Gender Disparities in End of Life Care: A Scoping Review

Sex-Based Analysis of Quality Indicators of End-of-Life Care in Gastrointestinal Malignancies

Indices of aggressive or supportive end-of-life (EOL) care are used to evaluate health services quality. Disparities according to sex were previously described, with studies showing that male sex is associated with aggressive EOL care. This is a secondary analysis of 69,983 patients who died of a GI malignancy in Ontario between 2006 and 2018. Quality indices from the last 14-30 days of life and aggregate measures for aggressive and supportive EOL care were derived from administrative data. Hospitalizations, emergency department use, intensive care unit admissions, and receipt of chemotherapy were considered indices of aggressive care, while physician house call and palliative home care were considered indices of supportive care. Overall, a smaller proportion of females experienced aggressive care at EOL (14.3% vs. 19.0%, standardized difference = 0.13, where ≥0.1 is a meaningful difference). Over time, rates of aggressive care were stable, while rates of supportive care increased for both sexes. Logistic regression showed that younger females (ages 18-39) had increased odds of experiencing aggressive EOL care (OR 1.71, 95% CI 1.30-2.25), but there was no such association for males. Quality of EOL care varies according to sex, with a smaller proportion of females experiencing aggressive EOL care.

Increasing access to palliative care for patients with advanced cancer of African and Latin American descent: a patient-oriented community-based study protocol

BACKGROUND

Cancer disparities are a major public health concern in Canada, affecting racialized communities of Latin American and African descent, among others. This is evident in lower screening rates, lower access to curative, and palliative-intent treatments, higher rates of late cancer diagnoses and lower survival rates than the general Canadian population. We will develop an Access to Palliative Care Strategy informed by health equity and patient-oriented research principles to accelerate care improvements for patients with advanced cancer of African and Latin American descent.

METHODS

This is a community-based participatory research study that will take place in two Canadian provinces. Patients and community members representatives have been engaged as partners in the planning and design of the study. We have formed a patient advisory council (PAC) with patient partners to guide the development of the Access to Palliative Care Strategy for people of African and Latin American descent. We will engage100 participants consisting of advanced cancer patients, families, and community members of African and Latin American descent, and health care providers. We will conduct in-depth interviews to delineate participants' experiences of access to palliative care. We will explore the intersections of race, gender, socioeconomic status, language barriers, and other social categorizations to elucidate their role in diverse access experiences. These findings will inform the development of an action plan to increase access to palliative care that is tailored to our study population. We will then organize conversation series to examine together with community partners and healthcare providers the appropriateness, effectiveness, risks, requirements, and convenience of the strategy. At the end of the study, we will hold knowledge exchange gatherings to share findings with the community.

DISCUSSION

This study will improve our understanding of how patients with advanced cancer from racialized communities in Canada access palliative care. Elements to address gaps in access to palliative care and reduce inequities in these communities will be identified. Based on the study findings a strategy to increase access to palliative care for this population will be developed. This study will inform ways to improve access to palliative care for racialized communities in other parts of Canada and globally.

Hospice and Palliative Care-Men and Gender-Specific Roles

All people face end of life as the final health outcome. When a person's health focus shifts from quantity to quality of life, palliative care comes into view. Clinicians serving patients across the health care spectrum must be aware of the nature and efficacy of palliative and hospice care, indications for referral to services, and current best practices. Creating an end-of-life trajectory requires an individualized and global personal plan, which palliative and hospice care can provide. Gender-specific care that includes gender minorities provides special and unique challenges to those seeking palliative and hospice care.

End-of-Life Medical Decisions: The Link Between Sociodemographic Characteristics and Treatment Preferences

INTRODUCTION

Advance directives (ADs) promote patient autonomy in end-of-life (EOL) care, including an individual's EOL medical treatment preferences. This study aims to better understand preferences regarding EOL medical treatment among community-dwelling adults (18 and older) residing in the United States and examine the association between sociodemographic characteristics and EOL medical treatment preferences.

METHODS

Utilizing a cross-sectional study and snowball sampling methodology, community-dwelling adults completed a survey containing two different ADs and a questionnaire with sociodemographic information. Univariate analyses were used to summarize EOL medical treatment preferences among the sample, and bivariate analyses (Chi-square and Fisher's Exact tests) were performed to examine the association between sociodemographic characteristics (age, gender, and race/ethnicity) and EOL medical treatment preferences.

RESULTS

The mean age of the 166 participants was 50 (SD: 21.65, range: 18-93), with 58.4% being White and 61.4% being female. Generally, when EOL scenarios involved brain damage or a coma, more participants indicated that they did not want life-support treatment. Age and race were both associated with EOL medical treatment preferences, but no significant differences were observed in the bivariate results by gender. Largely, young and middle-aged adults, along with Black participants, were more likely to prefer more aggressive EOL medical treatments than older adults and White participants.

CONCLUSION

Overall, EOL medical treatment preferences varied among participants. The study findings indicate that adults develop different preferences for EOL medical treatment, with some of the variation attributable to sociodemographic characteristics such as age and race.

Factors affecting do-not-attempt-resuscitation (DNAR) decisions among adult patients in the emergency department of a general tertiary teaching hospital in China: a retrospective observational study

OBJECTIVE

Do-not-attempt-resuscitation (DNAR) orders are designed to allow patients to opt out of receiving cardiopulmonary resuscitation in the event of a cardiac arrest. While DNAR has become a standard component of medical care, there is limited research available specifically focusing on DNAR orders in the context of emergency departments in China. This study aimed to fill that gap by examining the factors related to DNAR orders among patients in the emergency department of a general tertiary teaching hospital in China.

DESIGN

Retrospective observational study.

SETTING

Emergency department.

PARTICIPANTS

This study and analysis on adult patients with DNAR or no DNAR data between 1 January 2022 and 1 January 2023 in the emergency department of a large academic comprehensive tertiary teaching hospital. A total of 689 were included in our study.

PRIMARY OUTCOME MEASURES

Whether the patient received DNAR was our dependent variable.

RESULTS

Among the total patients, 365 individuals (53.0%) had DNAR orders. The following variables, including age, sex, age-adjusted Charlson comorbidity index (ACCI), primary diagnosis of cardiogenic or cancer related, history of neurological dysfunction or cancer, were independently associated with the difference between the DNAR group and the no DNAR group. Furthermore, there were significant statistical differences observed in the choice of DNAR among patients with different stages of cancer.

CONCLUSIONS

In comparison to the no DNAR group, patients with DNAR were characterised by being older, having a higher proportion of female patients, higher ACCI scores, a lower number of patients with a primary diagnosis of cardiogenic and a higher number of patients with a primary diagnosis of cancer related, history of neurological dysfunction or cancer.

Engaging and supporting the public on the topic of grief and bereavement: an evaluation of Good Grief Festival

Background

Good Grief Festival was originally planned as a face-to-face festival about grief and bereavement. Due to COVID-19, it was held online over 3 days in October 2020.

Objective

To evaluate the festival's reach and impact.

Design

Pre/post evaluation.

Methods

Pre-festival online surveys assessed reasons for attending and attitudes to bereavement across four items (fear of saying the wrong thing, avoiding talking to someone bereaved, knowing what to do if someone bereaved was struggling, knowing how to help). Post-festival online surveys evaluated audience experiences and the four attitude items. Free-text responses, analysed using thematic analysis, generated suggestions for improvement and general comments.

Results

Between 5003 and 6438 people attended, with most attending two to five events. Pre-festival survey participants (n = 3785) were mostly women (91%) and White (91%). About 9% were from Black or minoritised ethnic communities. About 14% were age ⩾65 years, 16% age ⩽34 years. Around 75% were members of the public, teachers, students or 'other'; 25% academics, clinicians or bereavement counsellors. A third had been bereaved in the last year; 6% had never been bereaved. People attended to learn about grief/bereavement (77%), be inspired (52%) and feel part of a community (49%). Post-festival participants (n = 685) reported feeling part of a community (68%), learning about grief/bereavement (68%) and being inspired (66%). 89% rated the festival as excellent/very good and 75% agreed that they felt more confident talking about grief after attending. Higher ratings and confidence were associated with attending more events. Post-festival attitudes were improved across all four items (p < 0.001). Attendees appreciated the festival, particularly valuing the online format, opportunities for connection during lockdown and the diversity and quality of speakers. Suggestions included improving registration, more interactive events and less content.

Conclusion

Good Grief Festival successfully reached a large public audience, with benefit in engagement, confidence and community-building. Evaluation was critical in shaping future events. Findings suggest festivals of this nature can play a central role in increasing death- and grief-literacy within a public health approach.

Perceived Barriers to Providing Spiritual Care in Palliative Care among Professionals: A Portuguese Cross-Sectional Study

Spiritual care is an important dimension of palliative care (PC) and a facet of holistic care that helps ill people find meaning in their suffering and lives. This study aims to: (a) develop and test the psychometric properties of a new instrument, Perceived Barriers to Spiritual Care (PBSC); (b) explore participants' perceptions of how prevalent those (pre-identified) barriers are; and (c) examine the association of their personal and professional characteristics with those perceptions. A descriptive cross-sectional study was carried out using a self-reporting online survey. In total, 251 professionals registered with the Portuguese Association of Palliative Care (APCP) completed the study. The majority of respondents were female (83.3%), nurses (45.4%), had more than 11 years of professional experience (66.1%), did not work in PC (61.8%), and had a religious affiliation (81.7%). The psychometric assessment using PBSC provided sound evidence for its validity and reliability. The three most common perceived barriers were late referral for palliative care (78.1%), work overload (75.3%), and uncontrolled physical symptoms (72.5%). The least commonly perceived barriers were different spiritual beliefs among professionals (10.8%), differences between the beliefs of professionals and patients (14.4%), and the shame of approaching spirituality in a professional context (26.7%). The findings show there is some relationship between sex, age, years of professional experience, working in PC, having a religious affiliation, the importance of spiritual/religious beliefs, and responses to the PBSC tool. The results highlight the importance of advanced training in spirituality and intervention strategies. Further research is needed to properly study the impacts of spiritual care and establish outcome assessments that accurately reflect the effects of the various spiritual care activities.

Emotional distress predicts palliative cancer care attitudes: The unique role of anger

OBJECTIVE

Although palliative care can mitigate emotional distress, distressed patients may be less likely to engage in timely palliative care. This study aims to investigate the role of emotional distress in palliative care avoidance by examining the associations of anger, anxiety, and depression with palliative care attitudes.

METHODS

Patients (N = 454) with heterogeneous cancer diagnoses completed an online survey on emotional distress and palliative care attitudes. Emotional distress was measured using the Patient-Reported Outcomes Measurement Information System anger, anxiety, and depression scales. The Palliative Care Attitudes Scale was used to measure palliative care attitudes. Regression models tested the impact of a composite emotional distress score calculated from all three symptom measures, as well as individual anger, anxiety, and depression scores, on palliative care attitudes. All models controlled for relevant demographic and clinical covariates.

RESULTS

Regression results revealed that patients who were more emotionally distressed had less favorable attitudes toward palliative care (p < 0.001). In particular, patients who were angrier had less favorable attitudes toward palliative care (p = 0.013) while accounting for depression, anxiety, and covariates. Across analyses, women had more favorable attitudes toward palliative care than men, especially with regard to beliefs about palliative care effectiveness.

CONCLUSIONS

Anger is a key element of emotional distress and may lead patients to be more reluctant toward timely utilization of palliative care. Although psycho-oncology studies routinely assess depression or anxiety, more attention to anger is warranted. More research is needed on how best to address anger and increase timely utilization of palliative cancer care.

Taiwanese Older Adults Prefer to Use Antibiotics and Intravenous Infusion at the End of Life based on a Cartoon Version of the Life Support Preferences Questionnaire

Asians believe discussing death-related topics is inauspicious and may bring bad luck. It is critical to explore the end-of-life care preferences of the Asian elderly with less-threatening tools. The study examined older adults' preferences regarding end-of-life treatments by applying a cartoon version of the Life Support Preferences Questionnaire (LSPQ). A cross-sectional survey was conducted to understand older adults' preferences for end-of-life treatments. A total of 342 older adults participated in the study, comprising 268 elderly patients from a veterans hospital located in northern Taiwan and 74 elderly family members of the patients. Regardless of scenario, cardiopulmonary resuscitation (CPR) had the lowest score, indicating that older adults considered it a less desirable medical treatment. By contrast, antibiotics and intravenous infusions had the highest scores, indicating that older adults tended to prefer them. End-of-life care preferences were significantly different in genders. CPR and surgical preferences of older adults differed significantly with education level. Different demographic characteristics had different end-of-life treatment preferences, and future research may develop advance care planning programs for different attributes. This cartoon version of the LSPQ can help healthcare professionals to understand older adults' preferences for end-of-life care and warrants further empirical research.