What justifies a hospital admission at the end of life? A focus group study on perspectives of family physicians and nurses

Factors Associated With Hospital Admission in the Last Month: A Retrospective Single Center Analysis

CONTEXT

Driven by concerns about care quality, patient experience, and national metrics, health systems are increasingly focusing on identifying risk factors for patients who are hospitalized in the last month of life.

OBJECTIVE

To evaluate patient factors associated with hospital admission in the last month (30 days).

METHODS

We analyzed a retrospective cohort of 8488 patients with a primary care visit in a tertiary health system in the last year of life using a linked electronic health record and decedent dataset. We examined healthcare utilization (primary care, emergency, hospital, intensive care unit encounters) and end-of-life related outcomes (palliative care consultation, do-not-resuscitate orders, advance care planning documentation, hospice at hospital discharge, death in health system). Multivariable logistic regressions identified patient factors associated with admission in the last month.

RESULTS

About 2202 (25.9%) patients had a hospital admission in the last month. Among the 1282 (15.1%) who died in a health system facility, most (1103/1282, 86.0%) were admitted to the hospital in the last month. Among patients with a hospital admission and discharged in the last month, 60.9% (686/1126) were discharged on hospice. Compared to those without these diseases, metastatic cancer, liver disease, or heart failure had the highest odds of admission in the last month (adjusted OR 2.36 95%CI 2.05-2.72; 2.28, 95%CI 1.98-2.62; and 2.17 95%CI 1.93-2.45 respectively).

CONCLUSIONS

As patients with heart or liver disease or metastatic cancer had the highest odds of admission in the last month, collaborative interventions between primary, palliative, and specialty care may improve quality of care at the end of life.

Nursing Home Resident, Family, and Staff Perspectives on Hospital Transfers for End-of-Life Care

Residents who are terminally ill often experience transfers to the emergency department resulting in hospitalizations, which may be potentially avoidable with treatment in the nursing home. This qualitative study explored the perspectives of 15 residents, 10 family members, and 20 nursing home staff regarding end-of-life care and the circumstances prompting resident transfers. Data analysis of participant interviews conducted January to May 2019 in a South Florida nursing home identified four themes related to transfer to the hospital: time left to live, when aggressive treatments would be unavailing, not knowing what the nursing home can do, and transfer decisions are situation-dependent. Study findings underscore the importance of increasing resident and family awareness of treatments available in the nursing home and person-centered advance care planning discussions. Further research should explore the reasons for residents' and family members' choice of aggressive therapies and their goals for care at the end of life.

End of life in general practice: trends 2009-2019

OBJECTIVES

To assess possible trends between 2009 and 2019 in the Netherlands of palliative care indicators: the provision of palliative care or treatment, hospitalisations in the last month before death, use of specialised palliative care services and place of death.

METHODS

The study design was a repeated retrospective cross-sectional design with questionnaires filled in by general practitioners within a clustered sample of 67 Sentinel practices. Patients whose death was non-sudden, and thus could have received palliative care, between 1 January 2009 and 31 December 2019 were included in the study, resulting in 3121 patients.

RESULTS

Between 2009 and 2019, there is a significant increase in the number of people who receive palliative care or treatment alongside life-prolonging or curative treatment and the number of people who die at home, while the number of hospitalisations in the last month before death and the number of people dying in hospital shows a significant decrease. However, there is no trend in the involvement of specialised palliative care services or people receiving solely palliative care or treatment.

CONCLUSION

This study suggests improvements in end-of-life care provided in primary care in the Netherlands. Trends coincided with increased attention to palliative care both in practice and policy. Yet, there is still considerable room for improvement as there is no significant increase in people solely receiving palliative care or treatment and the involvement of specialised palliative care services.

Factors Related to Family Caregivers’ Readiness for the Hospital Discharge of Advanced Cancer Patients

Background: Many family caregivers of advanced cancer patients worry about being unable to provide in-home care and delay the discharge. Little is known about the influencing factors of discharge readiness. Methods: This study aimed to investigate the influencing factors of family caregivers’ readiness, used a cross-sectional survey, and enrolled 123 sets of advanced cancer patients and family caregivers using convenience sampling from four oncology wards in a medical centre in northern Taiwan. A self-developed five-point Likert questionnaire, the “Discharge Care Assessment Scale”, surveyed the family caregivers’ difficulties with providing in-home care. Results: The study showed that the discharge readiness of family caregivers affects whether patients can be discharged home. Moreover, the influencing factors of family caregivers’ discharge readiness were the patient’s physical activity performance status and expressed discharge willingness; the presence of someone to assist family caregivers with in-home care; and the difficulties of in-home care. The best prediction model accuracy was78.0%, and the Nagelkerke R² was 0.52. Conclusion: Discharge planning should start at the point of admission data collection, with the influencing factors of family caregivers’ discharge readiness. It is essential to help patients increase the likelihood of being discharged home.

Providing palliative care for residents in LTC facilities: an analysis of routine data of LTC facilities in Lower Saxony, Germany

Background

Demographic trends show an increasing number of elderly people and thus a growing need for palliative care (PC). Such care is increasingly being provided by long-term care (LTC) facilities. The present study aimed at exploring PC indicators of residents at LTC facilities belonging to a non-profit provider in Lower Saxony, Germany, in order to identify potential improvements.

Methods

A descriptive cross-sectional study was conducted, drawing on routine nursing chart data. Structural data from 16 participating LTC facilities and the care data of all residents who died in 2019 (N = 471) were collected anonymously between March and May 2020. Based on key literature on quality indicators of PC in LTC facilities in Germany, a structured survey was developed by a multidisciplinary research team. The descriptive, comparative and inferential data analysis was conducted using the SPSS software package.

Results

In total, the complete records of 363 (77%) residents who died in the participating LTC facilities in 2019 were retrieved. The records reflected that 45% of the residents had been hospitalized at least once during the last 6 months of their lives, and 19% had died in hospital. Advance care planning (ACP) consultation was offered to 168 (46%) residents, and 64 (38%) declined this offer. A written advance directive was available for 47% of the residents. A specialized PC team and hospice service volunteers were involved in caring for 6% and 14% of the residents, respectively. Cancer patients received support from external services significantly more frequently (p < .001) than did non-cancer patients. Differences emerged in the distribution of PC indicators between LTC facilities. Facilities that have more PC trained staff offered more ACP, supported by more specialized PC teams and hospice services, and had fewer hospitalizations. In addition, more volunteer hospice services were offered in urban facilities.

Conclusions

Overall, a rather positive picture of PC in participating LTC facilities in Germany emerged, although there were differences in the expression of certain indicators between facilities. ACP consultation, volunteer hospice services, and hospital admissions appeared to be superior in LTC facilities with more trained PC staff. Therefore, PC training for staff should be further promoted.

Association between temporary discharge from the inpatient palliative care unit and achievement of good death in end-of-life cancer patients: A nationwide survey of bereaved family members

AIM

To explore the unclear association between temporary discharge home from the palliative care unit and achievement of good death, in the background of increases in discharge from the palliative care unit. Association between experiences and circumstances of patient and family and duration of temporary discharge was also examined.

METHODS

This study was a secondary analysis of data from a nationwide post-bereavement survey.

RESULTS

Among 571 patients, 16% experienced temporary discharge home from the palliative care unit. The total good death inventory score (p < .05) and sum of 10 core attributes (p < .05) were significantly higher in the temporarily discharged and stayed home ≥2 weeks group. Among all attributes, "Independent in daily activities" (p < .001) was significantly better in the temporarily discharged and stayed home ≥2 weeks group. Regarding the experience and circumstance of patient and family, improvement of patient's appetite (p < .05), and sleep (p < .05) and peacefulness (p < .05) of family caregivers, compared to the patient being hospitalized, were associated with longer stay at home after discharge.

CONCLUSIONS

Patient's achievement of good death was better in the temporarily discharged and stayed home longer group, but this seemed to be affected by high levels of independence of the patient. Temporary discharge from the palliative care unit and staying home longer was associated with improvement of appetite of patients and better sleep and mental health status of family caregivers. Discharging home from palliative care unit is worth being considered even if it is temporary.

Can we determine burdensome transitions in the last year of life based on time of occurrence and frequency? An explanatory mixed-methods study

Objective

Burdensome transitions are typically defined as having a transition in the last three days or multiple hospitalizations in the last three months of life, which is seldom verified with qualitative accounts from persons concerned. This study analyses types and frequencies of transitions in the last year of life and indicators of burdensome transitions from the perspective of bereaved relatives.

Method

Cross-sectional explanatory mixed-methods study with 351 surveyed and 41 interviewed bereaved relatives in a German urban area. Frequencies, t-tests, and Spearman correlations were computed for quantitative data. Qualitative data were analyzed using content analysis with provisional and descriptive coding/subcoding.

Results

Transitions rise sharply during the last year of life. 8.2% of patients experience a transition in the last three days and 7.8% three or more hospitalizations in the last three months of life. An empathetic way of telling patients about the prospect of death is associated with fewer transitions in the last month of life (r = 0.185, p = 0.046). Professionals being aware of the preferred place of death corresponds to fewer hospitalizations in the last three months of life (1.28 vs. 0.97, p = 0.021). Qualitative data do not confirm that burden in transitions is linked to having transitions in the last three days or multiple hospitalizations in the last three months of life. Burden is associated with (1) late and non-empathetic communication about the prospect of death, (2) not coordinating care across settings, and (3) not considering patients’ preferences.

Significance of results

Time of occurrence and frequency appear to be imperfect proxies for burdensome transitions. The subjective burden seems to be associated rather with insufficient information, preparation, and management of transitions.

Operationalizing Burdensome Transitions Among Adults at the End of Life: A Scoping Review

CONTEXT

Care transitions at the end of life are associated with reduced quality of life and negative health outcomes, yet up to half of patients in developed countries experience a transition within the last month of life. A variety of these transitions have been described as "burdensome" in the literature; however, there is currently no consensus on the definition of a burdensome transition.

OBJECTIVES

The purpose of this review was to identify current definitions of "burdensome transitions" and develop a framework for classifying transitions as "burdensome" at the end of life.

METHODS

A search was conducted in databases including Embase, PubMed, Cochrane Database of Systematic Reviews, Cochrane Controlled Register of Trials, CINAHL, and PsychINFO for articles published in English between January 1, 2000 and September 28, 2019.

RESULTS

A total of 37 articles met inclusion criteria for this scoping review. Definitions of burdensome transitions were characterized by the following features: transition setting trajectory, number of transitions, temporal relationship to end of life, or quality of transitions.

CONCLUSION

Definitions of burdensome transitions varied based on time before death, setting of cohorts, and study population. These definitions can be helpful in identifying and subsequently preventing unnecessary transitions at the end of life.

Discordance between the perceptions of clinicians and families about end-of-life trajectories in hospitalized dementia patients

BACKGROUND

Due to the unpredictable dementia trajectory, it is challenging to recognize illness progression and the appropriateness of a palliative approach. Further confusion occurs during hospitalization where the presence of comorbid conditions complicates prognostication. This research examined clinicians and families' perceptions of dementia as a terminal condition in relation to end-of-life admissions.

CONTEXT

The study was based in the General Medicine units of one Australian public hospital. Medical, nursing, and social work clinicians were recruited to reflect multidisciplinary perspectives. Bereaved caregivers of deceased patients with dementia were interviewed 3 months following death.

METHODS

Qualitative research underpinned by a social constructionist epistemology and framed through complex systems theory. Semi-structured interviews generated data that illuminated perceptions of deterioration observed toward the end of life.

RESULTS

Although participants anticipated general cognitive and physical deterioration associated with dementia, the emergence of comorbid illness made it difficult to predict the onset of the end of life. During a hospital admission, clinicians attributed the end of life to the advanced outcomes of dementia, whereas families described new medical crises. End-of-life admissions illuminated intersections between dementia and comorbidities rather than illness progression. In contrast with the perception that people with dementia lose awareness at the end of life, families drew attention to evidence that their loved one was present during the dying phase.

SIGNIFICANCE OF RESULTS

Our findings challenge the dominant understanding of dementia trajectories. Bifurcations between clinicians and families' views demonstrate the difficulties in recognizing end-of-life transitions. Implications for the integration of palliative care are considered.

Preferred and actual place of death in haematological malignancies: a report from the UK haematological malignancy research network

OBJECTIVES

Hospital death is comparatively common in people with haematological cancers, but little is known about patient preferences. This study investigated actual and preferred place of death, concurrence between these and characteristics of preferred place discussions.

METHODS

Set within a population-based haematological malignancy patient cohort, adults (≥18 years) diagnosed 2004-2012 who died 2011-2012 were included (n=963). Data were obtained via routine linkages (date, place and cause of death) and abstraction of hospital records (diagnosis, demographics, preferred place discussions). Logistic regression investigated associations between patient and clinical factors and place of death, and factors associated with the likelihood of having a preferred place discussion.

RESULTS

Of 892 patients (92.6%) alive 2 weeks after diagnosis, 58.0% subsequently died in hospital (home, 20.0%; care home, 11.9%; hospice, 10.2%). A preferred place discussion was documented for 453 patients (50.8%). Discussions were more likely in women (p=0.003), those referred to specialist palliative care (p<0.001), and where cause of death was haematological cancer (p<0.001); and less likely in those living in deprived areas (p=0.005). Patients with a discussion were significantly (p<0.05) less likely to die in hospital. Last recorded preferences were: home (40.6%), hospice (18.1%), hospital (17.7%) and care home (14.1%); two-thirds died in their final preferred place. Multiple discussions occurred for 58.3% of the 453, with preferences varying by proximity to death and participants in the discussion.

CONCLUSION

Challenges remain in ensuring that patients are supported to have meaningful end-of-life discussions, with healthcare services that are able to respond to changing decisions over time.

Does Time for (in)Direct Nursing Care Activities at the End of Life for Patients With or Without Specialized Palliative Care in a University Hospital Differ? A Retrospective Analysis

BACKGROUND

Nurses' end of life (EoL) care focuses on direct (eg, physical) and indirect (e,g, coordination) care. Little is known about how much time nurses actually devote to these activities and if activities change due to support by specialized palliative care (SPC) in hospitalized patients.

AIMS

(1) Comparing care time for EoL patients receiving SPC to usual palliative care (UPC);(2) Comparing time spent for direct/indirect care in the SPC group before and after SPC.

METHODS

Retrospective observational study; nursing care time for EoL patients based on tacs® data using nonparametric and parametric tests. The Swiss data method tacs measures (in)direct nursing care time for monitoring and cost analyses.

RESULTS

Analysis of tacs® data (UPC, n = 642; SPC, n = 104) during hospitalization before death in 2015. Overall, SPC patients had higher tacs® than UPC patients by 40 direct (95% confidence interval [CI]: 5.7-75, P = .023) and 14 indirect tacs® (95% CI: 6.0-23, P < .001). No difference for tacs® by day, as SPC patients were treated for a longer time (mean number of days 7.2 vs 16, P < .001).Subanalysis for SPC patients showed increased direct care time on the day of and after SPC (P < .001), whereas indirect care time increased only on the day of SPC.

CONCLUSIONS

This study gives insight into nurses' time for (in)direct care activities with/without SPC before death. The higher (in)direct nursing care time in SPC patients compared to UPC may reflect higher complexity. Consensus-based measurements to monitor nurses' care activities may be helpful for benchmarking or reimbursement analysis.

Perspectives of general practitioners and nursing staff on acute hospital transfers of nursing home residents in Germany: results of two cross-sectional studies

Background

Visits in emergency departments and hospital admissions are common among nursing home (NH) residents and they are associated with significant complications. Many of these transfers are considered inappropriate. This study aimed to compare the perceptions of general practitioners (GPs) and NH staff on hospital transfers among residents and to illustrate measures for improvement.

Methods

Two cross-sectional studies were conducted as surveys among 1121 GPs in the German federal states Bremen and Lower Saxony and staff from 1069 NHs (preferably nursing staff managers) from all over Germany, each randomly selected. Questionnaires were sent in August 2018 and January 2019, respectively. The answers were compared between GPs and NH staff using descriptive statistics, Mann-Whitney U tests and χ2-tests.

Results

We received 375 GP questionnaires (response: 34%) and 486 NH questionnaires (response: 45%). GPs estimated the proportion of inappropriate transfers higher than NH staff (hospital admissions: 35.0% vs. 25.6%, p < 0.0001; emergency department visits: 39.9% vs. 20.9%, p < 0.0001). The majority of NH staff and nearly half of the GPs agreed that NH residents do often not benefit from hospital admissions (NHs: 61.4% vs. GPs: 48.8%; p = 0.0009). Both groups rated almost all potential measures for improvement differently (p < 0.0001), however, GPs and NH staff considered most areas to reduce hospital transfers importantly. The two most important measures for GPs were more nursing staff (91.6%) and better communication between nursing staff and GP (90.9%). NH staff considered better care / availability of GP (82.8%) and medical specialists (81.3%) as most important. Both groups rated similarly the importance of explicit advance directives (GPs: 77.2%, NHs: 72.4%; p = 0.1492).

Conclusions

A substantial proportion of hospital transfers from NHs were considered inappropriate. Partly, the ratings of possible areas for improvement differed between GPs and NH staff indicating that both groups seem to pass the responsibility to each other. These findings, however, support the need for interprofessional collaboration.

Hospitalizations of nursing home residents at the end of life: A systematic review

BACKGROUND

End-of-life hospitalizations in nursing home residents are common, although they are often burdensome and potentially avoidable.

AIM

We aimed to summarize the existing evidence on end-of-life hospitalizations in nursing home residents.

DESIGN

Systematic review (PROSPERO registration number CRD42017072276).

DATA SOURCES

A systematic literature search was carried out in PubMed, CINAHL, and Scopus (date of search 9 April 2019). Studies were included if they reported proportions of in-hospital deaths or hospitalizations of nursing home residents in the last month of life. Two authors independently selected studies, extracted data, and assessed the quality of studies. Median with interquartile range was used to summarize proportions.

RESULTS

A total of 35 studies were identified, more than half of which were from the United States (n = 18). While 29 studies reported in-hospital deaths, 12 studies examined hospitalizations during the last month of life. The proportion of in-hospital deaths varied markedly between 5.9% and 77.1%, with an overall median of 22.6% (interquartile range: 16.3%-29.5%). The proportion of residents being hospitalized during the last month of life ranged from 25.5% to 69.7%, and the median was 33.2% (interquartile range: 30.8%-38.4%). Most studies investigating the influence of age found that younger age was associated with a higher likelihood of end-of-life hospitalization. Four studies assessed trends over time, showing heterogeneous findings.

CONCLUSION

There is a wide variation in end-of-life hospitalizations, even between studies from the same country. Overall, such hospitalizations are common among nursing home residents, which indicates that interventions tailored to each specific health care system are needed to improve end-of-life care.

End-of-life care of nursing home residents: A survey among general practitioners in northwestern Germany

AIM

To describe general practitioners' (GPs) perspectives on end-of-life care of nursing home residents.

METHODS

We carried out a cross-sectional study. A questionnaire was sent to a random sample of 1121 GPs in the German federal states of Bremen and Lower Saxony in 2018. Data were compared between GPs with a qualification in palliative medicine and those without such qualifications, and multivariable logistic regression was performed.

RESULTS

Overall, 375 questionnaires were returned (response rate 34%). The majority of GPs (71%) agreed that nursing home residents are treated too often in hospitals at the end of life, and more than half rated end-of-life care in nursing homes as "rather poor" (54%). For both questions, GPs with a qualification in palliative medicine showed higher agreements. In the multivariable analysis, a prior qualification in palliative medicine was also strongly associated with rating end-of-life care as "rather poor" (OR 1.89, 95% CI 1.10-3.23). Respondents cited higher staffing ratios and better trained nursing staff as the most important measures to improve end-of-life care. Furthermore, it was estimated that just 37% of residents have an advance directive, with only one-third including valid information on end-of-life hospitalizations.

CONCLUSIONS

This study showed that GPs tend to be critical regarding end-of-life care in nursing homes. To improve end-of-life care, better training in palliative care for nursing staff and GPs might be warranted. In addition, advance care planning can help to ensure that residents' wishes are respected. Geriatr Gerontol Int 2020; 20: 25-30.

A review of the literature on family decision-making at end of life precipitating hospital admission

Around 70% of people would prefer to die at home, yet around 50% die in hospital, according to Dying Matters. In collaboration with a local hospice, a literature review was undertaken to address the question: 'what factors precipitate admission to hospital in the last few days of a person's life for those who had expressed a preference to die at home?' Four electronic databases were searched, with a date range of 2008 to 2018. After 80 articles were screened, 13 were included in the review. The findings identified a number of barriers experienced by people with non-cancer conditions nearing the end of life and their family carers, which inhibit the transition to end-of-life care. The findings suggest that hospice support for non-cancer patients with a deteriorating health trajectory needs to precede patient and family recognition that end-of-life care is needed.

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.

Ambulance staff and end-of-life hospital admissions: A qualitative interview study

BACKGROUND

Hospital admissions for end-of-life patients, particularly those who die shortly after being admitted, are recognised to be an international policy problem. How patients come to be transferred to hospital for care, and the central role of decisions made by ambulance staff in facilitating transfer, are under-explored.

AIM

To understand the role of ambulance staff in the admission to hospital of patients close to the end of life.

DESIGN

Qualitative interviews, using particular patient cases as a basis for discussion, analysed thematically.

PARTICIPANTS/SETTING

Ambulance staff ( n = 6) and other healthcare staff (total staff n = 30), involved in the transfer of patients (the case-patients) aged more than 65 years to a large English hospital who died within 3 days of admission with either cancer, chronic obstructive pulmonary disease or dementia.

RESULTS

Ambulance interviewees were broadly positive about enabling people to die at home, provided they could be sure that they would not benefit from treatment available in hospital. Barriers for non-conveyance included difficulties arranging care particularly out-of-hours, limited available patient information and service emphasis on emergency care.

CONCLUSION

Ambulance interviewees fulfilled an important role in the admission of end-of-life patients to hospital, frequently having to decide whether to leave a patient at home or to instigate transfer to hospital. Their difficulty in facilitating non-hospital care at the end of life challenges the negative view of near end-of-life hospital admissions as failures. Hospital provision was sought for dying patients in need of care which was inaccessible in the community.

Psychometric evaluation and cultural adaptation of the Spanish version of the "Scale for End-of Life Caregiving Appraisal"

OBJECTIVE

To translate, culturally adapt, and psychometrically evaluate the Spanish version of the "Scale for End-of Life Caregiving Appraisal" (SEOLCAS).

METHOD

Observational cross-sectional study. Convenience sample of 201 informal end-of-life caregivers recruited in a southern Spanish hospital. The reliability of the questionnaire was assessed through its internal consistency (Cronbach's α) and temporal stability (Pearson's correlation coefficient [r] between test-retest). The content validity index of the items and the scale was calculated. Criterion validity was explored through performing a linear regression analysis to evaluate the SEOLCAS' predictive validity. Exploratory factor analysis was used to examine its construct validity.

RESULTS

The SEOLCAS' reliability was very high (Cronbach's α = 0.92). Its content validity was excellent (all items' content validity index = 0.8-1; scale's validity index = 0.88). Evidence of the SEOLCAS' criterion validity showed that the participants' scores on the SEOLCAS explained approximately 79.3% of the between-subject variation of their results on the Zarit Burden Interview. Exploratory factor analysis provided evidence of the SEOLCAS' construct validity. This analysis revealed that two factors ("internal contingencies" and "external contingencies") explained 53.77% of the total variance found and reflected the stoic Hispanic attitude toward adversity.Significance of resultsThe Spanish version of the SEOLCAS has shown to be an easily applicable, valid, reliable, and culturally appropriate tool to measure the impact of end-of-life care provision on Hispanic informal caregivers. This tool offers healthcare professionals the opportunity to easily explore Hispanic informal end-of-life caregivers' experiences and discover the type of support they may need (instrumental or emotional) even when there are communicational and organizational constraints.

General practice palliative care: patient and carer expectations, advance care plans and place of death-a systematic review

BACKGROUND

With an increasing ageing population in most countries, the role of general practitioners (GPs) and general practice nurses (GPNs) in providing optimal end of life (EoL) care is increasingly important.

OBJECTIVE

To explore: (1) patient and carer expectations of the role of GPs and GPNs at EoL; (2) GPs' and GPNs' contribution to advance care planning (ACP) and (3) if primary care involvement allows people to die in the place of preference.

METHOD

Systematic literature review.

DATA SOURCES

Papers from 2000 to 2017 were sought from Medline, Psychinfo, Embase, Joanna Briggs Institute and Cochrane databases.

RESULTS

From 6209 journal articles, 51 papers were relevant. Patients and carers expect their GPs to be competent in all aspects of palliative care. They valued easy access to their GP, a multidisciplinary approach to care and well-coordinated and informed care. They also wanted their care team to communicate openly, honestly and empathically, particularly as the patient deteriorated. ACP and the involvement of GPs were important factors which contributed to patients being cared for and dying in their preferred place. There was no reference to GPNs in any paper identified.

CONCLUSIONS

Patients and carers prefer a holistic approach to care. This review shows that GPs have an important role in ACP and that their involvement facilitates dying in the place of preference. Proactive identification of people approaching EoL is likely to improve all aspects of care, including planning and communicating about EoL. More work outlining the role of GPNs in end of life care is required.

Advance care planning in dementia: recommendations for healthcare professionals

Background

Advance care planning (ACP) is a continuous, dynamic process of reflection and dialogue between an individual, those close to them and their healthcare professionals, concerning the individual’s preferences and values concerning future treatment and care, including end-of-life care. Despite universal recognition of the importance of ACP for people with dementia, who gradually lose their ability to make informed decisions themselves, ACP still only happens infrequently, and evidence-based recommendations on when and how to perform this complex process are lacking. We aimed to develop evidence-based clinical recommendations to guide professionals across settings in the practical application of ACP in dementia care.

Methods

Following the Belgian Centre for Evidence-Based Medicine’s procedures, we 1) performed an extensive literature search to identify international guidelines, articles reporting heterogeneous study designs and grey literature, 2) developed recommendations based on the available evidence and expert opinion of the author group, and 3) performed a validation process using written feedback from experts, a survey for end users (healthcare professionals across settings), and two peer-review groups (with geriatricians and general practitioners).

Results

Based on 67 publications and validation from ten experts, 51 end users and two peer-review groups (24 participants) we developed 32 recommendations covering eight domains: initiation of ACP, evaluation of mental capacity, holding ACP conversations, the role and importance of those close to the person with dementia, ACP with people who find it difficult or impossible to communicate verbally, documentation of wishes and preferences, including information transfer, end-of-life decision-making, and preconditions for optimal implementation of ACP. Almost all recommendations received a grading representing low to very low-quality evidence.

Conclusion

No high-quality guidelines are available for ACP in dementia care. By combining evidence with expert and user opinions, we have defined a unique set of recommendations for ACP in people living with dementia. These recommendations form a valuable tool for educating healthcare professionals on how to perform ACP across settings.

Circumstances of hospital admissions in palliative care: A cross-sectional survey of patients admitted to hospital with palliative care needs

BACKGROUND

On average, people will experience 2.28 hospital admissions in the last year of life with the likelihood of a hospital admission increasing in the last 2 weeks of life. Reducing hospital admissions has become a focus for high-income countries as they work to manage the financial implications of an ageing population. However, the circumstances by which patients with palliative care needs are admitted to hospital remain poorly understood.

AIM

To explore the circumstances of hospital admissions for patients with palliative care needs.

DESIGN

Cross-sectional survey design using face-to-face questionnaires.

SETTING/PARTICIPANTS

In total, 116 patients aged >18 years admitted to a tertiary hospital with palliative care needs.

RESULTS

Those with a non-cancer diagnosis and those aged over 75 years were less likely to have hospice involved prior to the admission ( x² (1, n = 116) = 10.19, p = 0.00). Few patients recognised community services as having a role in enabling them to remain at home. Those with cancer placed a significantly higher priority on receiving information about their illness ( t(114) = 2.03, p = 0.04) and receiving tests and investigations ( t(114) = 2.37, p = 0.02) in hospital.

CONCLUSION

This study has demonstrated the complexity of hospital admissions in palliative care. Further research is needed to explore patient perceptions of care at home and the role of community services to enable them to remain at home. Understanding the motivation to come to hospital in the context of an incurable illness and limited treatment options may help to inform the development of services that can enable better care at home.

The Hospice Information System and its association with the congruence between the preferred and actual place of death

Objective:

A Hospice Information System (HIS) developed in eastern Taiwan in 2012 aimed to improve the quality of hospice care through an integrated system that provided telemetry-based vital sign records, online 24/7 consultations, online video interviews, and online health educations. The purpose of this study was to explore the congruence between the preferred and actual place of death (POD) among patients who received HIS services.

Materials and Methods:

A retrospective study was performed from January 2012 to August 2016. Data from patients enrolled in the HIS who died during this period were included. Data on basic characteristics and the actual and preferred POD were obtained from the HIS database. The primary outcome was the congruence between the preferred and actual POD. Secondary outcomes were comparisons between patients who did and did not achieve their preferred POD. Further comparisons between patients who did and did not achieve home death were also performed.

Results:

In total, we enrolled 481 patients who received HIS services and died. Of them, 444 (92.3%) died at their preferred POD. Patients who preferred an inpatient hospice as their POD had higher achievement rate than those who wanted a home death. High-intensity HIS utilization was associated with a higher likelihood of home death than low-intensity HIS utilization. Patients living in areas distant from the medical center had lower achievement of home death than those living in local areas.

Conclusions:

This study suggested that patients enrolled in the HIS had high congruence between the actual and preferred POD.

Final transitions to place of death: patients and families wishes

Purpose

This four-country study (Belgium, the Netherlands, Italy and Spain) examines prevalence and types of final transitions between care settings of cancer patients and the extent to which patient/family wishes are cited as a reason for the transition.

Methods

Data were collected from the EUROSENTI-MELC study over a 2-year period. General practitioners within existing Sentinel Networks registered weekly all deaths of patients within practices using a standardized questionnaire. This registration included place of care in the final 3 months and wishes for the final transition to place of death. All non-sudden deaths due to cancer (+18 years) were included in the analyses.

Results

We included 2048 non-sudden cancer deaths; 63% of patients had at least one transition between care settings in the final 3 months of life. 'Hospital death from home' (25-55%) and 'home death from hospital' (16-30%) were the most frequent types of final transitions in all countries. Patients' or families' wishes were mentioned as a reason for a final transition in 5-27% (P < 0.001) and 10-22% (P = 0.002) across countries.

Conclusions

'Hospital deaths from home' is the most prevalent final transition in three of four countries studied, in a significant minority of cases because of patient/family wishes.

Appropriateness and avoidability of terminal hospital admissions: Results of a survey among family physicians

BACKGROUND

Although the acute hospital setting is not considered to be an ideal place of death, many people are admitted to hospital at the end of life.

AIM

To examine what proportion of terminal hospital admissions among their patients family physicians consider to have been avoidable and/or inappropriate; which patient, family physician and admission factors are associated with the perceived inappropriateness or avoidability of terminal hospital admissions; and which interventions could have prevented them, from the perspective of family physicians.

DESIGN

Survey among family physicians, linked to medical record data.

SETTING

Patients who had died non-suddenly in the acute hospital setting of a university hospital in Belgium between January and August 2014.

RESULTS

We received 245 completed questionnaires (response rate 70%) and 77% of those hospital deaths ( n = 189) were considered to be non-sudden. Almost 14% of all terminal hospital admissions were considered to be potentially inappropriate, almost 14% potentially avoidable and 8% both, according to family physicians. The terminal hospital admission was more likely to be considered potentially inappropriate or potentially avoidable for patients who had died of cancer, when the patient's life expectancy at the time of admission was limited, by family physicians who had had palliative care training at basic, postgraduate or post-academic level, and when the admission was initiated by the patient, partner or other family.

CONCLUSION

Timely communication with the patient about their limited life expectancy and the provision of better support to family caregivers may be important strategies in reducing the number of hospital deaths.

Transitions Between Care Settings at the End of Life Among Older Homecare Recipients: A Population-Based Study

Objectives: Objectives were to (a) describe transitions between care settings in older homecare recipients at the end of life, and (b) examine what personal (e.g., age, sex) and health system factors (e.g., hospital bed supply) predict care transitions. Methods: The study involved analysis of administrative health care data and was based on a complete cohort of homecare recipients aged 65 years or older who died in Manitoba, Canada between 2003 and 2006 (N = 7,866). Results: More than half of homecare recipients had at least one care transition in the last 30 days before death and 21% had two or more hospitalizations in the last 90 days. Both personal characteristics and health system factors were related to transitions and hospitalizations. Discussion: The findings suggest that homecare recipients are an important population to focus on in terms of reducing potentially burdensome transitions and enhancing the end-of-life experience for them and their family.

Reasons for End-of-Life Hospital Admissions: Results of a Survey Among Family Physicians

CONTEXT

Although the acute hospital setting is not considered to be an ideal place of death, many people are admitted to hospital at the end of life.

OBJECTIVES

The present study aims to examine the reasons for hospital admissions that result in an expected death and the factors that play a role in the decision to admit to hospital.

METHODS

This was a survey among family physicians (FPs) about those of their patients who had died nonsuddenly in an acute university hospital setting in Belgium between January and August 2014. Questions were asked about the patient's health situation, care that the patient received before the admission, the circumstances of the hospital admission, the reasons necessitating the admission, and other factors that had played a role in the decision to admit the patient to hospital.

RESULTS

We received 245 completed questionnaires (response rate 70%), and 77% of those hospital deaths were considered to be nonsudden. FPs indicated that 55% of end-of-life hospitalizations were for palliative reasons and 26% curative or life-prolonging. Factors such as the patient feeling safer in hospital (35%) or family believing care to be better in hospital (54%) frequently played a role in the end-of-life hospitalization. When patients were admitted with a limited anticipated life expectancy, FPs were more likely to indicate that an inadequate caring capacity of the care setting had played a role in the admission.

CONCLUSION

To reduce the number of hospital deaths, a combination of structural support for out-of-hospital end-of-life care and a more timely referral to out-of-hospital palliative care services may be needed.

Interventions for Reducing Hospital Readmission Rates: The Role of Hospice and Palliative Care

Background:

Despite evidence that enrollment with hospice services has the potential to reduce hospital readmission rates, previous research has not examined exactly how hospitals may promote the appropriate use of hospice and palliative care for their discharged patients. Therefore, we sought to explore the strategies used by hospitals to increase the use of hospice and palliative care for patients at risk of readmission.

Methods:

We conducted a secondary analysis of qualitative data from a study of hospitals that were participating in the State Action on Avoidable Readmissions (STAAR) initiative, a quality improvement collaborative. We used data attained from 46 in-depth interviews conducted during 10 hospital site visits using a standard discussion guide and protocol. We used a grounded theory approach using the constant comparative method to generate recurrent and unifying themes.

Results:

We found that a positive effect for hospitals participating in the STAAR initiative was enhanced engagement in efforts to promote greater use of hospice and palliative care as a possible method of reducing unplanned readmissions, the central goal of the STAAR initiative. Hospital staff described strategies to increase the use of hospice and palliative care that included (1) designing and implementing tracking systems to identify patients most at risk of being readmitted, (2) providing education about hospice and palliative care to family, internal and external clinical groups, and (3) establishing closer links to posthospital settings.

Conclusion:

National efforts to reduce rehospitalizations may result in improved integration of hospice and palliative care for patients who are at risk of readmission.

The importance of identifying preferred place of death

Objectives

The majority of people would prefer to die at home and the stated intentions of both statutory and voluntary healthcare providers aim to support this. This service evaluation compared the preferred and actual place of death of patients known to a specialist community palliative care service.

Design

All deaths of patients (n=2176) known to the specialist palliative care service over a 5-year period were examined through service evaluation to compare the actual place of death with the preferred place of death previously identified by the patient. Triggers for admission were established when the patients did not achieve this preference.

Results

Between 2009 and 2013, 73% of patients who expressed a choice about their preferred place of death and 69.3% who wanted to die at home were able to achieve their preferences. During the course of their illness, 9.5% of patients changed their preference for place of death. 30% of patients either refused to discuss or no preference was elicited for place of death.

Conclusions

Direct enquiry and identification of preferences for end-of-life care is associated with patients achieving their preference for place of death. Patients whose preferred place of death was unknown were more likely to be admitted to hospital for end-of-life care.

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.

Care and communication between health professionals and patients affected by severe or chronic illness in community care settings: a qualitative study of care at the end of life

Background

Advance care planning (ACP) enables patients to consider, discuss and, if they wish, document their wishes and preferences for future care, including decisions to refuse treatment, in the event that they lose capacity to make decisions for themselves. ACP is a key component of UK health policy to improve the experience of death and dying for patients and their families. There is limited evidence about how patients and health professionals understand ACP, or when and how this is initiated. It is evident that many people find discussion of and planning for end of life care difficult, and tend to avoid the topic.

Aim

To investigate how patients, their relatives and health professionals initiate and experience discussion of ACP and the outcomes of advance discussions in shaping care at the end of life.

Design and data collection

Qualitative study with two workstreams: (1) interviews with 37 health professionals (general practitioners, specialist nurses and community nurses) about their experiences of ACP; and (2) longitudinal case studies of 21 patients with 6-month follow-up. Cases included a patient and, where possible, a nominated key relative and/or health professional as well as a review of medical records. Complete case triads were obtained for 11 patients. Four cases comprised the patient alone, where respondents were unable or unwilling to nominate either a family member or a professional carer they wished to include in the study. Patients were identified as likely to be within the last 6 months of life. Ninety-seven interviews were completed in total.

Setting

General practices and community care settings in the East Midlands of England.

Findings

The study found ACP to be uncommon and focused primarily on specific documented tasks involving decisions about preferred place of death and cardiopulmonary resuscitation, supporting earlier research. There was no evidence of ACP in nearly half (9 of 21) of patient cases. Professionals reported ACP discussions to be challenging. It was difficult to recognise when patients had entered the last year of life, or to identify their readiness to consider future planning. Patients often did not wish to do so before they had become gravely ill. Consequently, ACP discussions tended to be reactive, rather than pre-emptive, occurring in response to critical events or evidence of marked deterioration. ACP discussions intersected two parallel strands of planning: professional organisation and co-ordination of care; and the practical and emotional preparatory work that patients and families undertook to prepare themselves for death. Reference to ACP as a means of guiding decisions for patients who had lost capacity was rare.

Conclusions

Advance care planning remains uncommon, is often limited to documentation of a few key decisions, is reported to be challenging by many health professionals, is not welcomed by a substantial number of patients and tends to be postponed until death is clearly imminent. Current implementation largely ignores the purpose of ACP as a means of extending personal autonomy in the event of lost capacity.

Future work

Attention should be paid to public attitudes to death and dying (including those of culturally diverse and ethnic minority groups), place of death, resuscitation and the value of anticipatory planning. In addition the experiences and needs of two under-researched groups should be explored: the frail elderly, including those who manage complex comorbid conditions, unrecognised as vulnerable cases; and those patients affected by stigmatised conditions, such as substance abuse or serious mental illness who fail to engage constructively with services and are not recognised as suitable referrals for palliative and end of life care.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

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

The aim of this study was to explore reasons for the hospitalisation and place of death outcomes of terminal cancer patients. The methodology involved a qualitative content analysis of medical records pertaining to the last 3 months of life of 39 patients with one of four malignancies: prostate, breast, lung, or haematological. The results presentation is organised around three themes: decision hierarchy in health care, meanings of 'home', and late recognition of dying. Based on the detailed findings, this paper suggests that important insights into the broader goals of advanced cancer patients are offered by allied health staff, and that more effective use of the multidisciplinary team may support endeavours to achieve more home deaths for cancer patients who want this outcome. The analysis also provides new insights into the meaning of 'home' in interactions between advanced cancer patients and health professionals. The wish for 'home' appears bound up with other patient goals and the implications of this are discussed.

Critical decisions for older people with advanced dementia: a prospective study in long-term institutions and district home care

OBJECTIVE

To describe and compare the decisions critical for survival or quality of life [critical decisions (CDs)] made for patients with advanced dementia in nursing homes (NHs) and home care (HC) services.

DESIGN

Prospective cohort study with a follow-up of 6 months.

SETTING

Lombardy Region (NHs) and Reggio-Emilia and Modena Districts (HC), Italy.

PARTICIPANTS

Patients (496 total; 315 in NHs and 181 in HC) with advanced dementia (Functional Assessment Staging Tool score ≥ 7) and expected survival ≥ 2 weeks.

MEASUREMENTS

At baseline, the patients' demographic data, date of admission and of dementia diagnosis, type of dementia, main comorbidities, presence of pressure sores, ongoing treatments, and current prescriptions were abstracted from clinical records. At baseline and every 15 days thereafter, information regarding the patients' general condition and CDs (deemed critical by the doctor or team) was collected by an interview with the doctor. For each CD, the physician reported the problem that led to the decision, that was eventually made, the purpose of the decision, whether the decision had been discussed with and/or communicated to the family, who made the final decision, whether the decision was maintained after 1 week, whether it corresponded to what the doctor would have judged appropriate, and the expected survival of the patient (≤ 15 days).

RESULTS

For 267 of the 496 patients (53.8%; 60.3% in NHs and 42.5% at home), 644 CDs were made; for 95 patients, more than 1 CD was made. The problems that led to a CD were mainly infections (respiratory tract and other infections; 46.6%, 300/644 CDs); nutritional/hydration problems (20.6%; 133 CDs); and the worsening of a pre-existing disease (9.3%; 60 CDs). The most frequent type of decision concerned the prescription of antibiotics (overall 41.1%, 265/644; among NH patients 44.6%, 218/488; among HC patients, 30.2%, 47/156). The decision to hospitalize the patient was more frequently reported for HC than NH patients (25.5% vs 3.1%). The most frequent purposes of the CDs in both settings were reducing symptoms or suffering (more so in NHs; 81.1% vs 57.0% in HC) and prolonging survival (NH 27.5%; HC 23.1%; multiple purposes were possible). For 26 decisions (3.8%), the purpose was to ease death or not to prolong life.

CONCLUSIONS

Decisions critical for the survival or quality of life of patients with advanced dementia were made for approximately one-half of the patients during a 6-month time frame, and such decisions were made more frequently in NHs than in HC. HC patients were more frequently hospitalized, and a sizeable minority of these patients were treated with the goal of prolonging survival. Italian patients with advanced dementia may benefit from the implementation of palliative care principles, and HC patients may benefit from the implementation of measures to avoid hospitalizing patients near the end of life.

The acute hospital setting as a place of death and final care: a qualitative study on perspectives of family physicians, nurses and family carers

While the focus of end-of-life care research and policy has predominantly been on 'death in a homelike environment', little is known about perceptions of the acute hospital setting as a place of final care or death. Using a qualitative design and constant comparative analysis, the perspectives of family physicians, nurses and family carers were explored. Participants generally perceived the acute hospital setting to be inadequate for terminally ill patients, although they indicated that in some circumstances it might be a 'safe haven'. This implies that a higher quality of end-of-life care provision in the acute hospital setting needs to be ensured, preferably by improving communication skills. At the same time alternatives to the acute hospital setting need to be developed or expanded.