Cancer patients have a reduced likelihood of dying in hospital with advance care planning in primary health care and a summarizing palliative plan: a prospective controlled non-randomized intervention trial

BACKGROUND

Advance care planning (ACP) allows patients to define their goals and preferences. Spending more time at home and less time in the hospital, along with avoiding death in the hospital, are often considered desirable outcomes of palliative care (PC). In 2015, 36% of cancer patients died in the hospital and 13% died at home in Norway.

METHOD

From 2015 to 2022, this prospective controlled non-randomized intervention trial observed 144 cancer patients with or without an organized ACP conversation in primary health care and a summarizing palliative plan (ClinicalTrials.gov Identifier: NCT02170168, 23 June 2014). The patients were identified through contact with the local cancer outpatient clinic or hospital-based PC team.

RESULTS

A total of 128 patients died during the observation period. Of these, 67 patients had an organized ACP conversation and summarizing palliative plan (intervention (I) group) and 61 had not (control (C) group). Dying in the hospital was significantly less common for patients in the I group compared to the C group (17.9% vs. 34.4%; X2 (1, n = 128) = 4.55, p = 0.033). There were no differences between the groups in terms of where they spent their time in the last 90 days of life (home, nursing home, or hospital). Most patients (62%) preferred to die at home. The observed differences between the groups regarding preferred and actual places of death did not reach statistical significance.

CONCLUSION

With organized ACP conversations in primary health care and a summarizing palliative plan, cancer patients died less often in the hospital in our observational study. A structured ACP approach integrating palliative care for cancer patients into primary health care can support patients´ preferences at the end of life.

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

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

Prevalence of Preferences for End-of-Life Place of Care and Death Among Patients With Cancer in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

PURPOSE

There is limited information on preferences for place of care and death among patients with cancer in low- and middle-income countries (LMICs). The aim was to report the prevalence and determinants of preferences for end-of-life place of care and death among patients with cancer in LMICs and identify concordance between the preferred and actual place of death.

METHODS

Systematic review and meta-analysis guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses was conducted. Four electronic databases were searched to identify studies of any design that reported on the preferred and actual place of care and death of patients with cancer in LMICs. A random-effects meta-analysis estimated pooled prevalences, with 95% CI, with subgroup analyses for region and risk of bias.

RESULTS

Thirteen studies were included. Of 3,837 patients with cancer, 62% (95% CI, 49 to 75) preferred to die at home; however, the prevalence of actual home death was 37% (95% CI, 13 to 60). Subgroup analyses found that preferences for home as place of death varied from 55% (95% CI, 41 to 69) for Asia to 64% (95% CI, 57 to 71) for South America and 72% (95% CI, 48 to 97) for Africa. The concordance between the preferred and actual place of death was 48% (95% CI, 41 to 55) for South Africa and 92% (95% CI, 88 to 95) for Malaysia. Factors associated with an increased likelihood of preferred home death included performance status and patients with breast cancer.

CONCLUSION

There is very little literature from LMICs on the preferences for end-of-life place of care and death among patients with cancer. Rigorous research is needed to help understand how preferences of patients with cancer change during their journey through cancer.

End-of-Life Care for End-stage Heart Failure Patients

Although recent heart failure (HF) guidelines highlight integrative palliative care, including end-of-life (EOL), appropriate discussing EOL issues can be challenging due to possibility of unexpected deterioration throughout HF trajectory. Open communication and discussions with multidisciplinary team are important for setting patient and family expectations and establishing mutually agreed goals of care based firmly on the patient’s ‘human dignity’ and ‘right to self-determination.’ Especially when quality-of-life outweighs expanding quantity-of-life, transition to EOL care should be considered. Advanced care planning including resuscitation, device deactivation, site for last days, and bereavement support should focus on ensuring a good death, and be reviewed regularly.

Efforts to improve end-of-life (EOL) care have generally been focused on cancer patients, but high-quality EOL care is also important for patients with other serious medical illnesses including heart failure (HF). Recent HF guidelines offer more clinical considerations for palliative care including EOL care than ever before. Because HF patients can experience rapid, unexpected clinical deterioration or sudden death throughout the disease trajectory, choosing an appropriate time to discuss issues such as advance directives or hospice can be challenging in real clinical situations. Therefore, EOL issues should be discussed early. Conversations are important for understanding patient and family expectations and developing mutually agreed goals of care. In particular, high-quality communication with patient and family through a multidisciplinary team is necessary to define patient-centered goals of care and establish treatment based on goals. Control of symptoms such as dyspnea, pain, anxiety/depression, fatigue, nausea, anorexia, and altered mental status throughout the dying process is an important issue that is often overlooked. When quality-of-life outweighs expanding quantity-of-life, the transition to EOL care should be considered. Advanced care planning including resuscitation (i.e., do-not resuscitate order), device deactivation, site for last days and bereavement support for the family should focus on ensuring a good death and be reviewed regularly. It is essential to ensure that treatment for all HF patients incorporates discussions about the overall goals of care and individual patient preferences at both the EOL and sudden changes in health status. In this review, we focus on EOL care for end-stage HF patients.

Association between immigrant status and advanced cancer patients' location and quality of death

Background

Cancer patients often prefer to die at home, a location associated with better quality of death (QoD). Several studies demonstrate disparities in end‐of‐life care among immigrant populations in the United States. This study aimed to evaluate how immigrant status affects location and quality of death among patients with advanced cancer in the United States.

Methods

Data were derived from Coping with Cancer, a federally funded multi‐site prospective study of advanced cancer patients and caregivers. The sample of patients who died during the study period was weighted (N_w = 308) to reduce statistically significant differences between immigrant (N_w = 49) and nonimmigrant (N_w = 259) study participants. Primary outcomes were location of death, death at preferred location, and poor QoD.

Results

Analyses adjusted for covariates indicated that patients who were immigrants were more likely to die in a hospital than home (adjusted odds ratio [AOR], 3.33; 95% confidence interval [CI], 1.65–6.71) and less likely to die where they preferred (AOR, 0.42; 95% CI, 0.20–0.90). Furthermore, immigrants were more likely to have poor QoD (AOR, 5.47; 95% CI, 2.70–11.08).

Conclusions

Immigrants, as compared to nonimmigrants, are more likely to die in hospital settings, less likely to die at their preferred location, and more likely to have poor QoD.

Lay summary

Cancer patients typically prefer to die in their own homes, which is associated with improved quality of death.

However, disparities in end‐of‐life care among immigrant populations in the United States remain significant.

Our study found that immigrants are less likely to die in their preferred locations and more likely to die in hospital settings, resulting in poorer quality of death.

Disparities in end‐of‐life care and quality of death are prevalent among immigrants. The findings of this study illustrate that immigrants in the United States are more likely to die in hospital settings and less likely to die at their preferred location.

Factors Influencing Family Members in Choosing the Preferred Place of Death for Hospitalized Dying Older Patients

This study aims to explore the factors that influence family members in choosing the preferred place of death for hospitalized dying older patients in Taiwan. This study enrolled 100 family members. The relevant factors influencing the families' choice of the preferred place of death for older patients were family members' previous discussions with the patients about their expected place of death; patients' education levels; family members' incomes; whether they were hiring a caregiver to take care of the patients at the hospital; their degree of social support; and their family functioning. The logistic regression analysis showed that family members who had discussed the preferred place of death with the patients, and those with better family functioning, were 1.41 and 2.72 times more likely, respectively, to chose for patients to return home to die than for the patients to die in a hospital.

Development and Validation of Filial Piety Representations at Parents’ End of Life Scale

Filial piety has a long historical standing in Chinese communities. However, the filial piety practices of adult children at the end of a parent’s life are under-explored. This study aims to develop a measurement for filial piety representations of the adult children of Macao Chinese, whose parents are at the stage of end of life. By adopting a scale development and validation framework, a 19-item Filial Piety Representations at Parents’ End of Life Scale (FPR-EoL) was formulated based on a Dual Filial Piety Model and literature, through procedures of item identification, panel review, cognitive interviews, and pre-test. The FPR-EoL was examined on 274 individuals. Factor analysis showed four factors in the scale; respect and comfort, acceptance of death, spending final days, and disclosing bad news. The Cronbach’s alpha of FPR-EoL was 0.73, and the four factors were 0.73, 0.66, 0.58 and 0.77, respectively. Discriminant validity was examined between FPR-EoL, the Good Death Inventory (GDI) and the Filial Piety Scale (FPS). The results suggested that there were differences between the three scales. FPR-EoL is found to be a reliable, valid and novel measure of filial piety representations among Macao Chinese. It may be a potential tool to probe and achieve good death among older persons of Chinese ethnicity in clinical settings.

Evaluation of efficacy and safety of subcutaneous acetaminophen in geriatrics and palliative care (APAPSUBQ)

Introduction

Subcutaneous infusion (SC) or hypodermoclysis is an old perfusion technique that is often used off-label although it has been shown to be effective. Acetaminophen (paracetamol) subcutaneous injection is performed in some centers despite the lack of conclusive evidence on its effectiveness. This study aims to evaluate the efficacy of subcutaneous infusion of Acetaminophen in the treatment of pain and fever in geriatrics and in palliative care and to determine its safety profile and possible side effects.

Material and methods

This experimental study was conducted between 2018 and 2019 on adult patients in palliative care or in geriatrics in several hospitals and nursing homes in Lebanon. Primary outcomes were change in temperature; change in pain score on the numerical rating scale (NS) or on the Algoplus scale after 60 min from the start of the infusion; and the appearance of local side effects at the infusion site. Changes in the various parameters at 30 min and 180 min were also evaluated as secondary outcomes.

Results

Thirty-one patients were included in the study, with a total of 120 doses of acetaminophen. At 60 min, the mean decrease in pain on the NS was 5.35 points, while the mean decrease in temperature was 0.79 degrees Celsius. At 60 min, 75%, CI = [47.62-92.73] of the patients who received acetaminophen for pain and 66.67%, CI = [38.38-88.17] of those who received it for fever had clinically significant improvement. The overall effect of subcutaneous acetaminophen, defined as any clinically significant effect on pain or fever, was 70.97%, CI = [51.96-85.78]. The overall effect at 30 min and at 180 min was 23.33%, CI = [9.93-42.28] and 87.10%, CI = [70.17-96.37], respectively. The side effects reported 30 min after the injection and observed after at least one of the doses were: local edema in 16 patients (51.61%), induration in one patient (3.23%), local pain in one patient (3.23%) and local heat in one patient (3.23%). At 180 min, only 2 patients (6.45%) still had edema at the infusion site.

Conclusion

Subcutaneous administration of acetaminophen is effective and well tolerated in geriatric and palliative care patients. It is appropriate when no other route is available, especially for home-based care. Comparative studies are needed to allow the expansion of this practice.

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

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Preferred Place of Death in Adult Cancer Patients: A Systematic Review and Meta-Analysis

Background: Identifying the preferred place of death is a key indicator of the quality of death in cancer patients and one of the most important issues for health service policymakers. This study was done to determine the preferred place of death and the factors affecting it for adult patients with cancer.

Methods: In this systematic review and meta-analysis study four online databases (PubMed, Scopus, web of science, ProQuest) were searched by relevant keywords. Quality assessment of papers was conducted using Newcastle-Ottawa (NOS) criterion. Odds ratios, relative risks, and 95% confidence intervals were determined for each of the factors extracted from the investigations.

Results: A total of 14,920 participants of 27 studies were included into the meta-analysis. Based on the results, 55% of cancer patients with a confidence interval [95% CI (41–49)] preferred home, 17% of patients with a confidence interval [95% CI (−12%) 23)] preferred hospital and 10% of patients with confidence interval [95% CI (13–18)] preferred hospices as their favored place to die. Effective factors were also reported in the form of demographic characteristics, disease-related factors and psychosocial factors.

Conclusions: This study showed that more than half of cancer patients chose home as their preferred place of death. Therefore, guided policies need to ensure that the death of the patients in the preferred place should be considered with priority.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020218680, identifier: CRD42020218680.

Spiritual Care, Pain Reduction, and Preferred Place of Death Among Advanced Cancer Patients in Soweto, South Africa

CONTEXT

When religious and spiritual (R/S) care needs of patients with advanced disease are met, their quality of life (QoL) improves. We studied the association between R/S support and QoL of patients with cancer at the end of life in Soweto, South Africa.

OBJECTIVES

To identify R/S needs among patients with advanced cancer receiving palliative care services and to assess associations of receipt of R/S care with patient QoL and place of death.

METHODS

A prospective cohort study conducted from May 1, 2016 to April 30, 2018 at a tertiary hospital in Soweto, South Africa. Nurses enrolled patients with advanced cancer and referred them to the palliative care multidisciplinary team. Spiritual counselors assessed and provided spiritual care to patients. We compared sociodemographic, clinical, and R/S factors and QoL of R/S care recipients and others.

RESULTS

Of 233 deceased participants, 92 (39.5%) had received R/S care. Patients who received R/S care reported less pain (2.82 ± 1.23 vs. 1.93 ± 1.69), used less morphine, and were more likely to die at home than patients who did not (57.5% compared with 33.7%). On multivariate logistic regression analysis, adjusting for significant confounding influences and baseline African Palliative Care Association Palliative care Outcome Scale scores, receipt of spiritual care was associated with reduced pain and family worry (odds ratio 0.33; 95% CI 0.11-0.95 and odds ratio 3.43; 95% CI 1.10-10.70, respectively).

CONCLUSION

Patients with cancer have R/S needs. R/S care among our patients appeared to improve their end-of-life experience. More research is needed to determine the mechanisms by which R/S care may have improved the observed patient outcomes.

Place of death by region and urbanization among gynecologic cancer patients: 2006-2016

OBJECTIVE

To evaluate associations between US region of residence and urbanization and the place of death among women with gynecologic malignancies in the United States.

METHODS

A retrospective cross-sectional study was performed using publicly available death certificate data from the National Center for Health Statistics. All gynecologic cancer deaths were included from 2006 to 2016. Comparisons among categories were performed with a two-tailed chi-square test, with p-values <0.05 considered significant.

RESULTS

From 2006 to 2016, 328,026 women died from gynecologic malignancies in the US. Of these deaths, 40.1% (n = 134,333) occurred in the patient's home, 24.9%(n = 81,823) in the hospital, and 11.3% (37,188) in an inpatient hospice facility. Place of death varied by geographic region. The Northeast had the largest percentage of gynecologic cancer patients (31.3%) die as a hospital inpatient. The West had the highest percentage of deaths (49.3%) at home. Deaths in a hospice facility were the highest (14.1%) in the South. Place of death varied by urbanization; patients residing in large central metro or rural counties were the most likely to die during hospital admission (28.7% and 27.1%, respectively). Patients living in medium-sized metro areas were the least likely to die in hospitals (21.8%) and most likely to die in a hospice facility (14.3%). All comparisons were significant by study definition.

CONCLUSION

The place of death for patients with gynecologic malignancies varies by US region and urbanization. These disparities are multifactorial in nature, likely influenced by both sociodemographic factors and regional resource availability. In this study, however, rural and central metro areas are identified as regions that may benefit from further hospice development and advocacy.

Trends in Place of Death Among Patients With Gynecologic Cancer in the United States

OBJECTIVE

To describe the change over time in place of death (hospital, home, hospice) among all women in the United States who died of gynecologic malignancies and compare them with other leading causes of female cancer deaths.

METHODS

This is a retrospective cross-sectional study using national death certificate data from the Mortality Multiple Cause-of-Death Public Use Record Data. All women who died from gynecologic, breast, lung, and colorectal cancers were identified according to International Classification of Diseases, 10 Revision, cause of death from 2003 to 2015. Regression analyses with ordinary least-squares linear probability modeling were used to test for differences in location of death over time, and differences in trends by cancer type, while controlling for age, race, ethnicity, marital status, and education status.

RESULTS

From 2003 to 2015, 2,133,056 women died from gynecologic, lung, breast, and colorectal malignancies in the United States. A total of 359,340 died from gynecologic malignancies, including ovarian cancer (n=188,366 [52.4%]), uterine cancer (n=106,454 [29.6%]), cervical cancer (n=52,320 [14.6%]), and vulvar cancer (n=12,200 [3.4%]). Overall, 49.2% (n=176,657) of gynecologic cancer deaths occurred at home or in hospice. The relative increase from 2003 to 2015 in the rate of deaths at home or in hospice was 47.2% for gynecologic cancer deaths (40.5% in 2003 to 59.5% in 2015). In adjusted analyses, the trend in the percentage of deaths at home or in hospice increased at a rate of 1.6 percentage points per year for gynecologic cancer deaths (95% CI 1.5-1.6) vs 1.5 (95% CI 1.4-1.5, P<.001), 1.4 (95% CI 1.4-1.5, P<.001), and 1.5 (95% CI 1.4-1.5, P=.09) percentage points per year for lung, breast, and colorectal cancer deaths, respectively.

CONCLUSION

Between 2003 and 2015, there was a 47.2% increase (40.5-59.5%) in the rates of gynecologic cancer deaths occurring at home or in hospice. This trend may represent an increase in advance care planning and value-based treatment decisions.

A Prospective Cohort Study of Factors Associated With Place of Death Among Patients With Late-Stage Cancer in Southern Africa

CONTEXT

Identifying factors that affect terminally ill patients' preferences for and actual place of death may assist patients to die wherever they wish.

OBJECTIVE

The objective of this study was to investigate factors associated with preferred and actual place of death for cancer patients in Johannesburg, South Africa.

METHODS

In a prospective cohort study at a tertiary hospital in Johannesburg, South Africa, adult patients with advanced cancer and their caregivers were enrolled from 2016 to 2018. Study nurses interviewed the patients at enrollment and conducted postmortem interviews with the caregivers.

RESULTS

Of 324 patients enrolled, 191 died during follow-up. Preferred place of death was home for 127 (66.4%) and a facility for 64 (33.5%) patients; 91 (47.6%) patients died in their preferred setting, with a kappa value of congruence of 0.016 (95% CI = -0.107, 0.139). Factors associated with congruence were increasing age (odds ratio [OR]: 1.03, 95% CI: 1.00-1.05), use of morphine (OR: 1.87, 95% CI: 1.04-3.36), and wanting to die at home (OR: 0.44, 95% CI: 0.24-0.82). Dying at home was associated with increasing age (OR 1.03, 95% CI 1.00-1.05) and with the patient wishing to have family and/or friends present at death (OR 6.73, 95% CI 2.97-15.30).

CONCLUSION

Most patients preferred to die at home, but most died in hospital and fewer than half died in their preferred setting. Further research on modifiable factors, such as effective communication, access to palliative care and morphine, may ensure that more cancer patients in South Africa die wherever they wish.

A New Tool to Assess Family Caregivers’ Burden during End-of-Life Care

A significant challenge in virtually all care-giving studies is the measurement of burden, particularly within the specific context of palliative care. Existing tools in the caregiving field are not specifically designed for palliative care. A new tool, which specifically assesses family caregivers’ (FC) burden within the palliative care context, was systematically developed and validated. This paper describes the steps taken to develop this tool and to examine its psychometric properties. The Caregiver's Burden Scale in End-of-Life Care (CBS-EOLC) is a 16-item self-report questionnaire. Internal consistency reliability: Cronbach's alpha=0.95. Construct validity: Most inter-item associations were consistent with the conceptual framework that emerged from qualitative data analyses. Convergent validity: Interscale correlations: a) Zarit's Burden Interview (Bl)=0.72 (p<0.01); b) POMS (fatigue)=0.69 (p<0.01); d) POMS (vigour)=-0.27 (p<0.05). Social desirability was tested with the Crowne & Marlowe questionnaire ( r=-0.24). Sensitivity: Associations were consistent with patients’ functional status (ECOG) and FCs’ unmet needs. The CBS-EOLC is a reliable and valid measure available in French and English.

Behind the doors of home hospice patients: A secondary qualitative analysis of hospice nurse communication with patients and families

OBJECTIVE

Hospice nurses frequently encounter patients and families under tremendous emotional distress, yet the communication techniques they use in emotionally charged situations have rarely been investigated. In this study, researchers sought to examine hospice nurses' use of validation communication techniques, which have been shown in prior research to be effective in supporting individuals experiencing emotional distress.

METHOD

Researchers performed a directed content analysis of audiorecordings of 65 hospice nurses' home visits by identifying instances when nurses used validation communication techniques and rating the level of complexity of those techniques.

RESULT

All nurses used validation communication techniques at least once during their home visits. Use of lower level (i.e., more basic) techniques was more common than use of higher level (i.e., more complex) techniques.

SIGNIFICANCE OF RESULTS

Although hospice nurses appear to use basic validation techniques naturally, benefit may be found in the use of higher level techniques, which have been shown to result in improved clinical outcomes in other settings.

Assessing concordance between patient preferences in advance care plans and in-hospital care

Objective The aims of this study were to assess: (1) concordance between patient preferences stated in advance care plans (ACPs) and hospital care over the subsequent 12 months; (2) change in preferences over time; (3) justifications for discordant care; and (4) effects of ACP completion on hospital utilisation. Methods A retrospective study was conducted of 198 patients with an ACP form registered with an ACP registry and tagged with a hospital unique record number. Data collected from ACP forms and hospital records comprised ACP completion and revisions, care preferences, patient characteristics and hospital care. Instances of care discordant with preferences were analysed as Type A (no ascertainable justification) and Type B (direct patient request or appropriate clinical indications). In a survivor subset, hospital utilisation was compared before and after ACP completion. Results Mean (± s.d.) patient age was 79.5±11.8 years. Patients had a mean (± s.d.) of 5.5±2.5 comorbidities and 90 (46.4%) died within the 12 months after ACP completion. Most ACPs (130; 65.5%) were completed during index hospitalisation and 13 (6.5%) underwent revision, on average, 6.8 months later, all related to rescinding request for cardiopulmonary resuscitation. Hospital care was fully concordant for 154 (77.8%) patients, with 39 (22.2%) receiving 60 instances of discordant care (15 (25%) Type A, 45 (75%) Type B), mostly related to surgical procedures (20; 33%) and intravenous fluids or antibiotics (26; 43%). Patients receiving discordant care had higher mortality (77% vs 45%; P&lt;0.001) and more rapid response team activations (34% vs 13%; P=0.001) at 12 months than patients with concordant care. Among the 108 confirmed survivors at 12 months after ACP completion, emergency department presentations and hospital admissions per patient had decreased by ≥50% (P&lt;0.001) and hospital days had decreased by 25% (P=0.042) compared with the 12 months before ACP completion. Conclusion Most patients completing an ACP received hospital care fully concordant with their stated preferences, with few revising their preferences over time. Discordant care mostly related to justified supportive treatments or surgical procedures. Among survivors, ACP completion was associated with decreased use of hospital care. What is known about the topic? ACPs that list patient preferences and care goals relieve family and patient distress and uncertainty regarding future care decisions as death approaches, decrease unwanted medical interventions and hospitalisations, and are associated with more patients dying at home. However, uncertainty surrounds the extent to which in-patient care provided to patients’ concords with preferences stated in ACPs, which preferences are most adhered to, and whether preferences change over time, warranting revision of ACPs. What does this paper add? This retrospective study of 198 patients completing an ACP, of whom almost half died within the following 12 months, showed that more than 75% received hospital care fully concordant with their stated preferences and, for decedents, most died at their preferred place of death. Relatively few patients changed their documented preferences over time, and all changes were for less use of cardiopulmonary resuscitation (CPR). Instances of discordant care mostly related to the administration of supportive treatments or surgical procedures and most were justified on the basis of patient request or appropriate clinical indications. Among 108 survivors, the number of emergency department presentations and hospital admissions per patient at 12 months after ACP completion was half those seen in the 12 months before ACP completion, whereas hospital days per patient decreased by 25%. What are the implications for practitioners? Encouraging patients with progressive chronic disease to complete an ACP reduces their risk of receiving care they do not want, reflected in decreased use of hospital care. Preferences stated in ACPs are mostly stable over time and, if changed, tend to become more conservative in terms of CPR. Conversely, preferences stated in the ACP do not, as circumstances change, bind patients or clinicians to withholding care that relieves symptoms or prevents major morbidity in the short term.

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

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

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

Using Routinely Collected Data to Ascertain Concordance With Advance Care Planning Preferences

CONTEXT

One of the key outcomes of advance care planning is whether patients had received care that was consistent with their expressed goals and preferences.

OBJECTIVES

The aims of this study were to illustrate the feasibility of using routinely collected health care data that include hospital procedural codes, diagnosis-related codes, health services utilization, and death registry data and to ascertain the level of concordance between care received and the stated goals.

METHODS

In this retrospective cohort study, medical treatments were ascertained using a combination of hospital procedural codes and diagnosis-related codes. Places of care were obtained by reviewing the sequence of health services used, and the place of death was obtained from the national death registry. To ascertain concordance, medical treatment, places of care, and place of death were compared against the individual's preferences.

RESULTS

The sample includes 1731 decedents (aged 21 years and above) who completed their advance care planning documentation as part of a national program. Ninety-eight percent who wished for comfort measures met their preferences. Sixty-five percent of individuals who wished to be cared for at home received care at home. Nearly 40% of all individuals who opted to die at home achieved their wishes, whereas 76% of those who opted for home or hospital and home or hospice had their preferences fulfilled.

CONCLUSION

Administrative data offer a cost-efficient and powerful method for assessing outcomes for a large population-based national program. However, this approach is still at an early stage of development and needs to be further validated before it can be used at scale.

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

BACKGROUND

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

AIM

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

DESIGN

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

SETTING/PARTICIPANTS

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

RESULTS

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

CONCLUSION

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

The practice of terminal discharge: Is it euthanasia by stealth?

‘Terminal discharges’ are carried out in Singapore for patients who wish to die at home. However, if due diligence is not exercised, parallels may be drawn with euthanasia. We present a theoretical discussion beginning with the definition of terminal discharges and the reasons why they are carried out in Singapore. By considering the intention behind terminal discharges and utilising a multidisciplinary team to deliberate on the clinical, social and ethical intricacies with a patient- and context-specific approach, euthanasia is avoided. It is hoped that this will provide a platform for professionals in palliative medicine to negotiate challenging issues when arranging a terminal discharge, so as to avoid the pitfall of committing euthanasia in a country such as Singapore where euthanasia is illegal. It is hoped that a set of guidelines for terminal discharges may someday be realised to assist professionals in Singapore and around the world.

Investigation of Racial Disparities in Early Supportive Medication Use and End-of-Life Care Among Medicare Beneficiaries With Stage IV Breast Cancer

PURPOSE

Early supportive care may improve quality of life and end-of-life care among patients with cancer. We assessed racial disparities in early use of medications for common cancer symptoms (depression, anxiety, insomnia) and whether these potential disparities modify end-of-life care.

METHODS

We used 2007 to 2012 SEER-Medicare data to evaluate use of supportive medications (opioid pain medications and nonopioid psychotropics, including antidepressants/anxiolytics and sleep aids) in the 90 days postdiagnosis among black and white women with stage IV breast cancer who died between 2007 and 2012. We used modified Poisson regression to assess the relationship between race and supportive treatment use and end-of-life care (hospice, intensive care unit, more than one emergency department visit or hospitalization 30 days before death, in-hospital death).

RESULTS

The study included 752 white and 131 black women. We observed disparities in nonopioid psychotropic use between black and white women (adjusted risk ratio [aRR], 0.51; 95% CI, 0.35 to 0.74) but not in opioid pain medication use. There were also disparities in hospice use (aRR, 0.86; 95% CI, 0.74 to 0.99), intensive care unit admission or more than one emergency department visit or hospitalization 30 days before death (aRR, 1.28; 95% CI, 1.01 to 1.63), and risk of dying in the hospital (aRR, 1.59; 95% CI, 1.22 to 2.09). Supportive medication use did not attenuate end-of-life care disparities.

CONCLUSION

We observed racial disparities in early supportive medication use among patients with stage IV breast cancer. Although they did not clearly attenuate end-of-life care disparities, medication use disparities may be of concern if they point to disparities in adequacy of symptom management given the potential implications for quality of life.

Readmissions in Cancer Patients After Receiving Inpatient Palliative Care in Taiwan: A 9-Year Nationwide Population-Based Cohort Study

Few studies have reported on readmissions among cancer patients receiving inpatient palliative care (IPC). This study investigated readmissions in cancer patients after their first discharge from IPC in Taiwan from 2002 to 2010.This study was a secondary data analysis using information from the National Health Insurance Database in Taiwan from 2002 to 2010. We included subjects ≥20 years old diagnosed with malignant neoplasms who were listed in the registry of catastrophic illness. Patients diagnosed with cancer before January 1, 2002 or who had ever been admitted to an inpatient hospice palliative care unit before the study period were excluded. Readmission was defined as hospital readmission at least once after discharge from first admission to IPC until mortality or the end of the study period.A total of 42,022 patients who met the inclusion criteria were identified. The majority of these patients were male (60.4%). The mean age of cancer diagnosis was 64.0 ± 14.4 years for men and 64.5 ± 14.7 years for women. The mean age at first hospice ward admission was 65.2 ± 14.2 years for men and 65.9 ± 14.9 years for women. During their first admission to IPC, 59.2% patients died, and the median stay of first IPC admission was 8.0 days. Among those discharged alive from their first admission to IPC, 64.9% were readmitted, and 19.4% of these patients were readmitted on the same day of discharge. From first IPC discharge until mortality, 54.8% of patients were readmitted once, 23.9% were readmitted twice, 9.9% were readmitted 3 times, and 11.5% were readmitted 4 or more times. Being male, having a higher insurance premium level, having a longer length of stay during first IPC admission, being admitted to a teaching hospital, or being admitted to a tertiary hospital increased the adjusted hazard ratio for readmission.We found that terminal cancer patients in Taiwan received relatively late referrals for first admission to IPC and experienced a high rate of readmission after first discharge from IPC. Policies to improve hospice palliative care referrals and decrease readmissions should be considered.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Place of care: from referral to specialist palliative care until death

BACKGROUND

While there are many poorly standardised studies focusing on place of death, there are limited data on place(s) of care during the final stages of disease.

AIM

This study aims to identify where patients are cared for in the interval from referral to specialist palliative care until death.

METHODS

All patients who died while under the care of a specialist palliative care service over a 6-month period were considered.

RESULTS

Of the 507 patients included, 255 (50.3%) were men and 428 (84.4%) had a malignant diagnosis. The mean referral-to-death interval was 70 days (SD 113, Range 1-838). The majority (n=281, 55.4%) received care in a single care setting-hospital (28.4%), home (21.5%), nursing home/community hospital (4.1%), hospice (1.4%)-and had a shorter mean referral-to-death interval. Most patients with more than one care setting spent three-quarters of their time in their normal place of residence. A total of 199 (39.3%) died in hospital, 131 (25.8%) in hospice, 131 (25.8%) at home (25.8%) and 46 (9.1%) in a nursing home/community hospital. Patients referred by a general practitioner (n=80 patients, 15.8%) were more likely to be cared for at home (p<0.001), and die at home (p<0.001).

CONCLUSIONS

A significant number of patients received specialist palliative care across multiple care settings. Late referral is associated with a single domain of care. General practitioner involvement supports patient care and death at home. Place of care and ease of transfer between care settings may be better indicators of the quality of care we provide.

The support needs of terminally ill people living alone at home: a narrative review

Context: The number of terminally ill people who live alone at home and without a caregiver is growing and exerting pressure on the stretched resources of home-based palliative care services. Objectives: We aimed to highlight the unmet support needs of terminally ill people who live alone at home and have no primary caregiver and identify specific models of care that have been used to address these gaps. Methods: We conducted a narrative review of empirical research published in peer-reviewed journals in English using a systematic approach, searching databases 2002-2013. This review identified 547 abstracts as being potentially relevant. Of these, 95 were retrieved and assessed, with 37 studies finally reviewed. Results: Majority of the studies highlighted the reduced likelihood of this group to be cared for and die at home and the experiences of more psychosocial distress and more hospital admissions than people with a primary caregiver. Few studies reported on the development of models of care but showed that the challenges faced by this group may be mitigated by interventions tailored to meet their specific needs. Conclusion: This is the first review to highlight the growing challenges facing community palliative care services in supporting the increasing number of people living alone who require care. There is a need for more studies to examine the effectiveness of informal support networks and suitable models of care and to provide directions that will inform service planning for this growing and challenging group.

Terminally ill African American elders' access to and use of hospice care

The underuse of hospice care by terminally ill African American elders suggests they are suffering when hospice care could offer quality end of life care. Guided by the Behavioral Model for Vulnerable Populations, this study sought understanding of structural barriers faced when seeking access to hospice care and reasons for using it when access is possible. Data was collected through interviews with 28 African American hospice patients. Themes from directed content analysis provide insights into strategies used to overcome access barriers posed by income, health insurance and administrative procedure, as well as the role religion, family, information and health beliefs played in using it. Distributing educational materials and addressing spiritual/religious concerns in choosing hospice care are key in promoting African Americans' use of hospice care.

Uncovering an invisible network of direct caregivers at the end of life: a population study

BACKGROUND

Most palliative care research about caregivers relies on reports from spouses or adult children. Some recent clinical reports have noted the assistance provided by other family members and friends.

AIM

This population study aims to define the people who actually provide care at the end of life.

SETTING/PARTICIPANTS

A South Australian study conducted an annual randomized health population survey (n=23,706) over a 7 year period. A sample was obtained of self-identifying people who had someone close to them die and 'expected' death in the last 5 years (n=7915). Data were standardised to population norms for gender, 10-year age group, socioeconomic status, and region of residence.

RESULTS

People of all ages indicated they provided 'hands on' care at the end of life. Extended family members (not first degree relatives) and friends accounted for more than half (n=1133/2028; 55.9%) of identified hands-on caregivers. These people came from the entire age range of the adult community. The period of time for which care was provided was shorter for this group of caregivers. People with extended family or friends providing care, were much more likely to be supported to die at home compared to having a spousal carer.

CONCLUSION

This substantial network of caregivers who are mainly invisible to the health team provide the majority of care. Hospice and palliative care services need to create specific ways of identifying and engaging this cohort in order to ensure they are receiving adequate support in the role. Relying on 'next-of-kin' status in research will not identify them.

Factors affecting the place of death among hospice home care cancer patients in Taiwan

BACKGROUND

Some patients who receive hospice home care still end up dying in hospital. The significance of the variables possibly affecting the place of death in patients with terminal cancer who received hospice home care was examined.

METHODS

Retrospective study.

RESULTS

Four hundred and thirty-nine patients were enrolled in this study. In all, 60.8% of the patients died at home and 39.2% of the patients died in hospital. Multiple logistic regression analysis revealed that preferred place of death was the prior factor associated with home death, followed by average days of rehospitalization, education level, distance between home and hospital, and age.

CONCLUSIONS

For a better hospice care service, it is essential to inquire patients or their relatives on preferred place of death while concerning the influences of other factors.

Trend of urban-rural disparities in hospice utilization in Taiwan

AIMS

The palliative care has spread rapidly worldwide in the recent two decades. The development of hospice services in rural areas usually lags behind that in urban areas. The aim of our study was to investigate whether the urban-rural disparity widens in a country with a hospital-based hospice system.

METHODS

From the nationwide claims database within the National Health Insurance in Taiwan, admissions to hospices from 2000 to 2006 were identified. Hospices and patients in each year were analyzed according to geographic location and residence.

RESULTS

A total of 26,292 cancer patients had been admitted to hospices. The proportion of rural patients to all patients increased with time from 17.8% in 2000 to 25.7% in 2006. Although the numbers of beds and the utilizations in both urban and rural hospices expanded rapidly, the increasing trend in rural areas was more marked than that in urban areas. However, still two-thirds (898/1,357) of rural patients were admitted to urban hospices in 2006.

CONCLUSIONS

The gap of hospice utilizations between urban and rural areas in Taiwan did not widen with time. There was room for improvement in sufficient supply of rural hospices or efficient referral of rural patients.

Where do you want to spend your last days of life? Low concordance between preferred and actual site of death among hospitalized adults

BACKGROUND

Death in the U.S. frequently occurs in institutions despite the overwhelming majority of persons who state that they prefer to die at home. Little research to date has examined how well individual preferences compare to actual site of death.

OBJECTIVES

Determine the concordance between preferred and actual place of death and examine independent predictors for concordance.

DESIGN

Observational cohort study.

SETTING

Three area hospitals including a safety net hospital, veterans' hospital, and academic tertiary referral center.

PATIENTS

458 adult patients admitted to the general medical service from 2003-2005.

MEASUREMENTS

Patients were asked where they preferred to spend their last days of life. Data on date and actual site of death from 2005-2009 was collected from hospital records and death certificates.

RESULTS

The majority of patients preferred to die at home (75% n = 343). Low income and being married were significantly associated with a preference to die at home compared to nursing home or inpatient hospice (OR 2.71 95% CI 1.30-5.67 and OR 2.44 95% CI 1.14-5.21 respectively). Of the 123 patients who died during the follow up period, most (66% n = 80) died in an institutional setting. Overall concordance between preferred and actual site of death was only 37% (n = 41). Female gender was significantly associated with concordance between preferred and actual site of death (OR 3.30 95% CI 1.25-8.72).

CONCLUSIONS

Concordance between preferred and actual site of death is low and female gender was the sole patient level variable associated with concordance.

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

BACKGROUND

Meeting patient's preferences is an important outcome in palliative care. No Scandinavian study has reported systematically collected preferences from patients regarding place of care (POC) and place of death (POD). The extent of possible incongruence between patients' preferences and reality remains unknown.

AIM

The aim of this study was to describe patients' preferred POC and POD and changes in preferences over time and to evaluate congruence between preferences and reality. Furthermore, the aim was to search for predictive factors regarding patients' wishes and fulfilment of these.

METHOD

This is a prospective interview and questionnaire study.

SETTING/PARTICIPANTS

The study was conducted in the former Aarhus County, Denmark and 96 end-stage cancer patients participated.

RESULTS

Of the patients, who stated a preference, 84% preferred home care and 71% preferred home death. A positive association between living with a partner and both wishing for home care and home death was observed (prevalence ratio (PR): 1.66 (95% confidence intervals (CI): 1.07, 2.58), p = 0.02 and PR: 2.33 (95% CI: 1.14, 4.77), p = 0.02, respectively). Marked changes in preferences were observed. Overall, preferences were met for approximately half of the patients, although kappa values were low (κ=0.132 for POC and κ=0.034 for POD).We found a significant association between being cared for in the preferred place and having contact with a palliative care team (PR: 2.01 (95% CI: 1.02, 3.98), p = 0.045).

CONCLUSION

Regular discussions with patients on this subject are needed. Social and professional support is of importance in meeting patients' preferences. Larger scaled studies and research focusing on meeting patients' preferences are needed.

Predictors of emergent feeding tubes and tracheostomies in amyotrophic lateral sclerosis (ALS)

Predictable decline in ALS makes unplanned gastrostomy and tracheostomy avoidable. We determined whether gastrostomy or tracheostomy insertion during emergent hospitalization is associated with patient or hospital characteristics, changed Medicare policy in 2001, or proximity to specialized ALS care. We performed a retrospective analysis of hospitalizations and procedures for ALS/MND patients in Pennsylvania between 1996 and 2009. We identified predictors of gastrostomy/tracheostomy during emergent hospitalization and trends over time. Patients underwent 1748 gastrostomies and 373 tracheostomies. Thirty-two percent of gastrostomies and 67% of tracheostomies were placed emergently. Emergent hospitalizations involving gastrostomy were more expensive with fewer home discharges. Black patients and Medicaid patients had higher odds of emergent gastrostomy placement. Conversely, academic hospital affiliation decreased odds of emergent gastrostomy or tracheostomy placement (AOR 0.49, AOR 0.37, p < 0.001). After Medicare policy changes, gastrostomy use increased, while emergent gastrostomies decreased. Surprisingly, proximity to specialized care was associated with increased emergent gastrostomy placement. In conclusion, black patients and Medicaid patients were more likely to undergo emergent gastrostomy insertion. Patients receiving gastrostomy during emergent admissions had fewer home discharges and higher costs. Academic hospital affiliation decreased odds of emergent gastrostomy or tracheostomy. After Medicare changes broadening access, while gastrostomy use increased, the proportion of emergent procedures decreased.

Disparity in hospice utilization by African American patients with cancer

Patients with cancer represent the largest group of hospice users, making this population critically important in hospice research studies. Despite the potential benefits of hospice, many studies have noted lower levels of utilization among African Americans. The goal of this literature review was to determine whether this disparity exists within this population of patients with cancer. The largest studies focusing on multiple cancers found lower hospice use among African American patients with cancer. Disparities also existed after entry into hospice. Age, gender, geographic location, preference for aggressive care, and knowledge of hospice influenced hospice use by these patients. Since African American patients with cancer evidently use hospice at a lower rate, future studies should explore potential barriers to participation by this patient population and methods to remove these obstacles.

The mediation effect of anxiety between post-traumatic stress symptoms and preparatory grief in advanced cancer patients

CONTEXT

The relationship between anxiety and preparatory grief is complex and poorly understood.

OBJECTIVES

To investigate the relationship between anxiety, post-traumatic stress symptoms, and preparatory grief in a sample of patients with advanced cancer.

METHODS

Ninety-four patients with advanced cancer completed the Greek version of the Impact of Events Scale-Revised (IES-R-Gr), the Anxiety subscale of the Greek Hospital Anxiety and Depression Scale, and the Preparatory Grief in Advanced Cancer Patients (PGAC) scale.

RESULTS

Statistically significant associations were found between IES-R-Gr subscales, anxiety (P<0.0005), and PGAC (P<0.0005).

CONCLUSION

Some of the effect of post-traumatic stress symptoms on preparatory grief is mediated by anxiety.

Home care nurses' provision of support to families of the elderly at the end of life

In this article we describe our study of assistance for family decisions and caregiving by Japanese home care nurses to families of elderly relatives at the end of life. The participants were 31 nurses who had been evaluated as providing good end-of-life care. We carried out semistructured interviews concerning the practice of family support in two cases (cancer and noncancer). We conducted a qualitative analysis using the constant comparative approach and derived several categories inductively. Home care nurses are responsible for (a) estimating the possibility of dying at home, (b) visualizing what is coming and what can be done, (c) proposing where and how the family can say goodbye, (d) building family consensus, (e) coordinating resources, and (f) offering psychological support for end-of-life care. End-of-life family care by home care nurses is a process in which multiple components of care are provided with changing content as death approaches.

The trajectory of palliative care costs over the last 5 months of life: a Canadian longitudinal study

OBJECTIVE

This study aimed to highlight the trajectory of palliative care costs over the last five months of life in five urban centres across Canada.

SUBJECTS

The study sample was comprised of 160 terminally ill patients and their main informal caregivers.

RESEARCH DESIGN

A first interview took place in the patient's home, and subsequent follow-up interviews were conducted by telephone at two week intervals until the patient's passing.

MEASURES

Participants were asked to provide information on the goods and services they used related to the patients' health condition, and on informal caregiving time.

RESULTS

The overall costs of care gradually increased from the fifth to the last month of the patients' life. A large part of this cost increase was attributable to inpatient care. Among outpatient care costs the largest increase was observed for home care. Informal care costs were particularly high over the last 3 months of life.

CONCLUSIONS

The knowledge gained from this study would be useful to policy makers when developing policies that could help families caring for a terminally ill loved one at home.

End-of-life care in Germany: Study design, methods and first results of the EPACS study (Establishment of Hospice and Palliative Care Services in Germany)

BACKGROUND

In order to tackle the deficits in the provision of palliative home care, profound structural changes in the outpatient sector were introduced by law in Germany in 2007. The EPACS study was carried out (Research Accompanying the Establishment of Hospice and Palliative Care Services in Rhineland-Palatinate, Germany) to document the quality of inpatient and outpatient end-of-life care in Rhineland-Palatinate, Germany, before the implementation of these changes. With this article we focus on the study design and methods of the EPACS-Study. We further report first results regarding several aspects of outpatient end-of-life care.

METHODS

The cross-sectional survey was based on a random sample of 5000 inhabitants of Rhineland-Palatinate that had died from May 25 until August 24 of the year 2008. Relatives of these randomly drawn deceased persons were interviewed by means of a written survey.

RESULTS

The overall response proportion considering only those questionnaires that actually were delivered (n = 3833) was 36.0%. Factors influencing participation were age, sex, and marital status. 355 (25.8%) deceased persons had used professional home care in the four weeks prior to their death, but only very few persons had used a specialised palliative home care service (n = 30; 8.5%). There was a clear gap between the need for specialised outpatient care and the actual utilisation of these services.

CONCLUSIONS

Satisfaction with professional home care was relatively high, but physicians were rated less favourable than nurses. There were deficits especially with respect to physicians' communicative and supportive skills. Further analyses are necessary to provide more detailed information about quality of care in different care settings and for distinct groups. Predictors of good care, as well as obstacles to it, must be further investigated. In the long run, a follow-up survey must be conducted to compare quality of home care before and after the structural changes in Germany.

Palliative radiotherapy tailored to life expectancy in end-stage cancer patients: reality or myth?

BACKGROUND

The purpose of the study was to investigate the adequacy of palliative radiation treatment in end-stage cancer patients.

METHODS

Of 216 patients referred for palliative radiotherapy, 33 died within 30 days and constitute the population of the study. Symptoms, Karnofsky Performance Status (KPS), laboratory tests, and survival estimates were obtained. Treatment course was evaluated by medical records. Univariate analyses were performed by using the 2-sided chi-square test. With significant variables, multiple regression analysis was performed.

RESULTS

Median age was 65 years, and median survival was 15 days. Prevailing primary cancer types were lung (39%) and breast (18%). Metastases were present in 94% of patients, brain (36%), bone (24%) and lung (18%). In 91%, KPS was < 0%. KPS, lactate dehydrogenase, dyspnea, leucocytosis, and brain metastases conveyed a poor prognosis. From 85 survival estimates, only 16% were correct, but 21% expected more than 6 months. Radiotherapy was delivered to 91% of patients. In 90% of radiation treatments, regimens of at least 30 Gy with fractions of 2-3 Gy were applied. Half of the patients spent greater than 60% of their remaining lifespan on therapy. In only 58% of patients was radiotherapy completed. Progressive complaints were noted in 52% and palliation in 26%.

CONCLUSIONS

Radiotherapy was not appropriately customized to these patients considering the median treatment time, which resembles the median survival time. About half of the patients did not benefit despite spending most of their remaining lives on therapy. Prolonged irradiation schedules probably reflect overly optimistic prognoses and unrealistic concerns about late radiation damage. Single-fraction radiotherapy was too seldom used.

Barriers to dying at home: the impact of poor co-ordination of community service provision for patients with cancer

For patients dying of cancer, there is an emphasis on giving choice regarding preferred location for care, with the option of dying at home, which is integral to UK government health initiatives such as the End of Life Care Programme. However, patients continue to be admitted to hospital in the terminal phase of their illness when they have expressed a desire to die at home. A qualitative study, using two audio tape-recorded focus group interviews, with a purposive sample of district nurses and community specialist palliative care nurses (19) was undertaken across two primary care trusts in the north west of England. Data were analysed using a thematic analysis approach. From a service provision perspective, the results reveal that poor discharge planning and co-ordination, difficulty in establishing additional equipment and services together with inadequate out of hours medical provision were all factors contributing to hospital admissions for patients with cancer in the last hours and days of life, and thus were barriers to dying at home.

Risk factors for fatigue severity in primary brain tumor patients

BACKGROUND

In addition to neurologic symptoms, fatigue is commonly reported in patients with primary brain tumors during radiation therapy and in long-term survivors of low-grade brain tumors. Other factors have not been explored. The aim of this study was to identify demographic and clinical factors that predict fatigue severity and to evaluate the association of fatigue with other symptoms throughout the disease trajectory.

METHODS

Two hundred one patients with primary brain tumors completed the M. D. Anderson Symptom Inventory-Brain Tumor Module and a demographic checklist. Clinical data, including treatment, tumor grade, and performance status, were also collected. Correlations among fatigue and other recorded symptoms were evaluated. Logistic regression modeling was performed to evaluate factors associated with fatigue severity.

RESULTS

Fatigue severity was associated with symptoms including pain, drowsiness, distress, difficulty sleeping, and weakness as well as overall symptom severity and interference. Poor performance status (Karnofsky scale) (odds ratio [OR], 5.73; P = .001), female sex (OR, 2.48; P = .005), and disease status (OR, 2.20; P = .013) were the strongest predictors of fatigue. Severity of fatigue for women was primarily predicted by disease status (OR, 3.33; P = .01) For men, antidepressant use (OR, 4.43; P = .013) in addition to opioids (OR, 3.46; P = .017) and performance status (OR, 12.47; P = .0001) predicted fatigue severity.

CONCLUSIONS

Fatigue should not be considered a solitary symptom with 1 root cause, but a complex symptom related to the severity of other symptoms and potentially having various etiologies. Future studies should consider these factors in planning interventions and assessing response.

End-of-life concerns and care preferences: congruence among terminally ill elders and their family caregivers

This study examined the end-of-life challenges, concerns, and care preferences of terminally ill elders and their family caregivers, with a focus on areas of congruence and incongruence. Ten elders and 10 family caregivers participated in separate, semi-structured, face-to-face interviews. Data analysis included team coding and thematic analysis, guided by an a priori set of categories based on the study questions. Shared challenges and concerns included experiencing decline, managing pain and discomfort, and living with uncertainty. There was also congruence regarding end-of-life care preferences, specifically the importance of quality care, treatment with dignity and respect, and avoiding unnecessary life-sustaining treatment. Areas of incongruence included the elders' difficulties in accepting dependence, their fears of becoming a burden, and desire to be prepared for death. Family caregivers were most concerned with providing adequate care to meet the elders' physical and spiritual care needs. Open family communication was associated with greater congruence. The authors discuss implications of these findings for research and intervention.

Factors associated with congruence between preferred and actual place of death

Congruence between preferred and actual place of death may be an essential component in terminal care. Most patients prefer a home death, but many patients do not die in their preferred location. Specialized (physician, hospice, and palliative) home care visits may increase home deaths, but factors associated with congruence have not been systematically reviewed. This study sought to review the extent of congruence reported in the literature and examine factors that may influence congruence. In July 2009, a comprehensive literature search was performed using MEDLINE, PsychInfo, CINAHL, and Web of Science. Reference lists, related articles, and the past five years of six palliative care journals were also searched. Overall congruence rates (percentage of met preferences for all locations of death) were calculated for each study using reported data to allow cross-study comparison. Eighteen articles described 30%-91% congruence. Eight specialized home care studies reported 59%-91% congruence. A physician-led home care program reported 91% congruence. Of the 10 studies without specialized home care for all patients, seven reported 56%-71% congruence and most reported unique care programs. Of the remaining three studies without specialized home care for all patients, two reported 43%-46% congruence among hospital inpatients, and one elicited patient preference "if everything were possible," with 30% congruence. Physician support, hospice enrollment, and family support improved congruence in multiple studies. Research in this important area must consider potential sources of bias, the method of eliciting patient preference, and the absence of a single ideal place of death.