Does inpatient palliative care consultation impact outcomes following hospital discharge? A narrative systematic review

Advancing the Care Experience for patients receiving Palliative care as they Transition from hospital to Home (ACEPATH): Codesigning an intervention to improve patient and family caregiver experiences

BACKGROUND

Returning home from the hospital for palliative-focused care is a common transition, but the process can be emotionally distressing and logistically challenging for patients and caregivers. While interventions exist to aid in the transition, none have been developed in partnership with patients and caregivers.

OBJECTIVE

To undergo the initial stages of codesign to create an intervention (Advancing the Care Experience for patients receiving Palliative care as they Transition from hospital to Home [ACEPATH]) to improve the experience of hospital-to-home transitions for adult patients receiving palliative care and their caregiver(s).

METHODS

The codesign process consisted of (1) the development of codesign workshop (CDW) materials to communicate key findings from prior research to CDW participants; (2) CDWs with patients, caregivers and healthcare providers (HCPs); and (3) low-fidelity prototype testing to review CDW outputs and develop low-fidelity prototypes of interventions. HCPs provided feedback on the viability of low-fidelity prototypes.

RESULTS

Three patients, seven caregivers and five HCPs participated in eight CDWs from July 2022 to March 2023. CDWs resulted in four intervention prototypes: a checklist, quick reference sheets, a patient/caregiver workbook and a transition navigator role. Outputs from CDWs included descriptions of interventions and measures of success. In April 2023, the four prototypes were presented in four low-fidelity prototype sessions to 20 HCPs. Participants in the low-fidelity prototype sessions provided feedback on what the interventions could look like, what problems the interventions were trying to solve and concerns about the interventions.

CONCLUSION

Insights gained from this codesign work will inform high-fidelity prototype testing and the eventual implementation and evaluation of an ACEPATH intervention that aims to improve hospital-to-home transitions for patients receiving a palliative approach to care.

PATIENT OR PUBLIC CONTRIBUTION

Patients and caregivers with lived experience attended CDWs aimed at designing an intervention to improve the transition from hospital to home. Their direct involvement aligns the intervention with patients' and caregivers' needs when transitioning from hospital to home. Furthermore, four patient/caregiver advisors were engaged throughout the project (from grant writing through to manuscript writing) to ensure all stages were patient- and caregiver-centred.

Practicing Surgeons' Perception of Barriers to Palliative Care Delivery in British Columbia

BACKGROUND

Utilization of palliative care remains low among surgical patients. We aim to characterize general surgeons' perceptions of barriers to access palliative care in British Columbia (BC).

METHODS

Semi-structured interviews were carried out with a total of 11 surgeons in BC. Interviews were transcribed for thematic analysis via interpretive description. Dominant themes were identified and agreed upon between the authors.

RESULTS

Several barriers were identified, which include system and institution, communication and surgical workflow barriers. At the system and institutional level, there were difficulties accessing patient information and continuity of care. Themes in the communication included patient misconceptions about palliative care and communication challenges with consulting services. Surgical workflow barriers influenced the overall perceived role of surgeons when caring for patients with palliative care needs.

CONCLUSION

Understanding surgeons' perspectives on barriers to palliative care is an important step in changing management. This can aid in the development of strategies that ease access to palliative care.

Digital health and inpatient palliative care: a cohort-controlled study

OBJECTIVES

End of life has unacceptable levels of hospital admission and death. We aimed to determine the association of a novel digital specific system (Proactive Risk-Based and Data-Driven Assessment of Patients at the End of Life, PRADA) to modify such events.

METHODS

A cohort-controlled study of those discharged alive, who died within 90 days of discharge, comparing PRADA (n=114) with standard care (n=3730).

RESULTS

At 90 days, the PRADA group were more likely to die (78.9% vs 46.2%, p<0.001), had a shorter time to death (58±90 vs 178±186 days, p<0.001) but readmission (20.2% vs 37.9%, p<0.001) or death in hospital (4.4% vs 28.9%, p<0.001) was lower with reduced risk for a combined 90-day outcome of postdischarge non-elective admission or hospital death (OR 0.45, 95% CI 0.27-0.74, p<0.001). Tightening criteria with 1:1 matching (n=83 vs 83) showed persistent significant findings in PRADA contact with markedly reduced adverse events (OR 0.15, 95% CI 0.02-0.96, p<0.05).

CONCLUSIONS

Being seen in hospital by a specialist palliative care team using the PRADA tool was associated with significantly improved postdischarge outcomes pertaining to those destined to die after discharge.

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.

Association between inpatient palliative care encounter and 30-day all-cause readmissions after index hospitalization for chronic obstructive pulmonary disease

BACKGROUND

Studies exist on the association between inpatient Palliative Care Encounter (iPCE) and 30-day rehospitalization among cancer and several non-cancer conditions but limited in persons with Chronic Obstructive Pulmonary Disease (COPD).

OBJECTIVE

To assess the association between an iPCE with the risk of 30-day rehospitalization after an index hospitalization for COPD.

METHODS

We conducted a cross-sectional analysis of the Nationwide Readmissions Database (2010-2014). Index hospitalizations were defined as persons ≥ 18 years of age, discharge destinations of either Home/Routine, Home with Home Care, or a Facility, and an index hospitalization with Diagnosis Related Group of COPD. The International Classification of Diseases, 9th revision codes were used to extract comorbidities and a Palliative Care Encounter (V66.7).

RESULTS

There were 3,163,889 index hospitalizations and iPCE occurred in 21,330 (0.67%). There were 558,059 (17.63%) with a 30-day rehospitalization. An iPCE was associated with a significantly lower adjusted odds of 30-day readmission (Odds Ratio [OR], 0.50; 95% Confidence Interval [CI], 0.46 to 0.54).  By discharge destination, the odds of 30-day rehospitalization were for a discharged to a facility (OR, 0.37; 95% CI, 0.32 to 0.42), to home with home health (OR, 0.42; 95% CI, 0.37 to 0.47), and to home (OR, 0.98; 95% CI, 0.85 to 1.12) for those with relative to without iPCE.

CONCLUSION

Inpatient PCE was associated with a 50% lower relative odds of 30-day rehospitalization after an index hospitalization for COPD. This association varied by discharge destination being statistically significant among those with a discharge destination of a facility (63%) and home with home care (58%).

Delivering Palliative Care to Hospitalized Oncology Patients: A Scoping Review

CONTEXT

Early, longitudinal integration of palliative care (PC) is recommended for patients with advanced cancer, in both inpatient and outpatient settings. Despite the growth of specialty PC teams in the last decade, the majority of PC is still delivered in the inpatient setting using a traditional referral-based consult delivery model. However, traditional consultation can lead to significant variation or delay in inpatient PC utilization. New care delivery models and strategies are emerging to deliver PC to hospitalized oncology patients who would most benefit from their services and to better align with professional society recommendations.

OBJECTIVES

To identify different care models to deliver PC to ho`spitalized oncology patients and summarize their impact on patient and health system-related outcomes.

METHODS

We conducted a scoping review of peer-reviewed articles from 2006 to 2021 evaluating delivery of PC to oncology patients in acute inpatient care. We abstracted study characteristics, the study's intervention and comparison arms, and outcomes related to specialty PC intervention.

RESULTS

We identified four delivery models that have been reported to deliver PC: 1) traditional referral-based consultation, 2) criterion-based or "triggered" consultation, 3) co-rounding with primary inpatient team, and 4) PC clinicians serving as the primary team. We summarize the known outcomes data from each model, and compare the benefits and limitations of each model.

CONCLUSION

Our findings provide guidance to health systems about care delivery models to deploy and implement inpatient PC resources to best serve their unique populations.

Palliative care symptoms, concerns and well-being of older people with frailty and complex care needs upon hospital discharge: a cross-sectional study

Background

Little is known about the nature and intensity of palliative care needs of hospitalised older people. We aimed to describe the palliative care symptoms, concerns, and well-being of older people with frailty and complex care needs upon discharge from hospital to home, and to examine the relationship between palliative care symptoms and concerns, and well-being.

Methods

Cross-sectional study using baseline survey data of a pilot randomised controlled trial. Hospital staff identified patients (≥ 70 years) about to be discharged home, with a clinical frailty score of 5 to 7 and complex needs based on physician-assessment. Patients completed structured interviews, using the Integrated Palliative Care Outcome Scale (IPOS), ICEpop CAPability measure for supportive care (ICECAP-SCM) and IPOS Views on Care quality of life item. We calculated descriptive statistics.

Results

We assessed 37 older people with complex needs (49% women, mean age 84, standard deviation 6.1). Symptoms rated as causing severe problems were weakness (46%) and poor mobility (40%); 75% reported that their family felt anxious at least occasionally. Of the 17 IPOS items, 41% of patients rated five or more symptoms as causing severe problems, while 14% reported that they were not severely affected by any symptom. 87% expressed feeling supported. There was a negative correlation between symptoms (IPOS) and well-being (ICECAP); r = -0.41.

Conclusion

We identified a large variety of symptoms experienced by older people identified as having frailty and complex needs upon hospital discharge. Many were severely affected by multiple needs. This population should be considered for palliative care follow-up at home.

Admission Code Status and End-of-life Care for Hospitalized Patients With COVID-19

CONTEXT

The COVID-19 pandemic has highlighted variability in intensity of care. We aimed to characterize intensity of care among hospitalized patients with COVID-19.

OBJECTIVES

Examine the prevalence and predictors of admission code status, palliative care consultation, comfort-measures-only orders, and cardiopulmonary resuscitation (CPR) among patients hospitalized with COVID-19.

METHODS

This cross-sectional study examined data from an international registry of hospitalized patients with COVID-19. A proportional odds model evaluated predictors of more aggressive code status (i.e., Full Code) vs. less (i.e., Do Not Resuscitate, DNR). Among decedents, logistic regression was used to identify predictors of palliative care consultation, comfort measures only, and CPR at time of death.

RESULTS

We included 29,923 patients across 179 sites. Among those with admission code status documented, Full Code was selected by 90% (n = 15,273). Adjusting for site, Full Code was more likely for patients who were of Black or Asian race (ORs 1.82, 95% CIs 1.5-2.19; 1.78, 1.15-3.09 respectively, relative to White race), Hispanic ethnicity (OR 1.89, CI 1.35-2.32), and male sex (OR 1.16, CI 1.0-1.33). Of the 4951 decedents, 29% received palliative care consultation, 59% transitioned to comfort measures only, and 29% received CPR, with non-White racial and ethnic groups less likely to receive comfort measures only and more likely to receive CPR.

CONCLUSION

In this international cohort of patients with COVID-19, Full Code was the initial code status in the majority, and more likely among patients who were Black or Asian race, Hispanic ethnicity or male. These results provide direction for future studies to improve these disparities in care.

Inpatient palliative care encounter and 30-day readmission among hospitalizations for heart failure

Aim: To determine the association between inpatient palliative care encounter (PCE) and 30-day rehospitalization. Materials & methods: The Nationwide Readmission Database was used in a cross-sectional design study. Comorbidities and a palliative care encounter (PCE; V66.7) were defined using ICD-9 codes. Results: Overall, 21.28% of 3,534,480 index hospitalizations were readmitted. PCE occurred in 1.66% of index hospitalizations and was associated with a lower odds of 30-day rehospitalization (adjusted odds ratio, 0.38; 95% CI: 0.35-0.40). This association remained significant when assessed by discharge destination. Conclusion: PCE was associated with a lower relative odds of 30-day rehospitalization. A 73% decrease in the relative odds of 30-day rehospitalization among discharges to a facility, 64% for home with home health, and 22% for discharges to home.

Patient-Centered Discussion on End-of-Life Care for Patients with Advanced COPD

Exacerbations of chronic obstructive pulmonary disease (COPD) may lead to a rapid decline in health and subsequent death, an unfortunate tyranny of having COPD-an irreversible health condition of 16 million individuals in the USA totaling 60 million in the world. While COPD is the third largest leading cause of death, causing 3.23 million deaths worldwide in 2019 (according to the WHO), most patients with COPD do not receive adequate treatment at the end stages of life. Although death is inevitable, the trajectory towards end-of-life is less predictable in severe COPD. Thus, clinician-patient discussion for end-of-life and palliative care could bring a meaningful life-prospective to patients with advanced COPD. Here, we summarized the current understanding and treatment of COPD. This review also highlights the importance of patient-centered discussion and summarizes current status of managing patients with advanced COPD.

Doing More with the Same: Comparing Public and Private Hospital Palliative Care within California

Background: Public and private hospitals treat different patient populations, which may impact resources to deliver palliative care (PC). Objectives: Compare public and private hospital PC service structures, processes, and treatment outcomes. Design: Retrospective data analysis of the Palliative Care Quality Network between 2018 and 2019. Settings/Subjects: Six public and 40 private California hospitals provided PC consultations to 4244 and 38,354 adults, respectively. Measurements: PC team and patient characteristics, care processes, and treatment outcomes. Results: Public and private hospital PC services had similar full-time equivalent/100 beds (1.2 vs. 1.4, p = 0.4). Public hospital patients were younger (65.2 vs. 73.5, p < 0.001), less likely to be non-Hispanic Caucasian (22.5% vs. 57.5%, p < 0.001), or English speaking (51.1% vs. 79.9%, p < 0.001). Public hospital patients had more moderate/severe pain (21.3% vs. 19.3, p < 0.03), anxiety (12.4% vs. 9.2%, p < 0.001), nausea (6.5% vs. 4.7%, p < 0.001), and dyspnea (11.0% vs. 8.6%, p < 0.001). Both hospitals equally improved pain (70.9% vs. 70.5%, p = 0.83) and nausea (82.0% vs. 87.6%, p = 0.09), but public hospitals were less effective at improving anxiety (67.3% vs. 78.4%, p = 0.002) and dyspnea (58.4% vs. 67.9%, p = 0.05). Although there was no difference in hospital length of stay (public = 10.2 days vs. private = 9.5 days, p = 0.07), public hospitals conducted more patient visits (2.6 vs. 1.8, p < 0.001). They also more often clarified code status (87.7% vs. 84.4%, p < 0.001) and surrogate decision maker (94.9% vs. 89.9%, p < 0.001). Conclusions: Public hospital PC teams treat a more diverse symptomatic population. Yet, they achieved comparable outcomes with similar staffing to private hospitals. These findings have important ramifications for policy makers and public institution leaders.

The Influence of Palliative Care in Hospital Length of Stay and the Timing of Consultation

BACKGROUND

Inpatient palliative care may reduce length-of-stay, costs, mortality, and prevent readmissions. Timing of consultation may influence outcomes. The aim of this study was to explore the timing of consultation and its influences patient outcomes.

METHOD

This retrospective study of hospital consultations between July 1, 2019 and December 31, 2019 compared patients seen within 72 hours of admission with those seen after 72 hours. Outcomes length of stay and mortality. Chi-square analyses for categorical variables and independent t-tests for continuous normally distributed variables were done. For nonparametrically distributed outcome variables, Wilcoxon rank sum test was used. For mortality, a time-to-event analysis was used. 30-day readmissions were assessed using the Fine-Gray sub-distribution hazard model. Multiple regression models were used, controlling for other variables.

RESULTS

696 patients were seen, 424 within 72 hours of admission. The average age was 73 and 50.6% were female. Consultation within 72 hours was not associated with a shorter stay for cancer but was for patients with non-cancer illnesses. Inpatient mortality and 30-days mortality were reduced but there was a higher 30-day readmission rate.

DISCUSSION

Palliative consultations within 72 hours of admission was associated with lower hospital stays and inpatient mortality but increased the risk of readmission. Benefits were largely observed in patients followed in continuity.

CONCLUSION

Early inpatient palliative care consultation was associated with reduced hospital mortality, 30-day mortality and length of stay particularly if patients were seen by palliative care prior to hospitalization.

“That little bit of time”: Transition-to-Hospice Perspectives from Hospice Staff and Bereaved Family

Background and Objectives

Many patients lack understanding of hospice services and their preparation for the transition to hospice at home may be insufficient. This study explored how hospice admissions staff and caregivers of hospice patients perceive the hospice admission process and the transition to hospice at home.

Research Design and Methods

We conducted in-depth, semistructured interviews with 2 subgroups: hospice admissions staff (n = 15) and bereaved caregivers of former hospice patients (n = 20). We performed a 3-coder descriptive content analysis.

Results

There were 4 overall themes: (a) issues relating to the referring/prehospice provider, (b) issues relating to hospital discharge/care transition home, (c) issues relating to the first touch of hospice, and (d) the impact of coronavirus disease 2019 (COVID-19) on hospice admissions. Patients are often referred to hospice without clear prognostic understanding, at times placing staff in the uncomfortable position of breaking difficult news. Stigma may make patients and families fearful of enrolling in hospice, and misconceptions about hospice are common. Caregivers emphasize the need for increased attention to their emotional needs. Staff revealed the emotional challenges they experience conducting admissions. Both staff and caregivers indicate that the transition to hospice is often emotionally and logistically burdensome, especially when discharging home from the hospital. Both subgroups report insufficient caregiver preparation for taking care of a dying patient at home, particularly regarding medication management. COVID-19 created challenges yet prompted innovative changes to hospice admission processes.

Discussion and Implications

Findings demonstrate a need to improve the hospice admissions process, better supporting terminally ill patients and their families.

Inpatient Palliative Care Is Associated with the Receipt of Palliative Care in the Community after Hospital Discharge: A Retrospective Cohort Study

Background: For hospitalized patients with palliative care needs, there is little evidence on whether postdischarge outcomes differ if inpatient palliative care was delivered by a palliative care specialist or nonspecialist/generalist. Objective: To evaluate relationships between inpatient palliative care involvement and physician-delivered palliative care in the community after hospital discharge among individuals with limited life expectancy. Design: Population-based retrospective cohort study using administrative health data. Settings/Subjects: Adults with a predicted median survival of six months or less admitted to acute care hospitals in Ontario, Canada, between April 1, 2013, and March 31, 2017, and discharged to the community. Measurements: Inpatient palliative care involvement was classified as high (e.g., palliative care unit), medium (e.g., palliative care specialist consult), low (e.g., generalist-delivered palliative care), or none. Community palliative care included outpatient and home and clinic visits three weeks postdischarge. Results: Among 3660 hospitalized adults, 82 (2.2%) received inpatient palliative care with high level of involvement, 462 (12.6%) with medium level of involvement, 525 (14.3%) with low level of involvement, and 2591 (70.8%) had no inpatient palliative care. Patients who received inpatient palliative care were more likely to receive community palliative care after discharge than those who received no inpatient palliative care. These associations were stronger among patients who received high/medium palliative care involvement than patients who received low palliative care involvement. Conclusions: Inpatient palliative care, including that delivered by generalists, is associated with an increased likelihood of community palliative care after discharge. Increased inpatient generalist palliative care may help support patients' palliative care needs.

Prevalence of Life-Limiting and Life-Threatening Illness and Associated Palliative Care Needs Among Hospital Inpatients in Sudan

CONTEXT

Evidence is needed to inform expansion of hospital-based palliative care in low and middle-income countries.

OBJECTIVES

This study aimed to measure need for palliative care among adult inpatients at five hospitals in Sudan. Objectives were to 1) measure point prevalence of life-limiting and life-threatening illness (LL/LTI); 2) determine patient insight into diagnosis and prognosis; 3) assess palliative care-related symptoms and concerns.

METHODS

In this two-day census, data were extracted from charts on documented LL/LTI for each occupied bed. For patients with LL/LTI, self-report data was collected on symptoms, concerns and understanding of diagnosis and prognosis using Integrated African Palliative Outcome Scale (IAPOS).

RESULTS

1) Prevalence of LL/LTI in general hospitals was 30.9%-70.5%. 2) n = 439 patients gave self-report data (response rate 89.8%). Mean age was 52.3 (SD 17.8), 59% of patients correctly knew their diagnosis, and 36% knew their illness was progressive. Those with a non-cancer diagnosis were significantly less likely to know their prognosis (28.4% vs 40.7% respectively, P = 0.012). 3) Family anxiety was most burdensome (56.7% scoring on the two most severe categories on a 6-point Likert), followed by pain (52.4%), poor mobility (40.5%), patient worry (39.9%), and fatigue (36.9%). Patients unaware of prognosis had higher total IAPOS scores than those aware their prognosis was progressive, 38.9 (SD = 15.6) (t = -3.297, P = 0.001, mean difference = -5.010, 95% CI: -7.997, -2.023).

CONCLUSION

Care for those with life-limiting and life-threatening illness places a significant occupancy burden on public hospitals. Communication skills are required to provide patients with insight, and core palliative care skills for acute hospital clinicians are needed to manage the high burden of symptoms and concerns.

Estimation of age of transition from paediatric to adult healthcare for young people with long term conditions using linked routinely collected healthcare data

Introduction

Healthcare transitions, including from paediatric to adult services, can be disruptive and cause a lack of continuity in care. Existing research on the paediatric-adult healthcare transition often uses a simple age cut-off to assign transition status. This risks misclassification bias, reducing observed changes at transition (adults are included in the paediatric group and vice versa) possibly to differing extents between groups that transition at different ages.

Objective

To develop and assess methods for estimating the transition point from paediatric to adult healthcare from routine healthcare records.

Methods

A retrospective cohort of young people (12 to 23 years) with long term conditions was constructed from linked primary and secondary care data in England. Inpatient and outpatient records were classified as paediatric or adult based on treatment and clinician specialities. Transition point was estimated using three methods based on record classification (First Adult: the date of first adult record; Last Paediatric: date of last paediatric record; Fitted: a date determined by statistical fitting). Estimated transition age was compared between methods. A simulation explored impacts of estimation approaches compared to a simple age cut-off when assessing associations between transition status and healthcare events.

Results

Simulations showed using an age-based cut-off at 16 or 18 years as transition point, common in research on transition, may underestimate transition-associated changes. Many health records for those aged <14 years were classified as adult, limiting utility of the First Adult approach. The Last Paediatric approach is least sensitive to this possible misclassification and may best reflect experience of the transition.

Conclusions

Estimating transition point from routine healthcare data is possible and offers advantages over a simple age cut-off. These methods, adapted as necessary for data from other countries, should be used to reduce risk of misclassification bias in studies of transition in nationally representative data.

Examining the course of transitions from hospital to home-based palliative care: A mixed methods study

BACKGROUND

Hospital-to-home transitions in palliative care are fraught with challenges. To assess transitions researchers have used patient reported outcome measures and qualitative data to give unique insights into a phenomenon. Few measures examine care setting transitions in palliative care, yet domains identified in other populations are likely relevant for patients receiving palliative care.

AIM

Gain insight into how patients experience three domains, discharge readiness, transition quality, and discharge-coping, during hospital-to-home transitions.

DESIGN

Longitudinal, convergent parallel mixed methods study design with two data collection visits: in-hospital before and 3-4 weeks after discharge. Participants completed scales assessing discharge readiness, transition quality, and post discharge-coping. A qualitative interview was conducted at both visits. Data were analyzed separately and integrated using a merged transformative methodology, allowing us to compare and contrast the data.

SETTING AND PARTICIPANTS

Study was set in two tertiary hospitals in Toronto, Canada. Adult inpatients (n = 25) and their caregivers (n = 14) were eligible if they received a palliative care consultation and transitioned to home-based palliative care.

RESULTS

Results were organized aligning with the scales; finding low discharge readiness (5.8; IQR: 1.9), moderate transition quality (66.7; IQR: 33.33), and poor discharge-coping (5.0; IQR: 2.6), respectively. Positive transitions involved feeling well supported, managing medications, feeling well, and having healthcare needs met. Challenges in transitions were feeling unwell, confusion over medications, unclear healthcare responsibilities, and emotional distress.

CONCLUSIONS

We identified aspects of these three domains that may be targeted to improve transitions through intervention development. Identified discrepancies between the data types should be considered for future research exploration.

"Going Home [Is] Just a Feel-Good Idea With No Structure": A Qualitative Exploration of Patient and Family Caregiver Needs When Transitioning From Hospital to Home in Palliative Care

CONTEXT

Hospital-to-home transitions, particularly at the end of life, can be challenging for patients and their family caregivers. Therefore, there is a need to better understand gaps in expectations and experiences of these transitions. Theory can inform the creation of an intervention aimed at improving the hospital-to-home transition.

OBJECTIVES

1) Explore patients' and caregivers' expectations and subsequent experiences of the hospital-to-home transition while receiving palliative care, and 2) build a substantive grounded theory to enhance the understanding of hospital-to-home transitions from the patient and caregiver perspective.

METHODS

Longitudinal, prospective qualitative study with semistructured interviews at hospital discharge and three to four weeks after discharge home. We recruited adults receiving inpatient palliative care who were being discharged to home-based palliative care, and their family caregivers from two academic health centers in Toronto, Canada. Thirty-nine participants: 18 patients, 7 caregivers, and 7 patient-caregiver dyads participated. We conducted 52 interviews. We conducted a grounded theory qualitative study.

RESULTS

Through examining the expectations and subsequent experiences of the transition, and exploring the gaps between them, we identified various transitions needs: health and well-being needs, and practical needs (i.e., transportation, setting up the home for care, care providers in the home). Several enablers and disablers modified the likelihood of needs being met (e.g., caregiver role, education on symptom management, uncertainty, financial resources).

CONCLUSION

Our substantive grounded theory highlighted potentially measurable constructs that can be further tested. Future interventions should target the enablers/disablers to ensure health and well-being and practical needs are met in the transition.

Transitioning From Hospital to Palliative Care at Home: Patient and Caregiver Perceptions of Continuity of Care

CONTEXT

Continuity of care is important at improving the patient experience and reducing unnecessary hospitalizations when transitioning across care settings, especially at the end of life.

OBJECTIVE

To explore patient and caregiver understanding and valuation of "continuity of care" while transitioning from an in-hospital to a home-based palliative care team.

METHODS

Longitudinal qualitative design using semistructured interviews conducted with patients and their caregivers before and after transitioning from hospital to palliative care at home. Interviews were audio-recorded and transcribed verbatim. Data were analyzed using thematic analysis within a postpositivist framework. Thirty-nine participants (18 patients, seven caregivers, and seven patient-caregiver dyads) were recruited from two acute care hospitals, wherein they received care from an inpatient palliative care consultation team and transitioned to home-based palliative care.

RESULTS

Patients had a mean age of 68 years, 60% were female and 60% had a diagnosis of cancer. Caregivers had a mean age of 62 years and 50% were female. Participants perceived continuity of care to occur in three ways, depending on which stage they were at in their hospital-to-home transition. In hospital, continuity of care was experienced, as consistency of information exchanged between providers. During the transition from hospital to home, continuity of care was experienced as consistency of treatments. When receiving home-based palliative care, continuity of care was experienced as having consistent providers.

CONCLUSION

Patients' and their caregivers' valuation of continuity of care was dependent on their stage of the hospital-to-home transition. Optimizing continuity of care requires an integrated network of providers with reliable information transfer and communication.

Disparities in Palliative and Hospice Care and Completion of Advance Care Planning and Directives Among Non-Hispanic Blacks: A Scoping Review of Recent Literature

OBJECTIVES

Published research in disparities in advance care planning, palliative, and end-of-life care is limited. However, available data points to significant barriers to palliative and end-of-life care among minority adults. The main objective of this scoping review was to summarize the current published research and literature on disparities in palliative and hospice care and completion of advance care planning and directives among non-Hispanc Blacks.

METHODS

The scoping review method was used because currently published research in disparities in palliative and hospice cares as well as advance care planning are limited. Nine electronic databases and websites were searched to identify English-language peer-reviewed publications published within last 20 years. A total of 147 studies that addressed palliative care, hospice care, and advance care planning and included non-Hispanic Blacks were incorporated in this study. The literature review include manuscripts that discuss the intersection of social determinants of health and end-of-life care for non-Hispanic Blacks. We examined the potential role and impact of several factors, including knowledge regarding palliative and hospice care; healthcare literacy; communication with providers and family; perceived or experienced discrimination with healthcare systems; mistrust in healthcare providers; health care coverage, religious-related activities and beliefs on palliative and hospice care utilization and completion of advance directives among non-Hispanic Blacks.

DISCUSSION

Cross-sectional and longitudinal national surveys, as well as local community- and clinic-based data, unequivocally point to major disparities in palliative and hospice care in the United States. Results suggest that national and community-based, multi-faceted, multi-disciplinary, theoretical-based, resourceful, culturally-sensitive interventions are urgently needed. A number of practical investigational interventions are offered. Additionally, we identify several research questions which need to be addressed in future research.

Continuity in palliative care - analysis of intersectoral palliative care based on routine data of a statutory health insurance

Background

The goal of palliative care is to prevent and alleviate a suffering of incurable ill patients. A continuous intersectoral palliative care is important. The aim of this study is to analyse the continuity of palliative care, particularly the time gaps between hospital discharge and subsequent palliative care as well as the timing of the last palliative care before the patient’s death.

Methods

The analysis was based on claims data from a large statutory health insurance. Patients who received their first palliative care in 2015 were included. The course of palliative care was followed for 12 months. Time intervals between discharge from hospital and first subsequent palliative care as well as between last palliative care and death were analysed. The continuity in palliative care was defined as an interval of less than 14 days between palliative care. Data were analysed using descriptive statistics and Chi-Square.

Results

In 2015, 4177 patients with first palliative care were identified in the catchment area of the statutory health insurance. After general inpatient palliative care, 415 patients were transferred to subsequent palliative care, of these 67.7% (n = 281) received subsequent care within 14 days. After a stay in a palliative care ward, 124 patients received subsequent palliative care, of these 75.0% (n = 93) within 14 days. Altogether, 147 discharges did not receive subsequent palliative care. During the 12-months follow-up period, 2866 (68.7%) patients died, of these 78.7% (n = 2256) received palliative care within the last 2 weeks of life. Of these, 1223 patients received general ambulatory palliative care, 631 patients received specialised ambulatory palliative care, 313 patients received their last palliative care at a hospital and 89 patients received it in a hospice.

Conclusions

The majority of the palliative care patients received continuous palliative care. However, there are some patients who did not receive continuous palliative care. After inpatient palliative care, each patient should receive a discharge management for a continuation of palliative care. Readmissions of patients after discharge from inpatients palliative care can be an indication for a lack of support in the ambulatory health care setting and for an insufficient discharge management. Palliative care training and possibilities for palliative care consultations by specialists should strengthen the GPs in palliative care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00751-0.

Association of Race with End-of-Life Treatment Preferences in Older Adults with Cancer Receiving Outpatient Palliative Care

Background: End-of-life discussions and documentation of preferences are especially important for older cancer patients who are at high risk of morbidity and mortality. Objective: To evaluate influence of demographic factors such as religiosity, education, income, race, and ethnicity on treatment preferences for end-of-life care. Methods: A retrospective observational study was performed on baseline data from a multisite randomized clinical trial of Dignity Therapy in 308 older cancer patients who were receiving outpatient palliative care (PC). Interviews addressed end-of-life treatment preferences, religion, religiosity and spirituality, and awareness of prognosis. End-of-life treatment preferences for care were examined, including preferences for general treatment, cardiopulmonary resuscitation (CPR), and mechanical ventilation (MV). Bivariate associations and multiple logistic regression analysis of treatment preferences with demographic and other baseline variables were conducted. Results: Our regression models demonstrated that race was a significant predictor for CPR preference and preferences for MV, although not for general treatment goals. Minority patients were more likely to want CPR and MV than whites. Men were more likely to opt for MV, although not for CPR or overall aggressive treatment, than women. Higher level of education was a significant predictor for preferences for less aggressive care at the end-of-life but not for CPR or MV. Higher level of terminal illness awareness was also a significant predictor for preferences for CPR, but not MV or aggressive care at the end-of-life. Discussion: Race was significantly associated with all three markers for aggressive care in bivariate analysis and with two out of three markers in multiple regression analysis, with minorities preferring aggressive care and whites preferring less aggressive care. Contrary to our hypothesis, income was not significantly associated with treatment preferences, whereas religion was significantly associated with all markers for aggressive care in bivariate models, but not in multiple regression models. Clinical Trial Registration Number NCT03209440.

Applying Geriatric Principles to Transitions of Care in the Emergency Department

Each emergency department (ED) visit represents a crucial transition of care for older adults. Systems, provider, and patient factors are barriers to safe transitions and can contribute to morbidity and mortality in older adults. Safe transitions from ED to inpatient, ED to skilled nursing facility, or ED back to the community require a holistic approach, such as the 4-Ms model-what matters (patient goals of care), medication, mentation, and mobility-along with safety and social support. Clear written and verbal communication with patients, caregivers, and other members of the interdisciplinary team is paramount in ensuring successful care transitions.

Does Inpatient Palliative Care Facilitate Home-Based Palliative Care Postdischarge? A Retrospective Cohort Study

Introduction: Evidence of the impact of inpatient palliative care on receiving home-based palliative care remains limited.

Objectives: The objective of this study was to examine, at a population level, the association between receiving inpatient palliative care and home-based palliative care postdischarge.

Design: We conducted a retrospective cohort study to examine the association between receiving inpatient palliative care and home-based palliative care within 21 days of hospital discharge among decedents in the last six months of life.

Setting/Subjects: We captured all decedents who were discharged alive from an acute care hospital in their last 180 days of life between April 1, 2014, and March 31, 2017, in Ontario, Canada. The index event was the first hospital discharge furthest away from death (i.e., closest to 180 days before death).

Results: Decedents who had inpatient palliative care were significantly more likely to receive home-based palliative care after discharge (80.0% vs. 20.1%; p < 0.001). After adjusting for sociodemographic and clinical covariates, the odds of receiving home-based palliative care were 11.3 times higher for those with inpatient palliative care (95% confidence interval [CI]: 9.4–13.5; p < 0.001). The strength of the association incrementally decreased as death approached. The odds of receiving home-based palliative care after a hospital discharge 60 days before death were 7.7 times greater for those who received inpatient palliative care (95% CI: 6.0–9.8).

Conclusion: Inpatient palliative care offers a distinct opportunity to improve transitional care between hospital and home, through enhancing access to home-based palliative care.

Palliative care transitions from acute care to community-based care: A qualitative systematic review of the experiences and perspectives of health care providers

BACKGROUND

Transitioning from the hospital to community is a vulnerable point in patients' care trajectory, yet little is known about this experience within the context of palliative care. While some studies have examined the patient and caregiver experience, no study to date has synthesized the literature on the healthcare provider's perspective on their role and experience facilitating these transitions.

AIM

The purpose of this systematic review was to understand the experience and perspective of healthcare providers who support the transition of patients receiving palliative care as they move from acute care to community settings.

DESIGN

A qualitative systematic review of studies using thematic analysis as outlined by Thomas and Harden. PROSPERO: ID # CRD42018109662.

DATA SOURCES

We searched four databases: MEDLINE, Embase, ProQuest and CINAHL for studies published in English from 1995 until May 22, 2020. Four reviewers screened records using the following selection criteria: (1) peer-reviewed empirical study, (2) adult sample, (3) qualitative study design, (4) perspective of healthcare providers, and (5) included a component of transitions between acute to community-based palliative care. Study findings were analyzed using thematic analysis which entailed: (1) grouping the findings into recurring themes; (2) iteratively referring back to the articles to obtain nuances of the theme and quotations; and (3) defining and solidifying the themes.

RESULTS

Overall 1,791 studies were identified and 15 met inclusion criteria. Studies were published recently (>2015, n = 12, 80%) and used a range of qualitative methods including semi-structured interviews, focus groups, and field interviews. Three core themes related to the role and experience of healthcare providers were identified: (1) assessing and preparing for transition; (2) organizing and facilitating the logistics of transition; and (3) coordinating and collaborating transitional care across sectors. The majority of studies focused on the discharge process from acute care; there was a lack of studies exploring the experiences of healthcare providers in the community who receive patients from acute care and provide them with palliative care at home.

CONCLUSION

This review identified studies from a range of relatively high-income countries that included a diverse sample of healthcare providers. The results indicate that healthcare providers experience multiple complex roles during the transition facilitation process, and future research should examine how to better assist clinicians in supporting these transitions within the context of palliative care provision.

Acute Care Utilization and Place of Death among Patients Discharged from an Inpatient Palliative Care Unit

Background: Discharging patients from inpatient palliative care units to the community is aligned with patients' desires to be cared for and die at home. However, there is little research examining patient outcomes after discharge. Objective: To describe the outcomes of patients discharged from an inpatient palliative care unit. Design: A single-institution retrospective cohort study using medical record data linked to regional acute care hospital and home care data. Setting/Participants: Patients (n = 75) discharged to the community over a one-year period from a 31-bed inpatient palliative care unit in an academic continuing care facility. Measurements: Survival, postdischarge hospitalizations and emergency department visits, and place of death. Results: Patients discharged to the community had poor prognosis. Over one-third had a discharge Palliative Performance Score <50. The median survival after discharge was 96 days, and 36% of decedent patients died in an acute care hospital. Thirteen percent of patients were hospitalized, and 23% visited an emergency department within 30 days of discharge, often for reasons that could have been managed in the community. Certain groups of patients were at greater risk of acute care use and in-hospital deaths, including younger patients, patients with nonmalignant diseases, and patients discharged home or retirement home, compared to long-term care settings. Conclusions: Patients discharged from an inpatient palliative care setting are at risk of postdischarge hospitalizations, emergency department visits, and in-hospital deaths, despite having community supports in place. Variations in outcomes can point to groups of patients who may require greater intensity of supports postdischarge.