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Marston C, Morgan DD, Philip J, Agar MR. Experience and acceptability of a carer-focussed intervention in acute oncology settings: A qualitative study of people with advanced cancer and their carers. Aust Occup Ther J 2023; 70:570-580. [PMID: 37271728 DOI: 10.1111/1440-1630.12887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 05/10/2023] [Accepted: 05/13/2023] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Providing optimal support for carers of people with advanced cancer is critical to facilitating discharge home from hospital. Carer Support Needs Assessment Tool-Intervention (CSNAT-I) has shown promise in supporting carers' needs in this context. This study aimed to explore patient and carers experiences with and views on the acceptability of the CSNAT-I delivered by occupational therapists in an acute oncology setting. METHODS People with advanced cancer and their carers who had previously received the CSNAT-I as part of usual care while admitted to an Australian specialist cancer centre or acute hospital were invited to participate in interviews exploring their perceptions of the intervention. Data were analysed thematically. RESULTS Two patients and 10 carers participated in semi-structured interviews. Three themes were constructed from the data: Carers viewed the CSNAT-I as comprehensive process that (1) 'covered everything' related to discharge planning; (2) generated an 'increased awareness of needs' for themselves, patients, and clinicians; and (3) triggered an emotional response of feeling 'wrapped up in care' that was maintained as they moved from hospital to home. CONCLUSION This study has demonstrated that the CSNAT-I was highly acceptable to carers as part of existing discharge processes supporting them through the transition from hospital to home and can be delivered by occupational therapists and other clinicians with a natural synergy to discharge planning. These findings will inform further development and testing of the delivery model of the CSNAT-I in future trials.
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Affiliation(s)
- Celia Marston
- Department of Occupational Therapy, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Occupational Therapy, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Occupational Therapy, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Deidre D Morgan
- Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
- Research Centre for Palliative Care, Death and Dying, Flinders University, Adelaide, South Australia, Australia
| | - Jennifer Philip
- Palliative Care Service, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Palliative Care Service, St. Vincent's Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Palliative Care Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Meera R Agar
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
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Marston C, Morgan DD, Philip J, Agar M. Supporting Carers as Patients Move between Hospital and Home: A Systematic Review of Interventions to Support These Transitions in Care. J Palliat Med 2023; 26:270-298. [PMID: 36251853 DOI: 10.1089/jpm.2022.0221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background: Hospital-to-home transitions become more frequent and complex as people approach end of life. Although carers are critical to enabling these transitions, they report high levels of unmet need. A review of the interventions to assist these care transitions, along with understanding those intervention components and mechanisms that support carers of people with advanced illness, is required to inform an optimal care model for palliative care practice. Aim: To describe the characteristics and reporting quality of intervention studies aimed at improving hospital-to-home transitions for carers of people with advanced illness. Design: This is a systematic review with a narrative synthesis. (international prospective register of systematic reviews [PROSPERO] ID: CRD42020192088). Data Sources: MEDLINE, EMCare, and PsychINFO databases were searched (2000-2021) for prospective studies reporting on interventions that (1) aimed to improve hospital-to-home transitions and (2) targeted carers of people with advanced illness. The Template for Intervention Description and Replication (TIDieR) checklist and constructs of the Care Transition Framework were used to assess the reporting quality of intervention design, delivery, and outcomes. Results: In total, 37 articles were analyzed that included a range of study designs, interventions, and outcomes. Health care utilization (n = 29) and clinical patient-related (n = 21) measures were the most reported outcome. Theoretical discussion was minimal (n = 5) with most studies using efficacy data from past research to justify intervention choice. Conclusion: Carers are critical partners in hospital-to-home transitions at end of life; yet they are largely under-represented in intervention design, delivery, and outcomes. Improving the reporting quality of carer-focused care transition interventions will inform future study design and support translation into practice and policy.
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Affiliation(s)
- Celia Marston
- Department of Occupational Therapy, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Occupational Therapy, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Occupational Therapy, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Deidre D Morgan
- Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
- Research Centre for Palliative Care, Death and Dying, Flinders University, Adelaide, South Australia, Australia
| | - Jennifer Philip
- Palliative Care Service, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Palliative Care Service, St. Vincent's Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Palliative Care Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Meera Agar
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
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Whitehead K, Ala-Leppilampi K, Lee B, Menagh J, Spaner D. Factors That Determine the Experience of Transition to an Inpatient Palliative Care Unit for Patients and Caregivers: A Qualitative Study. J Palliat Care 2022; 37:579-585. [PMID: 35837725 PMCID: PMC9465532 DOI: 10.1177/08258597221105001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: Transitions in care settings near the end of life can
present challenges to patients and families, especially when there are also
adjustments in level of care and illness trajectory. In this study, we explored
what factors influenced how patients and family caregivers experienced a
transition to an inpatient Palliative Care Unit (PCU). Methods:
This qualitative study was conducted at a PCU in Toronto, Canada.
Semi-structured interviews were held with 29 participants (14 patients and 15
family caregivers) during their time on the PCU. Data was analyzed through an
iterative process of constant comparison to generate themes. The recruitment
process continued to the point of thematic saturation. Results:
Five themes were identified that represented the participants’ experiences in
transitioning to the PCU: Being prepared, Feeling supported, Coming to terms
with end of life issues, Dealing with uncertainty, and Continuity of care.
Conclusions: Our findings highlight the need for clear and
iterative communication with patients and family caregivers during the
transition to a PCU. Identification and consideration of the common themes
involved in the experience of transfer to PCU can help guide future practice and
improve the experience of patients and families during transitions at the end of
life.
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Affiliation(s)
- Katherine Whitehead
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Salvation Army Toronto Grace Health Centre, Palliative Care Unit, Toronto, ON, Canada
| | | | - Betty Lee
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Salvation Army Toronto Grace Health Centre, Palliative Care Unit, Toronto, ON, Canada
| | - Jacqueline Menagh
- Salvation Army Toronto Grace Health Centre, Palliative Care Unit, Toronto, ON, Canada
| | - Donna Spaner
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Salvation Army Toronto Grace Health Centre, Palliative Care Unit, Toronto, ON, Canada
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Kasdorf A, Dust G, Hamacher S, Schippel N, Rietz C, Voltz R, Strupp J. The last year of life for patients dying from cancer vs. non-cancer causes: a retrospective cross-sectional survey of bereaved relatives. Support Care Cancer 2022; 30:4971-4979. [PMID: 35190893 PMCID: PMC9046331 DOI: 10.1007/s00520-022-06908-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/10/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE To compare health care experiences of patients with cancer or non-cancer diseases in their last year of life. METHODS A cross-sectional post-bereavement survey was conducted using an adapted German version of the VOICES questionnaire (VOICES-LYOL-Cologne). Differences in the reported experiences were assessed using a two-sided Pearson's chi-square test and Mann-Whitney U test. RESULTS We collected data from 351 bereaved relatives. More than half of non-cancer patients were not informed that their disease could lead to death (p < 0.001). When this was communicated, in 46.7% of non-cancer and 64.5% of cancer patients, it was reported by the hospital doctor (p = 0.050). In all, 66.9% of non-cancer and 41.6% of cancer patients were not informed about death being imminent (p < 0.001). On average, non-cancer patients had significantly fewer transitions and hospital stays in their last year of life (p = 0.014; p = 0.008, respectively). Non-cancer patients were treated more often by general practitioners, and cancer patients were treated more often by specialists (p = 0.002; p = 0.002, respectively). A substantially lower proportion of non-cancer patients were treated by at least one member of or in the setting of general or specialized palliative care (p < 0.001). CONCLUSIONS Non-cancer patients experience disadvantages in communication regarding their care and in access to specialized palliative care in their last year of life compared to cancer patients. Regarding the assessment of palliative care needs and the lack of communication of an incurable disease, non-cancer patients are underserved. An early identification of patients requiring palliative care is a major public health concern and should be addressed irrespective of diagnosis. TRIAL REGISTRATION Prospectively registered by the German Clinical Trials Register (DRKS00011925, data of registration: 13.06.2017).
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Affiliation(s)
- Alina Kasdorf
- grid.6190.e0000 0000 8580 3777Department of Palliative Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Gloria Dust
- grid.6190.e0000 0000 8580 3777Department of Palliative Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Stefanie Hamacher
- grid.6190.e0000 0000 8580 3777Faculty of Medicine and University Hospital Cologne, Institute of Medical Statistics and Computational Biology, University of Cologne, Cologne, Germany
| | - Nicolas Schippel
- grid.6190.e0000 0000 8580 3777Department of Palliative Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christian Rietz
- grid.461780.c0000 0001 2264 5158Department of Educational Science and Mixed-Methods-Research, Faculty of Educational and Social Sciences, University of Education Heidelberg, Heidelberg, Germany
| | - Raymond Voltz
- grid.6190.e0000 0000 8580 3777Department of Palliative Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany ,grid.6190.e0000 0000 8580 3777Center for Health Services Research, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany ,grid.6190.e0000 0000 8580 3777Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO ABCD), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany ,grid.6190.e0000 0000 8580 3777Clinical Trials Center (ZKS), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Julia Strupp
- grid.6190.e0000 0000 8580 3777Department of Palliative Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Can we determine burdensome transitions in the last year of life based on time of occurrence and frequency? An explanatory mixed-methods study. Palliat Support Care 2021; 20:637-645. [DOI: 10.1017/s1478951521001395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Abstract
Objective
Burdensome transitions are typically defined as having a transition in the last three days or multiple hospitalizations in the last three months of life, which is seldom verified with qualitative accounts from persons concerned. This study analyses types and frequencies of transitions in the last year of life and indicators of burdensome transitions from the perspective of bereaved relatives.
Method
Cross-sectional explanatory mixed-methods study with 351 surveyed and 41 interviewed bereaved relatives in a German urban area. Frequencies, t-tests, and Spearman correlations were computed for quantitative data. Qualitative data were analyzed using content analysis with provisional and descriptive coding/subcoding.
Results
Transitions rise sharply during the last year of life. 8.2% of patients experience a transition in the last three days and 7.8% three or more hospitalizations in the last three months of life. An empathetic way of telling patients about the prospect of death is associated with fewer transitions in the last month of life (r = 0.185, p = 0.046). Professionals being aware of the preferred place of death corresponds to fewer hospitalizations in the last three months of life (1.28 vs. 0.97, p = 0.021). Qualitative data do not confirm that burden in transitions is linked to having transitions in the last three days or multiple hospitalizations in the last three months of life. Burden is associated with (1) late and non-empathetic communication about the prospect of death, (2) not coordinating care across settings, and (3) not considering patients’ preferences.
Significance of results
Time of occurrence and frequency appear to be imperfect proxies for burdensome transitions. The subjective burden seems to be associated rather with insufficient information, preparation, and management of transitions.
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Morey T, Scott M, Saunders S, Varenbut J, Howard M, Tanuseputro P, Webber C, Killackey T, Wentlandt K, Zimmermann C, Bernstein M, Ernecoff N, Hsu A, Isenberg S. Transitioning From Hospital to Palliative Care at Home: Patient and Caregiver Perceptions of Continuity of Care. J Pain Symptom Manage 2021; 62:233-241. [PMID: 33385479 DOI: 10.1016/j.jpainsymman.2020.12.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/21/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022]
Abstract
CONTEXT Continuity of care is important at improving the patient experience and reducing unnecessary hospitalizations when transitioning across care settings, especially at the end of life. OBJECTIVE To explore patient and caregiver understanding and valuation of "continuity of care" while transitioning from an in-hospital to a home-based palliative care team. METHODS Longitudinal qualitative design using semistructured interviews conducted with patients and their caregivers before and after transitioning from hospital to palliative care at home. Interviews were audio-recorded and transcribed verbatim. Data were analyzed using thematic analysis within a postpositivist framework. Thirty-nine participants (18 patients, seven caregivers, and seven patient-caregiver dyads) were recruited from two acute care hospitals, wherein they received care from an inpatient palliative care consultation team and transitioned to home-based palliative care. RESULTS Patients had a mean age of 68 years, 60% were female and 60% had a diagnosis of cancer. Caregivers had a mean age of 62 years and 50% were female. Participants perceived continuity of care to occur in three ways, depending on which stage they were at in their hospital-to-home transition. In hospital, continuity of care was experienced, as consistency of information exchanged between providers. During the transition from hospital to home, continuity of care was experienced as consistency of treatments. When receiving home-based palliative care, continuity of care was experienced as having consistent providers. CONCLUSION Patients' and their caregivers' valuation of continuity of care was dependent on their stage of the hospital-to-home transition. Optimizing continuity of care requires an integrated network of providers with reliable information transfer and communication.
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Affiliation(s)
- Trevor Morey
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
| | - Mary Scott
- Department of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Stephanie Saunders
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Canada; Department of Rehabilitation Sciences, McMaster University, Hamilton, Canada
| | - Jaymie Varenbut
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | | | - Colleen Webber
- Bruyere Research Institute, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada
| | - Tieghan Killackey
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Canada; University Health Network, Toronto, Canada; Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Kirsten Wentlandt
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada; University Health Network, Toronto, Canada
| | | | - Mark Bernstein
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Canada
| | - Natalie Ernecoff
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Amy Hsu
- Bruyere Research Institute, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada; Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - Sarina Isenberg
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada; Bruyere Research Institute, Ottawa, Canada
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7
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Hanna N, Quach B, Scott M, Qureshi D, Tanuseputro P, Webber C. Operationalizing Burdensome Transitions Among Adults at the End of Life: A Scoping Review. J Pain Symptom Manage 2021; 61:1261-1277.e10. [PMID: 33096215 DOI: 10.1016/j.jpainsymman.2020.10.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/09/2020] [Accepted: 10/16/2020] [Indexed: 12/15/2022]
Abstract
CONTEXT Care transitions at the end of life are associated with reduced quality of life and negative health outcomes, yet up to half of patients in developed countries experience a transition within the last month of life. A variety of these transitions have been described as "burdensome" in the literature; however, there is currently no consensus on the definition of a burdensome transition. OBJECTIVES The purpose of this review was to identify current definitions of "burdensome transitions" and develop a framework for classifying transitions as "burdensome" at the end of life. METHODS A search was conducted in databases including Embase, PubMed, Cochrane Database of Systematic Reviews, Cochrane Controlled Register of Trials, CINAHL, and PsychINFO for articles published in English between January 1, 2000 and September 28, 2019. RESULTS A total of 37 articles met inclusion criteria for this scoping review. Definitions of burdensome transitions were characterized by the following features: transition setting trajectory, number of transitions, temporal relationship to end of life, or quality of transitions. CONCLUSION Definitions of burdensome transitions varied based on time before death, setting of cohorts, and study population. These definitions can be helpful in identifying and subsequently preventing unnecessary transitions at the end of life.
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Affiliation(s)
- Nardin Hanna
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada.
| | - Bradley Quach
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mary Scott
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Danial Qureshi
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa
| | - Colleen Webber
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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8
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Larkin PJ, De Casterlé BD, Schotsmans P. Transition towards End of Life in Palliative Care: An Exploration of its Meaning for Advanced Cancer Patients in Europe. J Palliat Care 2019. [DOI: 10.1177/082585970702300202] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Transition as a concept in healthcare has been explored, but there is limited empirical work which considers transition in the context of palliative care, specifically from the patient perspective. This article reports findings from a qualitative study designed to explore transition experiences of 100 advanced cancer patients in six European countries. Data were analyzed using the ATLAS.ti program. Findings suggest that transition is a confusing time of mixed messages, poor communication, and uncertainty, but the physical environment of the hospice offers a place of ontological security from which to address this. Transition concepts fail to capture the palliative care experience fully. Transience, as an alternative concept, is reported, although further research is needed to explore this. In clinical practice, the value given to hospice by patients suggests that clinicians must carefully balance the benefit of mainstream integration with sensitive assimilation of hospice philosophy.
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9
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Wilson DM, Birch S. A scoping review of research to assess the frequency, types, and reasons for end-of-life care setting transitions. Scand J Public Health 2018; 48:376-381. [PMID: 30102574 DOI: 10.1177/1403494818785042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims: Most people approaching the end of life develop care needs, which typically change over time. Moves between care settings may be required as health deteriorates. However, in some cases, care setting transitions may have little to do with end-of-life care needs and instead reflect the needs, demands, availability, or funding provisions of the country or funding body and organizations providing care. This paper is a scoping review of the international peer-reviewed research literature to gain evidence on the frequency and types of end-of-life care setting transitions, and the reasons for these moves. Methods: All relevant print and open access research articles published in 2000+ were sought using the Directory of Open Access Journals and EBSCO Discovery Host. Results: A total of 39 research articles were identified and reviewed. However, minimal useful evidence was revealed. Most articles focused solely on hospital admissions near death, and some focused on nursing home admissions, with other moves infrequently studied. Conclusions: This review demonstrates the need to quantify and justify end-of-life care setting transitions as it appears dying people are frequently moved, often as death nears. This research is needed to distinguish transitions related to end-of-life care needs and those arising from pressures on or from care providers and others unrelated to the person's care needs.
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Affiliation(s)
- Donna M Wilson
- Faculty of Nursing, University of Alberta, Canada
- Faculty of Education and Health Sciences, University of Limerick, Ireland
| | - Stephen Birch
- Centre for Health Economics and Policy Analysis, McMaster University, Canada
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10
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Wilson DM, Birch S. Moving from place to place in the last year of life: A qualitative study identifying care setting transition issues and solutions in Ontario. HEALTH & SOCIAL CARE IN THE COMMUNITY 2018; 26:232-239. [PMID: 29108131 DOI: 10.1111/hsc.12513] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/12/2017] [Indexed: 06/07/2023]
Abstract
Moving from one care setting to another is common as death nears. Many concerns exist over these end-of-life (EOL) care setting transitions, including low-quality moves as mistakes and other mishaps can occur. Delayed or denied moves are also problematic, such as a move out of hospital for dying inpatients who want to spend their last hours or days at home. The aim of the study was to identify current issues or problems with care setting transitions during the last year of life as well as potential or actual solutions for these problems. A grounded theory analysis approach was used based on interviews with 38 key informants who represent a wide range of healthcare providers, healthcare managers, government representatives, lawyers, healthcare recipients and their family/friends across Ontario in 2016. Three interrelated themes were revealed: (a) communication complexities, (b) care planning and coordination gaps and (c) health system reform needs. Six solutions were highlighted, with these designed to prevent care setting transition issues and monitor care setting transitions for continued improvements.
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Affiliation(s)
- Donna M Wilson
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
- Department of Nursing and Midwifery, Faculty of Education and Health Sciences, University of Limerick, Limerick, Ireland
| | - Stephen Birch
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
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11
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Lakkappa B, Shah S, Rogers S, Holman LH. Mortality among referrals to a community-based intermediate care team. BMJ Support Palliat Care 2017; 9:263-266. [PMID: 29151044 DOI: 10.1136/bmjspcare-2017-001364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 08/12/2017] [Accepted: 10/25/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Intermediate care services have been introduced to help mitigate unnecessary hospital demand and premature placement in long-term residential care. Many patients are elderly and/or with complex comorbidities, but little consideration has been given to the palliative care needs of patients referred to intermediate care services. The objective of this study is to determine the proportion of patients referred to a community-based intermediate care team who died during care and up to 24 months after discharge and so to help inform the development of supportive and palliative care in this setting. METHODS A retrospective cohort study of all 4770 adult patients referred to Northamptonshire Intermediate Care Team (ICT) between 11 April 2010 and 10 April 2011. RESULTS Of 4770 patients referred, 60% were 75 years or older and 32% were 85 years of age or older. 4.0% of patients died during their ICT stay and 11% within 30 days of discharge. At the end of 12 months, 25% of the patients had died, increasing to 32% before the end of the second year. About 34% of all deaths occurred during the ICT stay or within 30 days of discharge, and a further 46% by the end of the first year. Male gender and higher age were associated with greater likelihood of death. CONCLUSIONS It is important for ICT clinicians to consider immediate and longer-term palliative care needs among patients referred to ICTs. Care models involving ICTs and palliative care teams working together could enable more people with end-stage non-cancer illnesses to die at home.
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Affiliation(s)
- Bharath Lakkappa
- Intermediate Care Team, Northamptonshire Healthcare NHS Foundation Trust, Northampton, UK
| | - Sanjay Shah
- Palliative Care, Northamptonshire Healthcare NHS Foundation Trust, Northampton, UK
| | - Stephen Rogers
- Research and Development, Northamptonshire Healthcare NHS Foundation Trust, Northampton, UK
| | - Leanne Helen Holman
- Research and Development, Northamptonshire Healthcare NHS Foundation Trust, Northampton, UK
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12
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How do treatment aims in the last phase of life relate to hospitalizations and hospital mortality? A mortality follow-back study of Dutch patients with five types of cancer. Support Care Cancer 2017; 26:777-786. [PMID: 28936558 PMCID: PMC5785603 DOI: 10.1007/s00520-017-3889-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 09/11/2017] [Indexed: 11/30/2022]
Abstract
Purpose The purpose of this study is to describe and compare the relation between treatment aims, hospitalizations, and hospital mortality for Dutch patients who died from lung, colorectal, breast, prostate, or pancreatic cancer. Methods A mortality follow-back study was conducted within a sentinel network of Dutch general practitioners (GPs), who recorded the end-of-life care of 691 patients who died from one of the abovementioned cancer types between 2009 and 2015. Differences in care by type of cancer were analyzed using multilevel analyses to control for clustering within general practices. Results Among all cancer types, patients with prostate cancer most often and patients with pancreatic cancer least often had a palliative treatment aim a month before death (95% resp. 84%). Prostate cancer patients were also least often admitted to hospital in the last month of life (18.5%) and least often died there (3.1%), whereas lung cancer patients were at the other end of the spectrum with 41.8% of them being admitted to hospital and 22.6% dying in hospital. Having a palliative treatment aim and being older were significantly associated with less hospital admissions, and having a palliative treatment aim, having prostate cancer, and dying in a more recent year were significantly associated with less hospital deaths. Conclusion There is large variation between patients with different cancer types with regard to treatment aims, hospital admissions, and hospital deaths. The results highlight the need for early initiation of GP palliative care to support patients from all cancer types to stay at the place they prefer as long as possible.
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Casotto V, Rolfini M, Ferroni E, Savioli V, Gennaro N, Avossa F, Cancian M, Figoli F, Mantoan D, Brambilla A, Ghiotto MC, Fedeli U, Saugo M. End-of-Life Place of Care, Health Care Settings, and Health Care Transitions Among Cancer Patients: Impact of an Integrated Cancer Palliative Care Plan. J Pain Symptom Manage 2017; 54:167-175. [PMID: 28479411 DOI: 10.1016/j.jpainsymman.2017.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 03/15/2017] [Accepted: 04/05/2017] [Indexed: 10/19/2022]
Abstract
CONTEXT Frequent end-of-life health care setting transitions can lead to an increased risk of fragmented care and exposure to unnecessary treatments. OBJECTIVES We assessed the relationship between the presence and the intensity of an Integrated Cancer Palliative Care (ICPC) plan and the occurrence of multiple transitions during the last month of life. METHODS Decedents of cancer aged 18-85 years residents in two regions of Italy were investigated accessing their integrated administrative data (death certificates, hospital discharges, hospice, and home care records). The principal outcome was defined as having 3+ health care setting transitions during the last month of life. The ICPC plans instituted 90-31 days before death represented the main exposure of interest. RESULTS Of the 17,604 patients, 6698 included in an ICPC, although spending in hospital a median number of only two days (interquartile range 1-2), experienced 1+ (59.8%), 2+ (21.1%), or 3+ (5.9%) health care transitions. Among the latter group, the most common trajectory of care is home-hospital-home-hospital (36.0%). The intensity of the ICPC plan showed a marked protective effect toward the event of 3+ health care setting transitions; the effect is already evident from an intensity of at least one home visit/week (odds ratio 0.73; 95% confidence interval 0.62-0.87). CONCLUSION A well-integrated palliative care approach can be effective in further reducing the percentage of patients who spent many days in hospital and/or undergo frequent and inopportune changes of their care setting during their last month of life.
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Affiliation(s)
| | - Maria Rolfini
- Direzione Sanità e Politiche Sociali, Emilia-Romagna Region, Italy
| | - Eliana Ferroni
- Epidemiological System of the Veneto Region, Padova, Italy.
| | - Valentina Savioli
- Servizio Sistema Informativo Sanità e Politiche Sociali, Emilia-Romagna Region, Italy
| | - Nicola Gennaro
- Epidemiological System of the Veneto Region, Padova, Italy
| | | | | | - Franco Figoli
- Palliative Care Unit, Local Health Unit n. 4, Thiene, Italy
| | | | | | | | - Ugo Fedeli
- Epidemiological System of the Veneto Region, Padova, Italy
| | - Mario Saugo
- Epidemiological System of the Veneto Region, Padova, Italy
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Coombs MA, Parker R, de Vries K. Managing risk during care transitions when approaching end of life: A qualitative study of patients' and health care professionals' decision making. Palliat Med 2017; 31:617-624. [PMID: 28618896 PMCID: PMC5476192 DOI: 10.1177/0269216316673476] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Increasing importance is being placed on the coordination of services at the end of life. AIM To describe decision-making processes that influence transitions in care when approaching the end of life. DESIGN Qualitative study using field observations and longitudinal semi-structured interviews. SETTING/PARTICIPANTS Field observations were undertaken in three sites: a residential care home, a medical assessment unit and a general medical unit in New Zealand. The Supportive and Palliative Care Indicators Tool was used to identify participants with advanced and progressive illness. Patients and family members were interviewed on recruitment and 3-4 months later. Four weeks of fieldwork were conducted in each site. A total of 40 interviews were conducted: 29 initial interviews and 11 follow-up interviews. Thematic analysis was undertaken. FINDINGS Managing risk was an important factor that influenced transitions in care. Patients and health care staff held different perspectives on how such risks were managed. At home, patients tolerated increasing risk and used specific support measures to manage often escalating health and social problems. In contrast, decisions about discharge in hospital were driven by hospital staff who were risk-adverse. Availability of community and carer services supported risk management while a perceived need for early discharge decision making in hospital and making 'safe' discharge options informed hospital discharge decisions. CONCLUSION While managing risk is an important factor during care transitions, patients should be able to make choices on how to live with risk at the end of life. This requires reconsideration of transitional care and current discharge planning processes at the end of life.
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Affiliation(s)
- Maureen A Coombs
- Graduate School of Nursing Midwifery and Health, Victoria University of Wellington, Wellington, New Zealand
- Capital & Coast District Health Board, Wellington, New Zealand
| | - Roses Parker
- Graduate School of Nursing Midwifery and Health, Victoria University of Wellington, Wellington, New Zealand
| | - Kay de Vries
- School of Health Sciences, University of Brighton, Brighton, UK
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The care experiences of patients who die in residential hospice: A qualitative analysis of the last three months of life from the views of bereaved caregivers. Palliat Support Care 2017; 16:421-431. [PMID: 28660841 DOI: 10.1017/s147895151700058x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Despite the increasing prominence of residential hospices as a place of death and that, in many regards, this specialized care represents a gold standard, little is known about the care experience in this setting. Using qualitative survey data, we examined the positive and negative perceptions of care in hospices and in other prior settings. METHOD Qualitative comments were extracted from the CaregiverVoice survey completed by bereaved caregivers of decedents who had died in 16 residential hospices in Ontario, Canada. On this survey, caregivers reported what was good and bad about the services provided during the last three months of life as separate open-text questions. A constant-comparison method was employed to derive themes from the responses. RESULTS A total of 550 caregivers completed the survey, 94% (517) of whom commented on either something good (84%) and/or bad (49%) about the care experience. In addition to residential hospice, the majority of patients represented also received palliative care in the home (69%) or hospital (59%). Overall, most positive statements were about care in hospice (71%), whereas the negative statements tended to refer to other settings (81%). The hospice experience was found to exemplify care that was compassionate and holistic, in a comforting environment, offered by providers who were personable, dedicated, and informative. These humanistic qualities of care and the extent of support were generally seen to be lacking from the other settings. SIGNIFICANCE OF RESULTS Our examination of the good and bad aspects of palliative care received is unique in qualitatively exploring palliative care experiences across multiple settings, and specifically that in hospices. Investigation of these perspectives affirmed the elements of care that dying patients and their family caregivers most value and that the hospices were largely effective at addressing. These findings highlight the need for reinforcing these qualities in other end-of-life settings to create comforting and supportive environments.
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Soares LGL, Japiassu AM, Gomes LC, Pereira R. Post-Acute Care Facility as a Discharge Destination for Patients in Need of Palliative Care in Brazil. Am J Hosp Palliat Care 2017; 35:198-202. [PMID: 28135810 DOI: 10.1177/1049909117691280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Patients with complex palliative care needs can experience delayed discharge, which causes an inappropriate occupancy of hospital beds. Post-acute care facilities (PACFs) have emerged as an alternative discharge destination for some of these patients. The aim of this study was to investigate the frequency of admissions and characteristics of palliative care patients discharged from hospitals to a PACF. We conducted a retrospective analysis of PACF admissions between 2014 and 2016 that were linked to hospital discharge reports and electronic health records, to gather information about hospital-to-PACF transitions. In total, 205 consecutive patients were discharged from 6 different hospitals to our PACF. Palliative care patients were involved in 32% (n = 67) of these discharges. The most common conditions were terminal cancer (n = 42, 63%), advanced dementia (n = 17, 25%), and stroke (n = 5, 8%). During acute hospital stays, patients with cancer had significant shorter lengths of stay (13 vs 99 days, P = .004), a lower use of intensive care services (2% vs 64%, P < .001) and mechanical ventilation (2% vs 40%, P < .001), when compared to noncancer patients. Approximately one-third of discharges from hospitals to a PACF involved a heterogeneous group of patients in need of palliative care. Further studies are necessary to understand the trajectory of posthospitalized patients with life-limiting illnesses and what factors influence their decision to choose a PACF as a discharge destination and place of death. We advocate that palliative care should be integrated into the portfolio of post-acute services.
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Affiliation(s)
- Luiz Guilherme L Soares
- 1 Post-Acute Care Services and Palliative Care Program, Hospital Placi, Niterói, Rio de Janeiro, Brazil
| | - André M Japiassu
- 2 Instituto Nacional de Infectologia-Fundação Oswaldo Cruz, Research Laboratory of Intensive Care Medicine, Niterói, Rio de Janeiro, Brazil
| | - Lucia C Gomes
- 1 Post-Acute Care Services and Palliative Care Program, Hospital Placi, Niterói, Rio de Janeiro, Brazil
| | - Rogéria Pereira
- 1 Post-Acute Care Services and Palliative Care Program, Hospital Placi, Niterói, Rio de Janeiro, Brazil
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Abraham S, Menec V. Transitions Between Care Settings at the End of Life Among Older Homecare Recipients: A Population-Based Study. Gerontol Geriatr Med 2016; 2:2333721416684400. [PMID: 28680944 PMCID: PMC5490842 DOI: 10.1177/2333721416684400] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/26/2016] [Accepted: 11/07/2016] [Indexed: 11/18/2022] Open
Abstract
Objectives: Objectives were to (a) describe transitions between care settings in older homecare recipients at the end of life, and (b) examine what personal (e.g., age, sex) and health system factors (e.g., hospital bed supply) predict care transitions. Methods: The study involved analysis of administrative health care data and was based on a complete cohort of homecare recipients aged 65 years or older who died in Manitoba, Canada between 2003 and 2006 (N = 7,866). Results: More than half of homecare recipients had at least one care transition in the last 30 days before death and 21% had two or more hospitalizations in the last 90 days. Both personal characteristics and health system factors were related to transitions and hospitalizations. Discussion: The findings suggest that homecare recipients are an important population to focus on in terms of reducing potentially burdensome transitions and enhancing the end-of-life experience for them and their family.
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Bähler C, Signorell A, Reich O. Health Care Utilisation and Transitions between Health Care Settings in the Last 6 Months of Life in Switzerland. PLoS One 2016; 11:e0160932. [PMID: 27598939 PMCID: PMC5012658 DOI: 10.1371/journal.pone.0160932] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 07/27/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Many efforts are undertaken in Switzerland to enable older and/or chronically ill patients to stay home longer at the end-of-life. One of the consequences might be an increased need for hospitalisations at the end-of-life, which goes along with burdensome transitions for patients and higher health care costs for the society. AIM We aimed to examine the health care utilisation in the last six months of life, including transitions between health care settings, in a Swiss adult population. METHODS The study population consisted of 11'310 decedents of 2014 who were insured at the Helsana Group, the leading health insurance in Switzerland. Descriptive statistics were used to analyse the health care utilisation by age group, taking into account individual and regional factors. Zero-inflated Poisson regression model was used to predict the number of transitions. RESULTS Mean age was 78.1 in men and 83.8 in women. In the last six months of life, 94.7% of the decedents had at least one consultation; 61.6% were hospitalised at least once, with a mean length of stay of 28.3 days; and nursing home stays were seen in 47.4% of the decedents. Over the same time period, 64.5% were transferred at least once, and 12.9% experienced at least one burdensome transition. Main predictors for transitions were age, sex and chronic conditions. A high density of home care nurses was associated with a decrease, whereas a high density of ambulatory care physicians was associated with an increase in the number of transitions. CONCLUSIONS Health care utilisation was high in the last six months of life and a considerable number of decedents were being transferred. Advance care planning might prevent patients from numerous and particularly from burdensome transitions.
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Affiliation(s)
- Caroline Bähler
- Department of Health Sciences, Helsana Insurance Group, P.O. Box, 8081 Zürich, Switzerland
| | - Andri Signorell
- Department of Health Sciences, Helsana Insurance Group, P.O. Box, 8081 Zürich, Switzerland
| | - Oliver Reich
- Department of Health Sciences, Helsana Insurance Group, P.O. Box, 8081 Zürich, Switzerland
- * E-mail:
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Nordsveen H, Andershed B. Pasienter med kreft i palliativ fase på vei hjem - Sykepleieres erfaringer av samhandling. ACTA ACUST UNITED AC 2015. [DOI: 10.18261/issn1892-2686-2015-03-02] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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De Korte-Verhoef MC, Pasman HRW, Schweitzer BP, Francke AL, Onwuteaka-Philipsen BD, Deliens L. General practitioners' perspectives on the avoidability of hospitalizations at the end of life: A mixed-method study. Palliat Med 2014; 28:949-958. [PMID: 24694377 DOI: 10.1177/0269216314528742] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Many patients are hospitalized in the last months of life. Little is known about the avoidability of these hospitalizations. AIM To explore whether and how hospitalizations could have been avoided in the last 3 months of life and barriers to avoid this, according to general practitioners in the Netherlands. DESIGN Sequential mixed-method design, starting with a cross-sectional nationwide questionnaire study among general practitioners, followed by in-depth interviews. SETTING/PARTICIPANTS General practitioners were asked about their most recent patient who died non-suddenly and who was hospitalized in the last 3 months of life. Additionally, 18 of these general practitioners were interviewed in depth about the situation surrounding hospitalization. RESULTS According to 24% of 319 general practitioners, the last hospitalization in the final 3 months of their patient's life could have been avoided. Of all avoidable hospitalizations, 46% could have been avoided by proactive communication with the patient, 36% by more communication between professionals around hospitalization, 28% by additional care and treatment at home, and 10% by patient and family support. In the in-depth interviews, general practitioners confirmed the aforementioned strategies, but also mentioned various barriers in daily practice, such as the timing of proactive communication with the patient, incompleteness of information transfer in acute situations, and the lack of awareness among patients and family that death was near. CONCLUSION A proactive approach could avoid some of the hospitalizations at the end of life, in the opinion of general practitioners. More insight is needed into communication and psychological barriers for timely discussions about end-of-life issues.
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Affiliation(s)
- Maria C De Korte-Verhoef
- Department of Public and Occupational Health & Expertise Center Palliative Care VUmc, EMGO Institute for Health and Care Research, VU University Medical Center (VUmc), Amsterdam, The Netherlands
| | - H Roeline W Pasman
- Department of Public and Occupational Health & Expertise Center Palliative Care VUmc, EMGO Institute for Health and Care Research, VU University Medical Center (VUmc), Amsterdam, The Netherlands
| | - Bart Pm Schweitzer
- Department of General Practice, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Anneke L Francke
- Department of Public and Occupational Health & Expertise Center Palliative Care VUmc, EMGO Institute for Health and Care Research, VU University Medical Center (VUmc), Amsterdam, The Netherlands Netherlands Institute for Health Services Research, NIVEL, Utrecht, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health & Expertise Center Palliative Care VUmc, EMGO Institute for Health and Care Research, VU University Medical Center (VUmc), Amsterdam, The Netherlands
| | - Luc Deliens
- Department of Public and Occupational Health & Expertise Center Palliative Care VUmc, EMGO Institute for Health and Care Research, VU University Medical Center (VUmc), Amsterdam, The Netherlands End-of-life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium
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De Korte-Verhoef MC, Pasman HRW, Schweitzer BPM, Francke AL, Onwuteaka-Philipsen BD, Deliens L. Reasons for hospitalisation at the end of life: differences between cancer and non-cancer patients. Support Care Cancer 2013; 22:645-52. [PMID: 24146344 DOI: 10.1007/s00520-013-2019-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 10/08/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE Many patients are hospitalised during the final phase of life, even though most prefer to receive care at home until the end. This study aimed to explore the reasons and characteristics of hospitalisation in the final 3 months of life for patients who died non-suddenly, with a comparison between cancer patients and non-cancer patients. METHODS This study used a nationwide retrospective cross-sectional survey among Dutch general practitioners. RESULTS Of the 317 hospitalised patients, 65 % had cancer. Most common reasons for hospitalisation in the final 3 months of life were respiratory symptoms (31 %), digestive symptoms (17 %), and cardiovascular symptoms (17 %). Seventy-three percent of patients experienced an acute episode before hospitalisation, and for 46 % of patients, their own GP initiated the hospitalisation. Compared to non-cancer patients, cancer patients were significantly more likely to be aged less than 80 (81 versus 46 %), were more likely to be hospitalised because of digestive symptoms (22 versus 7 %), were less likely to have a curative treatment goal before the last hospitalisation (6 versus 22 %) and were less likely to die in hospital (22 versus 49 %). CONCLUSIONS Respiratory problems were the most common reasons for hospitalisation in the group of patients as a whole. Digestive problems were a frequent reason for hospitalisation in cancer patients and cardiovascular symptoms in non-cancer patients. Hospitalisation can therefore be anticipated by monitoring these relatively common symptoms. Also, timely communication with the patient is recommended about their preferences for hospital or home treatment in the case of an acute episode.
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Affiliation(s)
- Maria C De Korte-Verhoef
- Department of Public and Occupational Health and Expertise Center Palliative Care VUmc, VU University Medical Center (VUmc), EMGO Institute for Health and Care Research, Amsterdam, The Netherlands,
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Aaltonen M, Forma L, Rissanen P, Raitanen J, Jylhä M. Effects of municipality factors on care transitions. Scand J Public Health 2013; 41:604-15. [DOI: 10.1177/1403494813484396] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims: To analyse whether transitions between care settings differ between municipalities in the last 2 years of life among older people in Finland. Methods: Data were derived from Finnish national registers, and include all those who died in 2002 and 2003 at the age of 70 or older except those living in very small municipalities ( n=67,027). Data include admissions and discharges from health and social care facilities (university hospitals, general hospitals, health centres, residential care facilities) and time spent outside care facilities for 730 days prior to death. Three-level negative binomial regression analyses were performed to study the effect of municipal factors on (1) the total number of all care transitions, (2) the number of transitions between home and different care facilities, and (3) transitions between different care facilities. Results: The municipality of residence had only a minor effect on the total number of care transitions, but greater variation between municipalities was found when different types of care transition were examined separately. Largest differences were found in care transitions involving specialised care. Age structure, urbanity, and economic situation of the municipality had an impact on several different care transitions. Conclusion: The total number of care transitions in 2 final years of life was approximately similar irrespective of the municipality of residence, but the findings imply differences in transitioning specialised care. Potentially, this may suggest inequality between the municipalities, but more detailed studies are needed to confirm the factors underlying these differences.
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Affiliation(s)
- Mari Aaltonen
- Gerontology Research Center and School of Health Sciences, University of Tampere, Tampere, Finland
| | - Leena Forma
- Gerontology Research Center and School of Health Sciences, University of Tampere, Tampere, Finland
| | - Pekka Rissanen
- School of Health Sciences, University of Tampere, Tampere, Finland
| | - Jani Raitanen
- School of Health Sciences, University of Tampere, Tampere, Finland
| | - Marja Jylhä
- Gerontology Research Center and School of Health Sciences, University of Tampere, Tampere, Finland
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D’Angelo D, Vellone E, Alvaro R, Chiara M, Casale G, Stefania L, Latina R, Matarese M, De Marinis MG. Transitions between care settings after enrolment in a palliative care service in Italy: a retrospective analysis. Int J Palliat Nurs 2013; 19:110-5. [DOI: 10.12968/ijpn.2013.19.3.110] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | | | | | | | - Roberto Latina
- School of Public Health, La Sapienza University, Rome, Italy
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De Korte-Verhoef MC, Pasman HRW, Schweitzer BPM, Francke AL, Onwuteaka-Philipsen BD, Deliens L. End-of-life hospital referrals by out-of-hours general practitioners: a retrospective chart study. BMC FAMILY PRACTICE 2012; 13:89. [PMID: 22913666 PMCID: PMC3515356 DOI: 10.1186/1471-2296-13-89] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 08/06/2012] [Indexed: 11/22/2022]
Abstract
Background Many patients are transferred from home to hospital during the final phase of life and the majority die in hospital. The aim of the study is to explore hospital referrals of palliative care patients for whom an out-of-hours general practitioner was called. Methods A retrospective descriptive chart study was conducted covering a one-year period (1/Nov/2005 to 1/Nov/2006) in all eight out-of-hours GP co-operatives in the Amsterdam region (Netherlands). All symptoms, sociodemographic and medical characteristics were recorded in 529 charts for palliative care patients. Multivariate logistic regression analysis was performed to identify the variables associated with hospital referrals at the end of life. Results In all, 13% of all palliative care patients for whom an out-of-hours general practitioner was called were referred to hospital. Palliative care patients with cancer (OR 5,1), cardiovascular problems (OR 8,3), digestive problems (OR 2,5) and endocrine, metabolic and nutritional (EMN) problems (OR 2,5) had a significantly higher chance of being referred. Patients receiving professional nursing care (OR 0,2) and patients for whom their own general practitioner had transferred information to the out-of-hours cooperative (OR 0,4) had a significantly lower chance of hospital referral. The most frequent reasons for hospital referral, as noted by the out-of-hours general practitioner, were digestive (30%), EMN (19%) and respiratory (17%) problems. Conclusion Whilst acknowledging that an out-of-hours hospital referral can be the most desirable option in some situations, this study provides suggestions for avoiding undesirable hospital referrals by out-of-hours general practitioners at the end of life. These include anticipating digestive, EMN, respiratory and cardiovascular symptoms in palliative care patients.
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Affiliation(s)
- Maria C De Korte-Verhoef
- VU University medical center, EMGO Institute for Health and Care Research, Department of Public and Occupational Health, Amsterdam, the Netherlands.
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Blum K, Sherman DW. Understanding the experience of caregivers: a focus on transitions. Semin Oncol Nurs 2011; 26:243-58. [PMID: 20971405 DOI: 10.1016/j.soncn.2010.08.005] [Citation(s) in RCA: 111] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To review the current knowledge on the challenges and benefits of informal family caregiving; and propose two conceptual frameworks for studying transitions common to patients with cancer and their family caregivers through the trajectory of the disease process leading to better, more focused, individualized interventions; DATA SOURCES A review of current and classic literature on patients with cancer and their caregivers. CONCLUSION Caregivers often take on burdens that they are not prepared for. As they become overwhelmed with the work, they often neglect themselves, leading to physical and emotional illnesses. Not all caregivers perceive the same amount of burden. Careful assessment of each caregiver/cared-for dyad to individualize their support is critical to supporting them along the journey of a cancer diagnosis. IMPLICATIONS FOR NURSING PRACTICE Operationalizing conceptual frameworks can accelerate nurses' understanding of patient and caregiver transitions, leading to more focused interventions and allocation of resources to assist them in these transitions.
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Affiliation(s)
- Kay Blum
- Department of Organizational Systems and Adult Health, University of Maryland School of Nursing, Baltimore, MD, USA.
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Duggleby WD, Penz KL, Goodridge DM, Wilson DM, Leipert BD, Berry PH, Keall SR, Justice CJ. The transition experience of rural older persons with advanced cancer and their families: a grounded theory study. BMC Palliat Care 2010; 9:5. [PMID: 20420698 PMCID: PMC2876144 DOI: 10.1186/1472-684x-9-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Accepted: 04/26/2010] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Transitions often occur suddenly and can be traumatic to both patients with advanced disease and their families. The purpose of this study was to explore the transition experience of older rural persons with advanced cancer and their families from the perspective of palliative home care patients, bereaved family caregivers, and health care professionals. The specific aims were to: (1) describe the experience of significant transitions experienced by older rural persons who were receiving palliative home care and their families and (2) develop a substantive theory of transitions in this population. METHODS Using a grounded theory approach, 27 open-ended individual audio-taped interviews were conducted with six older rural persons with advanced cancer and 10 bereaved family caregivers. Four focus group interviews were conducted with 12 palliative care health care professionals. All interviews were transcribed verbatim, coded, and analyzed using Charmaz's constructivist grounded theory approach. RESULTS Within a rural context of isolation, lack of information and limited accessibility to services, and values of individuality and community connectedness, older rural palliative patients and their families experienced multiple complex transitions in environment, roles/relationships, activities of daily living, and physical and mental health. Transitions disrupted the lives of palliative patients and their caregivers, resulting in distress and uncertainty. Rural palliative patients and their families adapted to transitions through the processes of "Navigating Unknown Waters". This tentative theory includes processes of coming to terms with their situation, connecting, and redefining normal. Timely communication, provision of information and support networks facilitated the processes. CONCLUSION The emerging theory provides a foundation for future research. Significant transitions identified in this study may serve as a focus for improving delivery of palliative and end of life care in rural areas. Improved understanding of the transitions experienced by advanced cancer palliative care patients and their families, as well as the psychological processes involved in adapting to the transitions, will help health care providers address the unique needs of this vulnerable population.
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Affiliation(s)
- Wendy D Duggleby
- Faculty of Nursing, University of Alberta, 3rd floor Clinical Sciences Building, Edmonton Alberta, T6G 2G3, Canada
| | - Kelly L Penz
- Nursing Division, Saskatchewan Institute of Applied Science and Technology, 4500 Wascana Parkway, Regina Saskatchewan, S4P 3A3, Canada
| | - Donna M Goodridge
- College of Nursing, University of Saskatchewan, Health Sciences Building, 107 Wiggins Road, Saskatoon, Saskatchewan, S7N 5E5, Canada
| | - Donna M Wilson
- Faculty of Nursing, University of Alberta, 3rd floor Clinical Sciences Building, Edmonton Alberta, T6G 2G3, Canada
| | - Beverly D Leipert
- School of Nursing, University of Western Ontario, Health Sciences Addition, London, Ontario, N6A 5C1, Canada
| | - Patricia H Berry
- Hartford Center of Geriatric Nursing Excellence, College of Nursing, University of Utah, 10 South 2000 East Front, Salt Lake City, 84112-5880, USA
| | - Sylvia R Keall
- Five Hills Health Region, 1000 Albert Street, Moose Jaw, Saskatchewan, S6H 2Y2, Canada
| | - Christopher J Justice
- Department of Anthropology University of Victoria, 3800 Finnerty Road Victoria British Columbia V8W 3P5, Canada
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Abarshi E, Echteld M, Van den Block L, Donker G, Deliens L, Onwuteaka-Philipsen B. Transitions between care settings at the end of life in the Netherlands: results from a nationwide study. Palliat Med 2010; 24:166-74. [PMID: 20007818 DOI: 10.1177/0269216309351381] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Multiple transitions between care settings in the last phase of life could jeopardize continuity of care and overall end-of-life patient care. Using a mortality follow-back study, we examined the nature and prevalence of transitions between Dutch care settings in the last 3 months of life, and identified potential characteristics associated with them. During the 2-year study period, 690 registered patients died 'totally expectedly and non-suddenly'. These made 709 transitions in the last 3 months, which involved a hospital two times out of three, and covered 43 distinct care trajectories. The most frequent trajectory was home-to-hospital (48%). Forty-six percent experienced one or more transitions in their last month of life. Male gender, multi-morbidities, and absence of GP awareness of a patient's wish for place of death were associated with having a transition in the last 30 days of life; age of < or = 85 years, having an infection and the absence of a palliative-centred treatment goal were associated with terminal hospitalization for > or = 7 days. Although the majority of the 'totally expected and non-sudden' deaths occurred at home, transitions to hospitals were relatively frequent. To minimize abrupt or frequent transitions just before death, timely recognition of the palliative phase of dying is important.
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Affiliation(s)
- Ebun Abarshi
- Department of Public and Occupational Care, The EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
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O'Leary N, Murphy NF, O'Loughlin C, Tiernan E, McDonald K. A comparative study of the palliative care needs of heart failure and cancer patients. Eur J Heart Fail 2009; 11:406-12. [PMID: 19196753 DOI: 10.1093/eurjhf/hfp007] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS Studies suggest that patients with advanced heart failure (HF) have unmet palliative care (PC) needs. However, many of these studies have been retrospective or based on patients receiving poorly coordinated ad hoc care. We aimed to demonstrate whether the PC needs of patients with advanced HF receiving specialist multidisciplinary coordinated care are similar to cancer patients deemed to have specialist PC needs; thereby justifying the extension of specialist PC services to HF patients. METHODS AND RESULTS This was a cross-sectional comparative cohort study of 50 HF patients and 50 cancer patients, using quantitative and qualitative methods. Both patient cohorts were statistically indistinguishable in terms of symptom burden, emotional wellbeing, and quality-of-life scores. HF patients had good access to community and social support. HF patients particularly valued the close supervision, medication monitoring, ease of access to service, telephone support, and key worker provided at the HF unit. A small subset of patients had unmet PC needs. A palliative transition point is described. CONCLUSION HF patients should not be excluded from specialist PC services. However, the majority of their needs can be met at a HF unit. Recognition of the palliative transition point may be key to ensuring that end-of-life issues are addressed. The palliative transition point needs further evaluation.
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Affiliation(s)
- Norma O'Leary
- Department of Palliative Medicine, St Vincent's University Hospital, Dublin, Ireland.
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Lawson BJ, Burge FI, Mcintyre P, Field S, Maxwell D. Palliative care patients in the emergency department. J Palliat Care 2008; 24:247-255. [PMID: 19227016 PMCID: PMC4894814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Although end-of-life care is not a primary function of the emergency department (ED), in reality, many access this department in the later stages of illness. In this study, ED use by patients registered with the Capital Health Integrated Palliative Care Service (CHIPCS) is examined and CHIPCS patient characteristics associated with ED use identified. Overall, 27% of patients made at least one ED visit while registered with CHIPCS; 54% of these resulted in a hospital admission. ED visiting was not associated with time of day or day of the week. Multivariate logistic regression results suggest older patients were significantly less likely to make an ED visit. Making an ED visit was associated with hospital death, rural residence (particularly for women), and having a parent or relative other than a spouse or child as the primary caregiver. Further research may suggest strategies to reduce unnecessary ED visits during the end of life.
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Abstract
As options for systemic therapy for cancer continue to expand and median survival for many solid tumors lengthens, the divisions between active oncologic and palliative care continue to blur. Despite the well-recognized need to integrate palliative support for those with metastatic cancer, data on best practices facilitating the transition from active oncologic to active palliative care are lacking. Recent evidence outlining evolving issues surrounding this transition in care is reviewed, emphasizing the need for rigorous research efforts to define best practices and interventions.
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Affiliation(s)
- Daniel Rayson
- Division of Medical Oncology, Queen Elizabeth II Health Sciences Centre, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada B3H 2Y9.
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