for GPs and of facilitators of change. Furthermore the actual modelling of two components: CME meeting and EDS. Phase 2 focused on pilot-testing and intervention assessment by process evaluation.

RESULTS

In phase 1 lack of identification of patients at the end of life and limited palliative knowledge among GPs were identified as barriers. The CME meeting and the EDS were developed. The CME meeting was a four-hour educational meeting performed by GPs and specialists in palliative care. The EDS consisted of two parts: a pop-up window for each patient with palliative needs and a list of all patients with palliative needs in the practice. The pilot testing in phase 2 showed that the CME meeting was performed as intended and 120 (14%) of the GPs in the region attended. The EDS was integrated in existing electronic records but was shut down early for external reasons; 50 (5%) GPs signed up. The pilot-testing demonstrated a need to strengthen the implementation as attending rate was low in the current set-up.

CONCLUSION

We developed a complex intervention to support GPs in providing end-of-life care. The pilot-test showed general acceptance of the CME meetings. The EDS was shut down early and needs further evaluation before examining the whole intervention in a larger study, where evaluation could be based on patient-related outcomes and impact on end-of-life care.

TRIAL REGISTRATION

Clinicaltrials.gov ( NCT02050256 ) January 30, 2014.

Influences on Care Preferences of Older People with Advanced Illness: A Systematic Review and Thematic Synthesis

Objectives

To determine and explore the influences on care preferences of older people with advanced illness and integrate our results into a model to guide practice and research.

Design

Systematic review using Medline, Embase, PsychINFO, Web of Science, and OpenGrey databases from inception to February 2017 and reference and citation list searching. Included articles investigated influences on care preference using qualitative or quantitative methodology. Thematic synthesis of qualitative articles and narrative synthesis of quantitative articles were undertaken.

Setting

Hospital and community care settings.

Participants

Older adults with advanced illness, including people with specific illnesses and markers of advanced disease, populations identified as in the last year of life, or individuals receiving palliative care (N = 15,164).

Measurements

The QualSys criteria were used to assess study quality.

Results

Of 12,142 search results, 57 articles were included. Family and care context, illness, and individual factors interact to influence care preferences. Support from and burden on family and loved ones were prominent influences on care preferences. Mechanisms by which preferences are influenced include the process of trading‐off between competing priorities, making choices based on expected outcome, level of engagement, and individual ability to form and express preferences.

Conclusion

Family is particularly important as an influence on care preferences, which are influenced by complex interaction of family, individual, and illness factors. To support preferences, clinicians should consider older people with illnesses and their families together as a unit of care.

Persistent inequalities in Hospice at Home provision

OBJECTIVE

To describe the nature and scope of a new Hospice at Home (H@H) service and to identify its equality of provision.

METHODS

Case note review of patients supported by a H@H service for 1 year from September 2012 to August 2013 (n=321). Descriptive analysis to report frequencies and proportions of quantitative data extracted from service logs, referral forms and care records; thematic analysis of qualitative data from care record free text.

RESULTS

Demand outstripped supply. Twice as many night care episodes were requested (n=1237) as were provided (n=613). Inequalities in access to the service related to underlying diagnosis and socioeconomic status. 75% of patients using the service had cancer (221/293 with documented diagnosis). Of those who died at home in the areas surrounding the hospice, 53% (163/311) of people with cancer and 11% (49/431) of those without cancer received H@H support. People who received H@H care were often more affluent than the population average for the area within which they lived. Roles of the service identified included: care planning/implementation, specialist end-of-life care assessment and advice, 'holding' complex patients until hospice beds become available and clinical nursing care.

CONCLUSION

There is significant unmet need and potentially large latent demand for the H@H service. People without cancer or of lower socioeconomic status are less likely to access the service. Action is needed to ensure greater and more equitable service provision in this and similar services nationally and internationally.

Propensity for paying home visits among general practitioners and the associations with cancer patients' place of care and death: a register-based cohort study

BACKGROUND

Previous studies of associations between home visits by general practitioners and end-of-life care for cancer patients have been subject to confounding.

AIM

To analyse associations between general practitioners' propensity to pay home visits and the likelihood of hospitalisation and dying out of hospital among their cancer patients.

DESIGN

A national register cohort study with an ecological exposure. Standardised incidence rates of general practitioner home visits were calculated as a measure for propensity. Practices were grouped into propensity quartiles. Associations between propensity groups and end-of-life outcomes for cancer patients aged 40 or above were calculated.

SETTING/PARTICIPANTS

Danish general practitioners and citizens aged 40 or above were included from 2003 to 2012.

RESULTS

We included 2670 practices with 2,518,091 listed patients (18,364,679 person-years); of whom 116,677 died from cancer. General practitioners were grouped into quartiles based on the general practitioners' propensity to pay home visits, which varied 6.6-fold between quartiles. Cancer patients in Group 4 (highest propensity) were less hospitalised than patients in Group 1 (lowest propensity): odds ratio: 1.13 (95% confidence interval: 1.08; 1.17) for ⩽3 bed-days and odds ratio: 0.95 (0.91-0.99) for ⩾20 bed-days. Group 4 patients were more likely to die out of hospital (odds ratio: 1.20 (1.16; 1.24)) than Group 1 patients.

CONCLUSION

We found a dose-response-like association between general practitioners' higher propensity to pay home visit and their patients' likelihood of less end-of-life hospitalisation and more often dying out of hospital.

The complex relationship between household income of family caregivers, access to palliative care services and place of death: A national household population survey

BACKGROUND

Previous work shows that more affluent patients with cancer are more likely to die at home, whereas those dying from non-cancer conditions are more likely to die in hospital. Family caregivers are an important factor in determining place of death.

AIM

To investigate associations between family caregivers' household income, patients' access to specialist palliative care and place of patients' death, by level of personal end-of-life care.

DESIGN

A cross-sectional community household population survey.

SETTING AND PARTICIPANTS

Respondents to the Household Survey for England.

RESULTS

One-third of 1265 bereaved respondents had provided personal end-of-life care (caregivers) (30%). Just over half (55%) of decedents accessed palliative care services and 15% died in a hospice. Place of death and access to palliative care were strongly related ( p < 0.001). Palliative care services reduced the proportion of deaths in hospital ( p < 0.001), and decedents accessing palliative care were more likely to die at home than those who did not ( p < 0.001). Respondents' income was not associated with palliative care access ( p = 0.233). Overall, respondents' income and home death were not related ( p = 0.106), but decedents with caregivers in the highest income group were least likely to die at home ( p = 0.069).

CONCLUSION

For people who had someone close to them die, decedents' access to palliative care services was associated with fewer deaths in hospital and more home deaths. Respondents' income was unrelated to care recipients' place of death when adjusted for palliative care access. When only caregivers were considered, decedents with caregivers from higher income quartiles were the least likely to die at home. Family caregivers from higher income brackets are likely to be powerful patient advocates. Caregiver information needs must be addressed especially with regard to stage of disease, aim of care and appropriate interventions at the end of life.

What factors influence emergency department visits by patients with cancer at the end of life? Analysis of a 124,030 patient cohort

BACKGROUND

Emergency department visits towards the end of life by patients with cancer are increasing over time. This is despite evidence of an association with poor patient and caregiver outcomes and most patients preferring home-based care.

AIM

To identify socio-demographic and clinical factors associated with end-of-life emergency department visits and determine the relationship between patients' prior emergency department use and risk of multiple (⩾2) visits in the last month of life.

DESIGN

Population-based cohort study.

SETTING/PARTICIPANTS

All adults who died from cancer, in England, between 1 April 2011 and 31 March 2012. Our primary outcome was the adjusted odds ratio for multiple emergency department visits in the last month of life, derived using multivariable logistic regression.

RESULTS

Among 124,030 cancer decedents (52.9% men; mean age: 74.1 years), 30.7% visited the emergency department once in their last month of life and 5.1% visited multiple times. Patients were more likely to visit multiple times if they were men, younger, Asian or Black, of lower socio-economic status, had greater comorbidity, and lung or head and neck cancer. Patients with ⩾4 emergency department visits in the 11 months prior to their last month of life were also more likely to make multiple visits during their last 30 days; this followed a dose-response pattern ( p for trend <0.001).

CONCLUSION

Patients with greater comorbidity, lung or head and neck cancer and a higher number of previous emergency department visits are more likely to visit the emergency department multiple times in the last month of life. Previously reported socio-demographic factors (men, younger age, Black, low socio-economic status) are also confirmed for the first time in a UK population.

Which patients die in their preferred place? A secondary analysis of questionnaire data from bereaved relatives

BACKGROUND

Previous studies on factors influencing the place of death have focused on cancer patients dying at home. However, home is not always the preferred place.

AIM

To provide insight into the extent to which patients with various diseases die in their preferred place and into factors associated with dying in the preferred place.

DESIGN

A secondary analysis of the data set of the evaluation study of the National Quality Improvement Programme for Palliative Care was undertaken to explore factors related to 'dying in the preferred place'.

SETTING/PARTICIPANTS

A total of 797 bereaved relatives filled in the Consumer Quality Index Palliative Care, a validated and reliable questionnaire.

RESULTS

Two-thirds of the patients died in the preferred place. A preference for dying at home and having had a stroke decreased the likelihood of dying in the preferred place, while having a partner, dementia, contact with the general practitioner in the last week before death, and continuity of care between professionals increased the likelihood of dying in the preferred place. Furthermore, people who wanted to die at home and also had dementia were more likely to die elsewhere than people without dementia who wanted to die at home.

CONCLUSION

Positive associations were found between continuity of care between healthcare professionals and contact with the general practitioner and the chance of people dying in their preferred place. Moreover, special attention for people who have had a stroke and for people with dementia who want to die at home seems indicated as their diagnosis is negatively associated with dying in their preferred place.

Preferred Place of Care and Death in Terminally Ill Patients with Lung and Heart Disease Compared to Cancer Patients

OBJECTIVES

The dual aim of this study is, first, to describe preferred place of care (PPOC) and preferred place of death (PPOD) in terminally ill patients with lung and heart diseases compared with cancer patients and second, to describe differences in level of anxiety among patients with these diagnoses.

BACKGROUND

Previous research on end-of-life preferences focuses on cancer patients, most of whom identify home as their PPOC and PPOD. These preferences may, however, not mirror those of patients suffering from nonmalignant fatal diseases.

DESIGN

The study was designed as a cross-sectional study.

SETTING

Eligible patients from the recruiting departments filled in questionnaires regarding sociodemographics, PPOC and PPOD, and level of anxiety.

RESULTS

Of the 354 eligible patients, 167 patients agreed to participate in the study. Regardless of their diagnosis, most patients wished to be cared for and to die at home. Patients with cancer and heart diseases chose hospice as their second most common preference for both PPOC and PPOD, whereas patients with lung diseases chose nursing home and hospice equally frequent as their second most common preference. Regardless of their diagnosis, all patients had a higher level of anxiety than the average Danish population; patients with heart diseases had a much higher level of anxiety than patients with lung diseases and cancer.

CONCLUSION

Patient preferences for PPOC and PPOD vary according to their diagnoses; tailoring palliative needs to patients' preferences is important regardless of their diagnosis.

Clinical and Socio-Demographic Predictors of Home Hospice Patients Dying at Home: A Retrospective Analysis of Hospice Care Association's Database in Singapore

CONTEXT

Hospice care can be delivered in different settings, but many patients choose to receive it at home because of familiar surroundings. Despite their preferences, not every home hospice patient manages to die at home.

OBJECTIVE

To examine the independent factors associated with home hospice patient dying at home.

METHODS

Retrospective analysis of Hospice Care Association's database. Hospice Care Association is the largest home hospice provider in Singapore. The study included all patients who were admitted into home hospice service from January 1, 2004 to December 31, 2013. Cox proportional hazards modeling with time as constant was used to study the relationship between independent variables and home death.

RESULTS

A total of 19,721 patients were included in the study. Females (adjusted risk ratio [ARR] 1.09, 95% CI 1.04-1.15), older patients (ARR 1.01, 95% CI 1.00-1.01), shorter duration of home hospice stay (ARR 0.88, 95% CI 0.82-0.94), fewer episodes of hospitalization (ARR 0.81, 95% CI 0.75-0.86), living with caregivers (ARR 1.54, 95% CI 1.05-2.26), doctor (ARR 1.05, 95% CI 1.01-1.08) and nurse (ARR 1.06, 95% CI 1.04-1.08) visits were positive predictors of dying-at-home. Diagnosis of cancer (ARR 0.93, 95% CI 0.86-1.00) was a negative predictor of dying-at-home.

CONCLUSION

Female, older age, living with a caregiver, non-cancer diagnosis, more doctor and nurse visits, shorter duration of home hospice stays, and fewer episodes of acute hospitalizations are predictive of dying-at-home for home hospice patients.

Exploring the Concept of Healing Spaces

Evidence-based design (EBD) research has demonstrated the power of environmental design to support improved patient, family, and staff outcomes and to minimize or avoid harm in healthcare settings. While healthcare has primarily focused on fixing the body, there is a growing recognition that our healthcare system could do more by promoting overall wellness, and this requires expanding the focus to healing. This article explores how we can extend what we know from EBD about health impacts of spatial design to the more elusive goal of healing. By breaking the concept of healing into antecedent components (emotional, psychological, social, behavioral, and functional), this review of the literature presents the existing evidence to identify how healthcare spaces can foster healing. The environmental variables found to directly affect or facilitate one or more dimension of healing were organized into six groups of variables—homelike environment, access to views and nature, light, noise control, barrier-free environment, and room layout. While there is limited scientific research confirming design solutions for creating healing spaces, the literature search revealed relationships that provide a basis for a draft definition. Healing spaces evoke a sense of cohesion of the mind, body, and spirit. They support healing intention and foster healing relationships.

Danish general practitioners' self-reported competences in end-of-life care

OBJECTIVE

General practitioners (GPs) are pivotal in end-of-life (EOL) care. This study aimed to assess GP-reported provision of EOL care and to assess associations with GP characteristics.

DESIGN

Population-based questionnaire study.

SETTING

Central Denmark Region with approximately 1.3 million inhabitants.

SUBJECTS

All 843 active GPs in the Central Denmark Region were sent a questionnaire by mail.

MAIN OUTCOME MEASURES

Responses to 18 items concerning four aspects: provision of EOL care to patients with different diagnosis, confidence with being a key worker, organisation of EOL care and EOL skills (medical and psychosocial).

RESULTS

In total, 573 (68%) GPs responded. Of these, 85% often/always offered EOL care to cancer patients, which was twice as often as to patients with non-malignancies (34-40%). Moreover, 76% felt confident about being a key worker, 60% had a proactive approach, and 58% talked to their patients about dying. Only 9% kept a register of patients with EOL needs, and 19% had specific EOL procedures. GP confidence with own EOL skills varied; from 55% feeling confident using terminal medications to 90% feeling confident treating nausea/vomiting. Increasing GP age was associated with increased confidence about being a key worker and provision of EOL care to patients with non-malignancies. In rural areas, GPs were more confident about administering medicine subcutaneously than in urban areas.

CONCLUSION

We found considerable diversity in self-reported EOL care competences. Interventions should focus on increasing GPs' provision of EOL care to patients with non-malignancies, promoting better EOL care concerning organisation and symptom management. KEY POINTS GPs are pivotal in end-of-life (EOL) care, but their involvement has been questioned. Hence, GPs' perceived competencies were explored. GPs were twice as likely to provide EOL care for patients with cancer than for patients with non-malignancies. EOL care was lacking clear organisation in general practice in terms of registering palliative patients and having specific EOL procedures. GPs were generally least confident with their skills in terminal medical treatment, for example, using medicine administered subcutaneously.

Characteristics Associated with In-Hospital Death among Commercially Insured Decedents with Cancer

BACKGROUND

A majority of patients with poor-prognosis cancer express a preference for in-home death; however, in-hospital deaths are common.

OBJECTIVE

We sought to identify characteristics associated with in-hospital death.

DESIGN

Case series.

SETTING/SUBJECTS

Commercially insured patients with cancer who died between July 2010 and December 2013 and who had at least two outpatient visits at a tertiary cancer center during the last six months of life.

MEASUREMENTS

Patient characteristics, healthcare utilization, and in-hospital death (primary outcome) were ascertained from institutional records and healthcare claims. Bivariate and multivariable analyses were used to evaluate the association of in-hospital death with patient characteristics and end-of-life outcome measures.

RESULTS

We identified 904 decedents, with a median age of 59 years at death. In-hospital death was observed in 254 patients (28%), including 110 (12%) who died in an intensive care unit. Hematologic malignancy was associated with a 2.57 times increased risk of in-hospital death (95% confidence interval [CI] 1.91-3.45, p < 0.001), and nonenrollment in hospice was associated with a 14.5 times increased risk of in-hospital death (95% CI 9.81-21.4, p < 0.001). Time from cancer diagnosis to death was also associated with in-hospital death (p = 0.003), with the greatest risk among patients dying within six months of cancer diagnosis. All significant associations persisted in multivariable analyses that were adjusted for baseline characteristics.

CONCLUSIONS

In-hospital deaths are common among commercially insured cancer patients. Patients with hematologic malignancy and patients who die without receiving hospice services have a substantially higher incidence of in-hospital death.

Patients' perceptions of palliative care quality in hospice inpatient care, hospice day care, palliative units in nursing homes, and home care: a cross-sectional study

Background

Patients’ perceptions of care quality within and across settings are important for the further development of palliative care. The aim was to investigate patients’ perceptions of palliative care quality within settings, including perceptions of care received and their subjective importance, and contrast palliative care quality across settings.

Method

A cross-sectional study including 191 patients in late palliative phase (73 % response rate) admitted to hospice inpatient care, hospice day care, palliative units in nursing homes, and home care was conducted, using the Quality from the Patients’ Perspective instrument-palliative care (QPP-PC). QPP-PC comprises four dimensions and 12 factors; “medical–technical competence” (MT) (2 factors), “physical–technical conditions” (PT) (one factor), “identity–orientation approach” (ID) (4 factors), “sociocultural atmosphere” (SC) (5 factors), and three single items (S); medical care, personal hygiene and atmosphere. Data were analysed using paired-samples t-test and analysis of covariance while controlling for differences in patient characteristics.

Results

Patients’ perceptions of care received within settings showed high scores for the factors and single items “honesty” (ID) and “atmosphere” (S) in all settings and low scores for “exhaustion” (MT) in three out of four settings. Patients’ perceptions of importance scored high for “medical care” (S), “honesty” (ID), “respect and empathy” (ID) and “atmosphere” (S) in all settings. No aspects of care scored low in all settings. Importance scored higher than perceptions of care received, in particular for receiving information. Patients’ perceptions of care across settings differed, with highest scores in hospice inpatient care for the dimensions; ID, SC, and “medical care” (S), the SC and “atmosphere” (S) for hospice day care, and “medical care” (S) for palliative units in nursing homes. There were no differences in subjective importance across settings.

Conclusion

Strengths of services related to identity–orientation approach and a pleasant and safe atmosphere. Key areas for improvement related to receiving information. Perceptions of subjective importance did not differ across settings, but perceptions of care received scored higher in more care areas for hospice inpatient care, than in other settings. Further studies are needed to support these findings, to investigate why perceptions of care differ across settings and to highlight what can be learned from settings receiving high scores.

Intensive care at the end of life in patients dying due to non-cancer chronic diseases versus cancer: a nationwide study in Denmark

Introduction

It is unknown to what extent use of palliative care and focus on proactive planning of end-of-life (EOL) care among cancer patients is also reflected by less use of intensive care. We aimed to examine the use of intensive care in the EOL in patients dying as a result of non-cancer diseases compared with patients dying due to cancer.

Methods

We conducted a nationwide follow-up study among 240,757 adults dying as a result of either non-cancer chronic disease or cancer in Denmark between 2005 and 2011. Using the Danish Intensive Care Database, we identified all admissions and treatments in intensive care units (ICU) during the patients’ last 6 months before death. We used prevalence ratios (aPRs) adjusted for age, sex, comorbidity, marital status and residential region to compare the 6-month prevalence of ICU admissions as well as treatment with invasive mechanical ventilation (MV), non-invasive ventilation (NIV), renal replacement therapy (RRT) and inotropes and/or vasopressors. In addition, length of ICU stay and death during ICU admission were compared among non-cancer and cancer patients dying between 2009 and 2011.

Results

Overall 12.3 % of non-cancer patients were admitted to an ICU within their last 6 months of life, compared with 8.7 % of cancer patients. The overall aPR for ICU admission was 2.11 [95 % confidence interval (CI) 1.98–2.24] for non-cancer patients compared with cancer patients and varied widely within the non-cancer patients (patients with dementia, aPR 0.19, 95 % CI 0.17–0.21; patients with chronic obstructive lung disease, aPR 3.19, 95 % CI 2.97–3.41). The overall aPRs for treatment among non-cancer patients compared with cancer patients were 1.40 (95 % CI 1.35–1.46) for MV, 1.62 (95 % CI 1.50–1.76) for NIV, 1.19 (95 % CI 1.07–1.31) for RRT and 1.05 (95 % CI 0.87–1.28) for inotropes and/or vasopressors. No difference in admission length was observed. Non-cancer patients had an increased risk of dying in an ICU (aPR 1.23, 95 % CI 0.99–1.54) compared with cancer patients.

Conclusions

Overall, patients dying as a result of non-cancer diseases were twice as likely to be admitted to ICUs at the EOL as patients dying due to cancer. Further studies are warranted to explore whether this difference in use of intensive care reflects an unmet need of palliative care, poor communication about the EOL or lack of prognostic tools for terminally ill non-cancer patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1124-1) contains supplementary material, which is available to authorized users.

Preferred and Actual Location of Death: What Factors Enable a Preferred Home Death?

BACKGROUND

Fulfillment of patient preferences for location of dying is of continued end-of-life care interest. Of those voicing a preference, most prefer home. However the majority of deaths occur in an institutional setting.

OBJECTIVES

The study objective was to report on the congruence between the last preferred and actual location of death among adult Nova Scotians who died from chronic disease, and to identify individual, illness-related, and environmental factors associated with achieving a preferred home death.

METHODS

The study employed a population-based mortality follow-back telephone survey interview. Subjects were eligible death certificate identified informants (next-of-kin) of adults (aged 18+) (n = 1316) who died of advanced chronic diseases in the Canadian province of Nova Scotia between June 2009 and May 2011 who were knowledgeable about the decedent's care over the last month of life. Congruence was assessed as to whether or not the decedent died in their preferred death location. Among decedents preferring a home death, individual, illness-related, and environmental risk factor multivariable analyses were used to identify predictors of home death achievement.

RESULTS

Among all who voiced a preference (n = 606), 52% died in their preferred location (kappa: 0.29). Factors contributing independently to achievement of a preferred home death were emotional needs being met, nursing and family physician home visits, palliative care program involvement, and being at home for the majority of the last month.

CONCLUSIONS

This study identifies elements of primary and integrated care that address the gap between preferred and actual place of care.

Factors associated with preference for dying at home among terminally ill patients with cancer

INTRODUCTION

An important element in end-of-life care advocacy is to meet patients' end-of-life preferences. Most Scandinavian patients die in hospitals even though the majority prefers to die at home. Earlier studies have shown socio-economic differences in relation to dying at home, but more knowledge is needed in relation to preferences for place of death. Hence, on valid Danish register-based socio-economic data, we aimed to investigate whether demographic and socio-economic factors were associated with preference for dying at home.

METHOD

Population-based, historic cohort study among 282 relatives of deceased patients who died of cancer in Denmark in 2006. Bereaved relatives were asked to state patient's preference concerning place of death at the beginning and end of the palliative period. These data were recently combined with updated, extensive demographic and socio-economic data from Danish national health registers. Generalised linear models were used modelling prevalence ratio (PR).

RESULTS

We found a significant positive association at the beginning of the palliative trajectory between preferring home death and being male (PR = 1.26 (95% CI: 1.00;1.58) (p = 0.048)) and a significant negative association between having medium income compared with high income (PR = 0.81 (95% CI 0.67;0.98) (p = 0.031)). At the end of the palliative trajectory, a significant negative association was found between preferring home death and living in a community with more than 100 000 inhabitants (PR = 0.63 (95% CI 0.45;0.89) (p = 0.008)) compared with living in communities with less than 10 000 inhabitants.

CONCLUSION

The study showed that socio-economic factors such as gender, level of income and size of community were associated with preference for dying at home. Hence, this study qualifies prior studies on preferences for end-of-life care and advocates for a more nuanced picture of the subject. Advocacy in end-of-life nursing recommends optimising active listening and communication skills striving towards more patients' preferences in all settings may be heard and fulfilled.

Are Cancer Patients' Socioeconomic and Cultural Factors Associated with Contact to General Practitioners in the Last Phase of Life?

Introduction. General practitioners (GPs) play an important role in end of life care, which should be offered regardless of socioeconomic position and cultural factors. The aim was to analyse associations between GP contacts at the end of life and socioeconomic and cultural characteristics of Danish cancer patients. Method. Population-based study identifying 599 adults who died of cancer from March to November 2006, in Aarhus County, Denmark. Associations between health register-based data on "total GP face-to-face contacts" and "GP home visits" during the last 90 days of life and patients' socioeconomic and cultural characteristics were calculated. Results. Having low income (RR: 1.18 (95% CI: 1.03; 1.35)) and being immigrants or descendants of immigrants (RR: 1.17 (95% CI: 1.02; 1.35)) were associated with GP face-to-face contacts. However, patients living in large municipalities had lower likelihood of having both GP face-to-face contacts in general (RR: 0.85 (95% CI: 0.77;0.95)) and GP home visits (RR: 0.89 (95% CI: 0.80; 0.99)). Conclusion. This study indicates higher proportion of GP contacts to economically deprived patients and immigrants/descendants of immigrants. These subgroups were, however, small and results should be looked upon with caution. Furthermore, palliative needs were not included and together with urban/rural the underlying causes need further investigation.

A population-level study of place of death and associated factors in Sweden

Aims: The aims of this study were to examine, on a population level, where people die in Sweden, and to investigate associations between place of death and underlying cause of death, socioeconomic and environmental characteristics, with a particular interest in people dying from life-limiting conditions typically in need of palliative care. Methods: This population-level study is based on death certificate data for all deceased individuals in Sweden in 2012, with a registered place of death ( n=83,712). Multivariable logistic regression was performed to investigate associations between place of death and individual, socioeconomic and environmental characteristics. Results: The results show that, in 2012, 42.1% of all deaths occurred in hospitals, 17.8% occurred at home and 38.1% in nursing home facilities. Individuals dying of conditions indicative of potential palliative care needs were less likely to die in hospital than those dying of other conditions (OR = 0.73; 95% CI = 0.70–0.77). Living at home in urban areas was associated with higher likelihood of dying in hospital or in a nursing home (OR = 1.04 and 1.09 respectively). Educational attainment and marital status were found to be somewhat associated with the place of death. Conclusions: The majority of deaths in Sweden occur in institutional settings, with comparatively larger proportions of nursing home deaths than most countries. Associations between place of death and other variables point to inequalities in availability and/or utilization of health services at the end of life.

Preferred and actual place of death in haematological malignancy

Objectives

Home is considered the preferred place of death for many, but patients with haematological malignancies (leukaemias, lymphomas and myeloma) die in hospital more often than those with other cancers and the reasons for this are not wholly understood. We examined preferred and actual place of death among people with these diseases.

Methods

The study is embedded within an established population-based cohort of patients with haematological malignancies. All patients diagnosed at two of the largest hospitals in the study area between May 2005 and April 2008 with acute myeloid leukaemia, diffuse large B-cell lymphoma or myeloma, who died before May 2010 were included. Data were obtained from medical records and routine linkage to national death records.

Results

323 deceased patients were included. A total of 142 (44%) had discussed their preferred place of death; 45.8% wanted to die at home, 28.2% in hospital, 16.9% in a hospice, 5.6% in a nursing home and 3.5% were undecided; 63.4% of these died in their preferred place. Compared to patients with evidence of a discussion, those without were twice as likely to have died within a month of diagnosis (14.8% vs 29.8%). Overall, 240 patients died in hospital; those without a discussion were significantly more likely to die in hospital than those who had (p≤0.0001). Of those dying in hospital, 90% and 75.8% received haematology clinical input in the 30 and 7 days before death, respectively, and 40.8% died in haematology areas.

Conclusions

Many patients discussed their preferred place of death, but a substantial proportion did not and hospital deaths were common in this latter group. There is scope to improve practice, particularly among those dying soon after diagnosis. We found evidence that some people opted to die in hospital; the extent to which this compares with other cancers is of interest.

Patients' preferences in palliative care: A systematic mixed studies review

BACKGROUND

It is necessary to develop palliative care to meet existing and future needs of patients and their families. It is important to include knowledge of patient preferences when developing high-quality palliative care services. Previous reviews have focused on patient preferences with regard to specific components of palliative care. There is a need to review research on patient's combined preferences for all elements that constitute palliative care.

AIM

The aim of this study is to identify preferences for palliative care among patients in the palliative phase of their illness, by synthesizing existing research.

DATA SOURCES

Studies were retrieved by searching databases - the Cochrane Library, Medline, CINAHL, PsycINFO, Scopus and Sociological Abstracts - from 1946 to 2014, and by hand searching references in the studies included.

DESIGN

A systematic mixed studies review was conducted. Two reviewers independently selected studies for inclusion and extracted data according to the eligibility criteria. Data were synthesized using integrative thematic analysis.

RESULTS

The 13 qualitative and 10 quantitative studies identified included participants with different illnesses in various settings. Four themes emerged representing patient preferences for care. The theme 'Living a meaningful life' illustrated what patients strived for. The opportunity to focus on living required the presence of 'Responsive healthcare personnel', a 'Responsive care environment' and 'Responsiveness in the organization of palliative care'.

CONCLUSION

The four themes may be useful for guiding clinical practice and measurements of quality, with the overall goal of meeting future needs and improving quality in palliative care services to suit patients' preferences.