Predictors of place of death for seniors in Ontario: a population-based cohort analysis

Exploring perceptions of online calculators for identifying community-dwelling older people at risk of dying: A qualitative study

Objectives

This study aimed to assess the acceptability, value, and perceived barriers of using electronic risk calculators for predicting and communicating the risk of death in community-dwelling older adults.

Methods

One focus group and eight interviews were conducted with 16 participants with experience caring for patients or family members at end of life. A prototype mortality risk tool was used to anchor discussions. Data were analysed using a qualitative content analysis approach.

Results

Five themes emerged: acceptability, communication, barriers to use, broadening the circle of care, and tool limitations. Participants found the tool helpful for preparation, planning, and providing care, but disagreed on its community availability. Personalized risk estimates were valued for facilitating early goals of care conversations and normalizing discussions about death. However, concerns were raised about the tool's interpretation for individuals with different language, cultural, or educational backgrounds.

Conclusions

While electronic risk calculators were found to be acceptable, balancing autonomy with varying preferences for receiving the information and potential need for support is crucial.

Innovation

Providing patient-oriented life-expectancy estimates can enhance decisional capacity and facilitate shared decision-making between patients, their families, and healthcare professionals. Further research is needed to explore effective communication of personalized risk tools and additional benefits, harms, and barriers to implementation.

Changes in End-of-Life Symptom Management Prescribing among Long-Term Care Residents during COVID-19

OBJECTIVE

To examine changes in the prescribing of end-of-life symptom management medications in long-term care (LTC) homes during the COVID-19 pandemic.

DESIGN

Retrospective cohort study using routinely collected health administrative data in Ontario, Canada.

SETTING AND PARTICIPANTS

We included all individuals who died in LTC homes between January 1, 2017, and March 31, 2021. We separated the study into 2 periods: before COVID-19 (January 1, 2017, to March 17, 2020) and during COVID-19 (March 18, 2020, to March 31, 2021).

METHODS

For each LTC home, we measured the percentage of residents who died before and during COVID-19 who had a subcutaneous symptom management medication prescription in their last 14 days of life. We grouped LTC homes into quintiles based on their mean prescribing rates before COVID-19, and examined changes in prescribing during COVID-19 and COVID-19 outcomes across quintiles.

RESULTS

We captured 75,438 LTC residents who died in Ontario's 626 LTC homes during the entire study period, with 19,522 (25.9%) dying during COVID-19. The mean prescribing rate during COVID-19 ranged from 46.9% to 79.4% between the lowest and highest prescribing quintiles. During COVID-19, the mean prescribing rate in the lowest prescribing quintile increased by 9.6% compared to before COVID-19. Compared to LTC homes in the highest prescribing quintile, homes in the lowest prescribing quintile experienced the highest proportion of COVID-19 outbreaks (73.4% vs 50.0%), the largest mean outbreak intensity (0.27 vs 0.09 cases/bed), the highest mean total days with a COVID-19 outbreak (72.7 vs 24.2 days), and the greatest proportion of decedents who were transferred and died outside of LTC (22.1% vs 8.6%).

CONCLUSIONS AND IMPLICATIONS

LTC homes in Ontario had wide variations in the prescribing rates of end-of-life symptom management medications before and during COVID-19. Homes in the lower prescribing quintiles had more COVID-19 cases per bed and days spent in an outbreak.

[What are the effects of different places of death of old people?]

Background

Inadequate quality of medical postmortem examinations has been discussed in the forensic medical literature for many years. It is known that older deceased persons are less likely to have a non-natural cause of death certified and autopsies are performed less frequently compared to younger deceased persons.

Methods

Death certificates of all deaths that occurred in Munich with an age of ≥ 75 years during the death period 01/01/2013-31/12/2014 were analyzed. Standardized, anonymized data entry was performed. The collected data were analyzed descriptively.

Results

A total of 26,303 persons died during the study period. Of these deaths, 16,146 (60.7%) were ≥ 75 years. Most common places of death for the aged were hospital (56.1%), private address (21.8%), and nursing home (20.0%). A natural mode of death was reported in 88.5%, unexplained in 8.8%, and non-natural in 2.7%. Most common immediate causes of death were diseases of the circulatory system (23.5%), inaccurately designated or unknown causes of death (20.0%), and diseases of the respiratory system (16.3%). Autopsies were performed on 4.9%, largely judicial. The parameters studied showed large differences in the analyses depending on the place of death.

Discussion

This study again shows considerable quality deficiencies in the issuance of death certificates. Despite the dual approach of the Munich health authority (control, training), the quality of death certificates could not be sustainably improved in recent years. Types and causes of death showed partly considerable differences depending on the place of death and the doctor who issued the certificate. The deficits identified in the information provided under the heading "Causes of death" are also likely to have a negative impact on the cause of death statistics.

Preferred place of death and end-of-life care for adult cancer patients in Iran: A cross-sectional study

Background

More than 50,000 deaths in terms of cancer occur annually in Iranian hospitals. Determining the preferred place of end-of-life care and death for cancer patients in Iran is a quality marker for good end-of-life care and good death. The purpose of this study was to determine the preferred place of end-of-life care and death in cancer patients.

Method

In 2021, the current descriptive cross-sectional investigation was carried out. Using the convenience sample approach, patients were chosen from three Tehran referral hospitals (the capital of Iran). A researcher-made questionnaire with three parts for demographic data, clinical features, and two questions on the choice of the desired location for end-of-life care and the death of cancer patients served as the data collecting instrument. Data were analyzed using SPSS software version 18. The relationship between the two variables preferred place for end-of-life care and death and other variables was investigated using chi-square, Fisher exact test, and multiple logistic regression.

Result

The mean age of patients participating in the study was 50.21 ± 13.91. Three hundred ninety (69.6%) of the patients chose home, and 170 (30.4%) patients chose the hospital as the preferred place of end-of-life care. Choosing the home as a preferred place for end-of-life care had a significant relationship with type of care (OR = .613 [95% CI: 0.383–0.982], P = .042), level of education (OR = 2.61 [95% CI: 1.29–5.24], P = 0.007), type of cancer (OR = 1.70 [1.01–2.89], P = .049), and income level (Mediate: (OR: 3.27 (1.49, 7.14), P = .003) and Low: (OR: 3.38 (1.52–7.52), P = .003). Also, 415 (75.2%) patients chose home and 137 (24.8%) patients chose hospital as their preferred place of death. Choosing the home as a preferred place of death had a significant relationship with marriage (OR = 1.62 [95% CI: 1.02–2.57], P = .039) and time to diagnostic disease less than 6 months (OR = 1.62 [95% CI: 0.265–0.765], P = .002).

Conclusion

The findings of the current research indicate that the majority of cancer patients selected their homes as the preferred location for end-of-life care and final disposition. Researchers advise paying more attention to patients’ wishes near the end of life in light of the findings of the current study. This will be achieved by strengthening the home care system using creating appropriate infrastructure, insurance coverage, designing executive instructions, and integration of palliative care in home care services.

[COVID-19 deaths among residents of inpatient nursing homes in Munich-causes and places of death]

INTRODUCTION

The new infectious disease COVID-19 first appeared in China in December 2019. So far, a systematic evaluation of death certificates of COVID-19-associated deaths of residents in inpatient nursing homes has not been presented.

METHODS

Death certificates of all deaths in Munich in the death period from 1 March to 31 July 2020 were analyzed. Inclusion criteria were the presence of "Corona, COVID-19, SARS-CoV-2" on the death certificates. Standardized, anonymized data entry was performed. The collected data were analyzed descriptively.

RESULTS

During the study period, a total of 5840 persons died, 281 (4.8%) of whom died of confirmed COVID-19 disease. Of those, 72 deaths involved residents of Munich nursing facilities. The most frequent causes of death were respiratory insufficiency (54 cases) and multiple organ failure (9 cases). On the death certificates, an average of two preexisting diseases had been reported; the average age at death was 88 years. All deaths of nursing home residents occurred in association with nosocomial COVID-19 outbreaks, which affected one-third of the facilities. The vast majority of these homes did not have a COVID-19 hygiene plan in place at the time.

DISCUSSION

One quarter of all COVID-19 deaths in Munich occurred in the context of nosocomial outbreaks in elderly, chronically ill residents of nursing facilities. Evidence of inadequate risk assessment and inadequate hygiene management emerged. In the opinion of the authors, the appropriate structures for adequate hygiene management must be created and a hygiene regulation must be issued in which the tasks and responsibilities of the facility operators are defined.

[COVID-19- and influenza-associated deaths in Munich as of March 2020-a standardized analysis of death certificates]

INTRODUCTION

In light of the current COVID-19 pandemic, the idea arose to conduct a study to comparatively evaluate deaths from two respiratory transmissible infectious diseases (pandemic COVID-19 and seasonal influenza) by means of death certificates received by the health department.

METHODS

Death certificates of all deaths in Munich in the death period from 1 March-31 December 2020 were analyzed. The predefined inclusion criteria were the indication of "Corona, COVID-19, SARS-CoV‑2, Influenza (A/B)" on the death certificates. Standardized data entry was performed. The collected data were analyzed descriptively in aggregated form.

RESULTS

A total of 12,441 persons died during the study period, 1029 (8.3%) from confirmed COVID-19 and 22 (0.1%) from influenza. The two collectives matched well in the parameters studied. The mean age at death was approximately 80 years and the most common site of death was in hospital. Infectious disease was the cause of death in more than 90% of cases. The most common causes of death were acute respiratory distress syndrome/respiratory failure and multiorgan failure. An average of two previous illnesses were reported, most commonly diseases of the circulatory system and nervous system. There was no influenza death in the second pandemic wave.

DISCUSSION

In this study, COVID-19- and influenza-associated deaths were compared for the first time. The deaths of both collectives matched well in the parameters studied, but still require verification in a larger study given the small numbers of influenza cases. An English full-text version of this article is available at SpringerLink as Supplementary Information.

[COVID-19-associated deaths]

INTRODUCTION

In December 2019, the new infectious coronavirus disease 2019 (COVID-19) first appeared in China. So far, no systematic evaluation of death certificates of COVID-19-associated deaths has been presented.

METHODS

The death certificates of all deaths in Munich during the period from 1 March to 31 July 2020 were analyzed. The previously defined inclusion criteria were the indication of corona, COVID-19 and SARS-CoV‑2 in the death certificates. The variables were entered anonymously according to a developed key. The collected data were evaluated descriptively.

RESULTS

In the period under investigation, a total of 5840 people died in the Munich City area. Of these deaths 332 (5.7%) were COVID-19-associated. In 281 deaths (84.6%) there was a definite COVID-19 and in 51 deaths (15.4%) the suspicion of this disease. The most frequent causes of death were acute respiratory distress syndrome or respiratory insufficiency (59.1%), multiple organ failure (21.4%) and sepsis (10%). An average of 1.8 pre-existing illnesses were reported in the death certificates. Most frequently mentioned were diseases of the circulatory system (54.8%), the nervous system (22.8%) and metabolic diseases (18.9%). The average age at death was 79 years and the most frequent place of death was a hospital (85%). An autopsy was attempted by the doctors who issued the death certificates for 18.1% of the collective, most frequently in the case of unexplained or unnatural causes of death and young age of the deceased. Clinical pathological autopsies were performed on 11% of the collective and judicial autopsies on 1%.

DISCUSSION

This study is the first evaluation of death certificates with respect to the novel infectious COVID-19. Number and essential characteristics of COVID-19-associated deaths in Munich during the so-called first wave could be mapped. The interest of physicians in autopsies was rather low despite the appearance of a new infectious disease.

The use of laboratory-identified event surveillance to classify adverse outcomes due to Clostridioides difficile infection in Canadian long-term care facilities

OBJECTIVE

Adverse outcomes following Clostridioides difficile infection (CDI) are not often reported for long-term care facility (LTCF) residents. We focused on the adverse outcomes due to CDI identified in Alberta LTCFs.

METHODS

All positive Clostridioides difficile stool specimens identified by laboratory-identified (LabID) event surveillance in Alberta from 2011 to 2018, along with Alberta Continuing Care Information System, were used to define CDI in Alberta LTCFs. CDI cases were classified as long-term care onset, hospital onset, and community onset. Laboratory records were linked to provincial databases to analyze acute-care admissions and mortality within 30-day post CDI. Age, sex, case classification, episode, and operator type, were investigated using logistic regression.

RESULTS

Overall, 902 CDI cases were identified in 762 LTCF residents. Of all CDI events, 860 (95.3%) were long-term care onset, 38 (4.2%) were hospital onset, and 4 (0.4%) were community onset. The CDI rate was 2.0 of 100,000 resident days. In total, 157 residents (20.6%) had 30-day all-cause mortality, 126 CDI cases (14.0%) had 30-day all-cause acute-care admissions. The 30-day all-cause mortality rate was significantly higher in residents aged >80 versus ≤80 years (24.9 vs 12.3 per 100 residents; P < .05). Residents aged >80 years, with hospital-onset CDI, and those staying in private or voluntary LTCFs were more likely to have 30-day all-cause acute-care admissions.

CONCLUSIONS

The prevalence of CDI adverse outcomes is in LTCFs was found to be high using LabID event surveillance. Annual review of CDI adverse outcomes using LabID event can minimize the burden of surveillance and standardize the process across all Alberta LTCFs.

Temporal trends in place of death for end-of-life patients: Evidence from Toronto, Canada

Understanding the temporal trends in the place of death among patients in receipt of home-based palliative care can help direct health policies and planning of health resources. This paper aims to assess the temporal trends in place of death and its determinants over the past decade for patients receiving home-based palliative care. This paper also examines the impact of early referral to home-based palliative care services on patient's place of death. Survey data collected in a home-based end-of-life care program in Toronto, Canada from 2005 to 2015 were analysed using a multivariate logistic model. The results suggest that the place of death for patients in receipt of home-based palliative care has changed over time, with more patients dying at home over 2006-2015 when compared to 2005. Also, early referral to home-based palliative care services may not increase a patient's likelihood of home death. Understanding the temporal shifts of place of death and the associated factors is essential for effective improvements in home-based palliative care programs and the development of end-of-life care policies.

The Impact of Socioeconomic Status on Place of Death Among Patients Receiving Home Palliative Care in Toronto, Canada: A Retrospective Cohort Study

BACKGROUND

Socioeconomic disparities in home death have been noted in the literature. Home-based palliative care increases access to home death and has been suggested as a means to decrease these disparities.

AIM

Our study examines the association between socioeconomic status and other demographic factors on place of death in a population receiving home palliative care in Toronto, Canada.

DESIGN

This is a retrospective chart review of patients who died between August 2013 and August 2015 when admitted to a home-based palliative care service. Multivariate multinomial regression examined the relationship between the place of death (home, palliative care unit [PCU], or acute care) with age, gender, primary diagnosis, and income quintile. Bivariate logistic regression was fitted to calculate the odds ratio (OR) and probability of preference for home death.

SETTING/PARTICIPANTS

Patients receiving home-based palliative care services from the Latner Centre for Palliative Care in Toronto, Canada.

RESULTS

A total of 2066 patients were included in multivariate analysis. Patients in the lowest income quintile had increased odds of dying in acute care (OR = 2.41, P < .001) or dying in PCU (OR = 1.64, P = .008) than patients in highest income quintile. Patients in the next lowest income quintiles 2 and 3 were also more likely to die in acute care. The rate of preference for home death was significantly lower in the lowest income quintile (OR = 0.47, P = .0047).

CONCLUSIONS

Patients in lower income quintiles are less likely to die at home, despite receiving home-based palliative care, although they may also be less likely to prefer home death.

How End-Of-Life Home Care Services Are Used from Admission to Death: A Population-Based Cohort Study

Aim: Our goal was to describe the trajectories of end-of-life nursing and personal support worker (PSW) use from home care admission until death. Methods: We studied a historical prospective cohort of end-of-life home care patients in Ontario, Canada, linking administrative databases. We calculated the odds of using any nursing or PSW hours and the incidence rate ratio of services used for each week approaching death, controlling for confounders. Results: Among all patients (n=11,867), the odds of using any nursing and PSW hours increased by 4 percent and 10 percent, respectively, each week closer to death. Among patients using services, the ratio of nursing and PSW hours increased 20 percent and 11 percent, respectively, in the last 4 weeks of life compared to use at 24 weeks before death. Conclusion: Use of nursing and PSW hours increases slightly each week before death and sharply in the last month of life. Understanding the trajectory of home care services use can help decision makers design better end-of-life care.

Determinants of Home Death in Patients With Cancer: A Population-Based Study in Ontario, Canada

AIM

To determine factors associated with home death in patients with cancer in Ontario, particularly to assess the association between death at home and (1) patients' rural/urban residence and (2) neighborhood income in urban areas.

MATERIALS AND METHODS

We conducted a retrospective cross-sectional study in Ontario (2003-2010) using linked administrative databases. In order to account for clustering phenomenon, multivariable generalized estimating equation model was used to evaluate factors associated with home death. Analysis was performed in both rural and urban areas. For urban areas, neighborhood income was tested as a determinant of the place of death.

RESULTS

A total of 193 783 deaths were analyzed, 9.1% of which occurred at home. In urban areas, home death was more likely for patients living in richer neighborhoods (odds ratio 1.69 for the highest compared to lowest neighborhood income quintile, 95% confidence interval: 1.54-1.86). The odds of dying at home when living in a rural area were no different from those living in the poorest urban neighborhood. Other variables associated with lower odds of home death were comorbidity index, certain cancers, and year of death.

CONCLUSION

The likelihood of dying at home significantly increases with living in higher-income urban neighborhoods and decreases with rural residence. Urban neighborhoods with lowest income have odds of home death similar to rural areas. These findings underline the importance of targeting proper populations for public support at the end of life.

The interaction of socioeconomic status with place of death: a qualitative analysis of physician experiences

Background

Home is a preferred place of death for many people; however, access to a home death may not be equitable. The impact of socioeconomic status on one’s ability to die at home has been documented, yet there remains little literature exploring mechanisms that contribute to this disparity. By exploring the experiences and insights of physicians who provide end-of-life care in the home, this study aims to identify the factors perceived to influence patients’ likelihood of home death and describe the mechanisms by which they interact with socioeconomic status.

Methods

In this exploratory qualitative study, we conducted interviews with 9 physicians who provide home-based care at a specialized palliative care centre. Participants were asked about their experiences caring for patients at the end of life, focusing on factors believed to impact likelihood of home death with an emphasis on socioeconomic status, and opportunities for intervention. We relied on participants’ perceptions of SES, rather than objective measures. We used an inductive content analysis to identify and describe factors that physicians perceive to influence a patient’s likelihood of dying at home.

Results

Factors identified by physicians were organized into three categories: patient characteristics, physical environment and support network. Patient preference for home death was seen as a necessary factor. If this was established, participants suggested that having a strong support network to supplement professional care was critical to achieving home death. Finally, safe and sustainable housing were also felt to improve likelihood of home death. Higher SES was perceived to increase the likelihood of a desired home death by affording access to more resources within each of the categories. This included better health and health care understanding, a higher capacity for advocacy, a more stable home environment, and more caregiver support.

Conclusions

SES was not perceived to be an isolated factor impacting likelihood of home death, but rather a means to address shortfalls in the three identified categories. Identifying the factors that influence ability is the first step in ensuring home death is accessible to all patients who desire it, regardless of socioeconomic status.

Factors promoting resident deaths at aged care facilities in Japan: a review

Due to an increasingly ageing population, the Japanese government has promoted elderly deaths in aged care facilities. However, existing facilities were not designed to provide resident end-of-life care and the proportion of aged care facility deaths is currently less than 10%. Consequently, the present review evaluated the factors that promote aged care facility resident deaths in Japan from individual- and facility-level perspectives to exploring factors associated with increased resident deaths. To achieve this, MEDLINE, CINAHL, Web of Science and Ichushi databases were searched on 23 January 2016. Influential factors were reviewed for two healthcare services (insourcing and outsourcing facilities) as well as external healthcare agencies operating outside facilities. Of the original 2324 studies retrieved, 42 were included in analysis. Of these studies, five focused on insourcing, two on outsourcing, seven on external agencies and observed facility/agency-level factors. The other 28 studies identified individual-level factors related to death in aged care facilities. The present review found that at both facility and individual levels, in-facility resident deaths were associated with healthcare service provision, confirmation of resident/family end-of-life care preference and staff education. Additionally, while outsourcing facilities did not require employment of physicians/nursing staff to accommodate resident death, these facilities required visits by physicians and nursing staff from external healthcare agencies as well as residents' healthcare input. This review also found few studies examining outsourcing facilities. The number of healthcare outsourcing facilities is rapidly increasing as a result of the Japanese government's new tax incentives. Consequently, there may be an increase in elderly deaths in outsourcing healthcare facilities. Accordingly, it is necessary to identify the factors associated with residents' deaths at outsourcing facilities.

Socioeconomic Differences and Trends in the Place of Death among Elderly People in China

China is facing a dramatic aging of its population. Little is known about the factors that influence the place of death and the trends in the place of death for elderly people in China. The purposes of this study were: (1) to examine the impact of the socioeconomic status (SES) on place of death for elderly Chinese residents; and (2) to assess temporal trends in the place of death over the last 15 years. Data were derived from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) (1998–2012). Place-of-death as an outcome was dichotomized into either death at home or death outside the home. Logistic regression analyses were used to examine the impact of SES on place of death. The results showed that, of the 23,098 deaths during the study period, 87.78% occurred at home. The overall trend in home death has increased since 2005. SES was shown to be an important factor affecting place of death. The elderly with higher SES were more likely to die where health resources were concentrated, i.e., in a hospital or other type of institution. Our finding suggests that the trend towards a greater emphasis on death at home may call for the development of more supportive home care programs in China. Our finding also suggests that the socioeconomic differences in the place of death may be related to the availability of or access to health care services.

End-of-life care bonus promoting end-of-life care in nursing homes: An 11-year retrospective longitudinal prefecture-wide study in Japan

The end-of-life (EOL) care bonus introduced by the Japanese government works as a financial incentive and framework of quality preservation, including advance care planning, for EOL care among nursing home residents. This study aims to clarify the effects of the EOL care bonus in promoting EOL care in nursing homes. A longitudinal observational study using a questionnaire was conducted. We invited 378 nursing homes in Kanagawa prefecture in Japan, a region with a rapidly aging population, to participate in the study. The outcome was the number of residents dying in nursing homes from 2004 to 2014. In a linear mixed model, fixed-effect factors included year established, unit care, regional elderly population rate and hospital beds, adjacent affiliated hospital, full-time physician on site, physician's support during off-time, basic EOL care policy, usage of the EOL care bonus, EOL care conference, and staff experience of EOL care. A total of 237 nursing home facilities responded (62.7%). The linear mixed model showed that the availability of the EOL care bonus (coefficient 3.1, 95 % CI 0.67-5.51, p = 0.012) and years of usage of the EOL care bonus (p < 0.001) were significantly associated with increased numbers of residents dying in nursing homes. Our analysis revealed that the EOL care bonus has the potential to increase the number of residents receiving EOL care in nursing homes over several years. EOL care conferences, physician support for emergency care during off-time, and the presence of an adjacent affiliated hospital may also increase the number of residents receiving EOL care in nursing homes. These results suggest that a government financial incentive may contribute to effective EOL care among nursing home residents in other developed countries with rapidly aging populations.

"When I Said I Wanted to Die at Home I Didn't Mean a Nursing Home": Care Trajectories at the End of Life

Background and Objectives

Little is known regarding the care trajectories older adults experience at the end of life (EOL). We drew on a structural/institutional life course perspective to examine the trajectories evident among older adults transitioning through the Canadian formal long-term care system. The sequence of care transitions as well as the impact of social location, social and economic resources, and health-related factors on these trajectories were examined.

Research Design and Methods

To identify EOL care trajectories, we used administrative data collected on older adults (aged 65+) who received publicly subsidized long-term care services (e.g., nursing home and home and community-based care) in one health region in British Columbia, Canada from January 1, 2008 through December 31, 2011 and who died by March 31, 2012 (n = 11,816). Multinomial logistic regression analyses assessed the impact of selected covariates on these trajectories.

Results

The majority of those studied (65.4%) died outside of acute hospital settings. The most common trajectories involved transitions from home care to nursing home/residential care to non-hospital death (39.5%) and transitions from in-home care to hospital death (22.4%). These and other trajectories were shaped by social structural factors, access to social and economic resources, as well as health status and prior hospitalizations.

Discussion and Implications

Despite calls for minimizing hospital-based deaths and maximizing home-based deaths, older LTC recipients often experience EOL care trajectories that end in death in a nursing home care setting. Our findings point to the value of a structural/institutional life course perspective in informing an understanding of who experiences this and other major EOL care trajectories. In doing so, they also provide direction for policy and practice designed to address inequalities and enhance the quality of EOL care.

Factors associated with hospital deaths in the oldest old: a cross-sectional study

AIMS/OBJECTIVES

to study associations between the likelihood of hospital death with patient demographics, cause of death and co-morbidities for people aged ≥85 at death who have been previously admitted (within 12 months of death) to hospital.

METHODS

a cross-sectional study, using death registration data and hospital episode statistics, for 671,178 England residents who had been admitted to hospital during the 12 months before death and were aged 85 or over at death during 2008-12. The outcome variable was the likelihood of dying in hospital. Covariates included gender, age, social deprivation, care home residence, cause of death and co-morbidity. Potential associations were explored by multivariable regression analysis.

RESULTS

sixty-two per cent of the sample died in hospital. The likelihood of dying in hospital varies significantly with age, cause of death, deprivation, number of emergency hospital and co-morbidities. People aged over 90 at the time of death are less likely to die in hospital than those aged 85-89 [odds ratio (OR) for aged 90-94, 0.99; 95% confidence interval (CI) 0.98-1.00, OR for aged 95 and over, 0.91; 95% CI: 0.89-0.92]. People who are care home residents at the time of death are significantly less likely to die in hospital (OR 0.34; 95% CI: 0.34-0.35). Having a mention of dementia on the death certificate was significantly associated with a reduction in the likelihood of dying in hospital (OR 0.32; 95% CI: 0.31-0.32).

CONCLUSIONS

the likelihood of an older person dying in hospital is significantly associated with a number of socio-demographic factors, such as age and level of deprivation. Care home residence is significantly associated with a reduction in likelihood of hospital death.

The determinants of home and nursing home death: a systematic review and meta-analysis

Background

Most Canadians die in hospital, and yet, many express a preference to die at home. Place of death is the result of the interaction among sociodemographic, illness- and healthcare-related factors. Although home death is sometimes considered a potential indicator of end-of-life/palliative care quality, some determinants of place of death are more modifiable than others. The objective of this systematic review was to evaluate the determinants of home and nursing home death in adult patients diagnosed with an advanced, life-limiting illness.

Methods

A systematic literature search was performed for studies in English published from January 1, 2004 to September 24, 2013 that evaluated the determinants of home or nursing home death compared to hospital death in adult patients with an advanced, life-limiting condition. The adjusted odds ratios, relative risks, and 95 % confidence intervals of each determinant were extracted from the studies. Meta-analyses were performed if appropriate. The quality of individual studies was assessed using the Newcastle-Ottawa scale and the body of evidence was assessed according to the GRADE Working Group criteria.

Results

Of the 5,900 citations identified, 26 retrospective cohort studies were eligible. The risk of bias in the studies identified was considered low. Factors associated with an increased likelihood of home versus hospital death included multidisciplinary home palliative care, preference for home death, cancer as opposed to other diagnoses, early referral to palliative care, not living alone, having a caregiver, and the caregiver’s coping skills.

Conclusions

Knowledge about the determinants of place of death can be used to inform care planning between healthcare providers, patients and family members regarding the feasibility of dying in the preferred location and may help explain the incongruence between preferred and actual place of death.

Modifiable factors such as early referral to palliative care, presence of a multidisciplinary home palliative care team were identified, which may be amenable to interventions that improve the likelihood of a patient dying in the preferred location. Place of death may not be a very good indicator of the quality of end-of-life/palliative care since it is determined by multiple factors and is therefore dependent on individual circumstances.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-016-0077-8) contains supplementary material, which is available to authorized users.

The association between individual income and aggressive end-of-life treatment in older cancer decedents in Taiwan

OBJECTIVES

To examine the association of individual income and end of life (EOL) care in older cancer decedents in Taiwan.

DESIGN

Retrospective cohort study.

SETTING

National Health Insurance Research Database (NHIRD) in Taiwan.

PARTICIPANTS

28,978 decedents >65 years were diagnosed with cancer and died during 2009-2011 in Taiwan. Of these decedents, 10941, 16535, and 1502 were categorized by individual income as having low, moderate, and high SES, respectively.

MAIN OUTCOME MEASURES

Indicators of aggressiveness of EOL care: chemotherapy use before EOL, more than one emergency department (ER) visit, more than one hospital admission, hospital length of stay >14 days, intensive care unit (ICU) admission, and dying in a hospital.

RESULTS

Low individual income was associated with more aggressive EOL treatment (estimate -0.30 for moderate income, -0.27 for high income, both p<0.01). The major source of aggressiveness was the tendency for older decedents with low income to die in the acute care hospital. The indicators had an increasing trend from 2009 to 2011, except for hospital stay >14 days.

CONCLUSIONS

Low individual income is associated with more aggressive EOL treatment in older cancer decedents. Public health providers should make available appropriate education and hospice resources to these decedents and their families, to reduce the amount of aggressive terminal care such decedents receive.

Co-trimoxazole and sudden death in patients receiving inhibitors of renin-angiotensin system: population based study

OBJECTIVE

To determine whether the prescription of co-trimoxazole with an angiotensin converting enzyme inhibitor or angiotensin receptor blocker is associated with sudden death.

DESIGN

Population based nested case-control study.

SETTING

Ontario, Canada, from 1 April 1994 to 1 January 2012.

PARTICIPANTS

Ontario residents aged 66 years or older treated with an angiotensin converting enzyme inhibitor or angiotensin receptor blocker. Cases were those who died suddenly shortly after receiving an outpatient prescription for one of co-trimoxazole, amoxicillin, ciprofloxacin, norfloxacin, or nitrofurantoin. Each case was matched with up to four controls on age, sex, chronic kidney disease, and diabetes.

MAIN OUTCOME MEASURE

Odds ratio for the association between sudden death and exposure to each antibiotic relative to amoxicillin, after adjustment for predictors of sudden death according to a disease risk index.

RESULTS

Of 39,879 sudden deaths, 1027 occurred within seven days of exposure to an antibiotic and were matched to 3733 controls. Relative to amoxicillin, co-trimoxazole was associated with an increased risk of sudden death (adjusted odds ratio 1.38, 95% confidence interval 1.09 to 1.76). The risk was marginally higher at 14 days (adjusted odds ratio 1.54, 1.29 to 1.84). This corresponds to approximately three sudden deaths within 14 days per 1000 co-trimoxazole prescriptions. Ciprofloxacin (a known cause of QT interval prolongation) was also associated with an increased risk of sudden death (adjusted odds ratio 1.29, 1.03 to 1.62), but no such risk was observed with nitrofurantoin or norfloxacin.

CONCLUSIONS

In older patients receiving angiotensin converting enzyme inhibitors or angiotensin receptor blockers, co-trimoxazole is associated with an increased risk of sudden death. Unrecognized severe hyperkalemia may underlie this finding. When appropriate, alternative antibiotics should be considered in such patients.

Preferences on End-Of-Life Decisions Among Older Chinese in Macau

Purpose: The purpose of the present study was to learn about the perspectives on end-of-life decision making among older Chinese people in Macau. Method: A qualitative approach was used, and interviews were conducted with 18 Chinese aged 65 years or older. Results: Four major themes were identified: (a) institutionalized care at the end of life was preferred as not to be a burden on family, (b) life-prolonging measures were not preferred, (c) funeral arrangement preferences were based on personal and religious beliefs, and (d) end-of-life decision making would be deferred to others. Discussion and Conclusions: These themes provide an understanding of personal preferences of older Chinese on end-of-life issues, and personal preferences are always secondary to their respect toward family and medical doctors. This compliance with family and medical authority can be understood through Chinese cultural beliefs. Implications for Practice: Knowledge of cultural influences is needed for nursing professionals to deal effectively with older adults and families regarding end-of-life issues.

Why Did an Out-of-Hospital Shift of Death and Dying Occur in Canada after 1994?

Canadian population mortality data reveal a significantly reduced proportion of deaths occurring in hospitals after 1994. Hospital deaths peaked at 80.5% in 1994, after a longstanding hospitalization-of-death trend in Canada. A decline in hospital-based death and dying has also occurred in some other countries. As the place of death can have multiple significant direct and indirect impacts on dying individuals, their families, and health services utilization and costs, it is important to understand factors for an out-of-hospital shift. An integrative review of Canadian print literature from 1995 was undertaken to identify these factors, with three themes emerging: (1) changes in health care and health system reforms after 1994 reduced both the availability and desirability of hospital-based care, (2) sociodemographic developments including aging of the population, increased multiculturalism, and diversity in accepted end-of-life care practices shifted place preferences, and (3) advances in palliative and end-of-life care, including a palliative care expansion out of hospital, supported nonhospital death, and dying processes. The period following 1994 was thus a time of major transformation during which the place of death and dying underwent important changes that supported and promoted a transition from hospital-based end-of-life care.

Barriers and facilitators to care for the terminally ill: a cross-country case comparison study of Canada, England, Germany, and the United States

BACKGROUND

Why do many patients not die at their preferred location?

AIM

Analyze system-level characteristics influencing the ability to implement best practices in delivering care for terminally ill adults (barriers and facilitators).

DESIGN

Cross-country comparison study from a "most similar-most different" perspective, triangulating evidence from a scoping review of the literature, document analyses, and semi-structured key informant interviews.

SETTING

Case study of Canada, England, Germany, and the United States.

RESULTS

While similar with regard to leading causes of death, patient needs, and potential avenues to care, different models of service provision were employed in the four countries studied. Although hospice and palliative care services were generally offered with standard care along the disease continuum and in various settings, and featured common elements such as physical, psycho-social, and spiritual care, outcomes (access, utilization, etc.) varied across jurisdictions. Barriers to best practice service provision included legislative (including jurisdictional), regulatory (e.g. education and training), and financial issues as well as public knowledge and perception ("giving up hope") challenges. Advance care planning, dedicated and stable funding toward hospice and palliative care, including caregiver benefits, population aging, and standards of practice and guidelines to hospice and palliative care, were identified as facilitators.

CONCLUSION

Successful implementation of effective and efficient best practice approaches to care for the terminally ill, such as shared care, requires concerted action to align these system-level characteristics; many factors were identified as being essential but not sufficient. Policy implementation needs to be tailored to the respective health-care system(s), monitored, and fine-tuned.

Determinants of place of death: a population-based retrospective cohort study

Background

As Canada’s population ages, the location of end of life care (whether at home, extended care facility or hospital) may change depending on the location of death. We carried out a study to identify determinants of the place of death.

Methods

Data on deaths in British Columbia between 2004 and 2008 were obtained from the Vital Statistics Agency. Place of death was categorized into home, extended care facility, hospital or other. Logistic regression analyses were used to estimate the effects of age, sex, marital status, residence, place of birth and cause of death on place of death using adjusted odds ratios and 95% confidence intervals (95% CI).

Results

Of the 153,111 deaths in the study, 16.5% occurred at home, 29.0% in extended care, 51.0% in hospital and 3.5% occurred elsewhere. Male deaths were less likely to occur in extended care as compared with female deaths (odds ratio 0.73, 95% CI 0.71–0.75). Age (odds ratio 3.31, 95% CI 3.19–3.45 for those for ≥90 vs 70–79 years), marital status (odds ratio 1.42, 95% CI 1.38–1.47 widowed vs married), residence (odds ratio 0.80, 95% CI 0.76–0.83 rural vs Vancouver), place of birth (odds ratio 0.80, 95% CI 0.75–0.86 China vs Canada) and cause of death (odds ratio 3.91, 95% CI 3.69–4.13 dementia vs cancer) were also associated with death in extended care.

Conclusions

Information on determinants of place of death can inform public health policy regarding care at the end of life and make resource allocation more efficient.

[Place and cause of death in community-dwelling disabled elderly people]

AIM

To examine the place and cause of death in community-dwelling disabled elderly people.

METHODS

The baseline data of 1,875 participants and their caregivers in the Nagoya Longitudinal Study for Frail Elderly were used for the analysis. Cox proportional hazard models were used to assess the associations between the variables and the place of death during the 3-year follow-up period.

RESULTS

During the observation period of three years, 454 died (hospital death: 347, home death: 107). In total, the rates of pneumonia-, cancer- and heart failure-related death were 22.7%, 14.5%, and 13.2%, respectively. Among the home deaths, 22.4% were age-related deaths and 18.7% were heart failure-related deaths. Females, older, and participants with dementia were more likely to die at home, while those with cancer or a spouse caregiver were more likely to die in the hospital. There were no differences in the levels of caregiver burden or formal service use between the cases of home and hospital death. Multivariate Cox hazard models revealed that home death was associated with an older age and the absence of diabetes mellitus and cancer at baseline.

CONCLUSIONS

We demonstrated that death at home among community-dwelling disabled elderly is associated with an older age, and the absence of diabetes mellitus and cancer. Due to the lack of important factors that should be addressed, a further study is required in the future.

A national study of chaplaincy services and end-of-life outcomes

BACKGROUND

Medicine has long acknowledged the role of chaplains in healthcare, but there is little research on the relationship between chaplaincy care and health outcomes. The present study examines the association between chaplaincy services and end-of-life care service choices.

METHODS

HealthCare Chaplaincy purchased the AHA survey database from the American Hospital Association. The Dartmouth Atlas of Health Care database was provided to HealthCare Chaplaincy by The Dartmouth Institute for Health Policy & Clinical Practice, with the permission of Dartmouth Atlas Co-Principal Investigator Elliot S. Fisher, M.D., M.P.H. The Dartmouth Atlas of Health Care is available interactively on-line at http://www.dartmouthatlas.org/. Patient data are aggregated at the hospital level in the Dartmouth Atlas of Health Care. IRB approval was not sought for the project because the data are available to the public through one means or another, and neither database contains data about individual patients, i.e. all the variables are measures of hospital characteristics. We combined and analyzed data from the American Hospital Association's Annual Survey and outcome data from The Dartmouth Atlas of Health Care in a cross-sectional study of 3,585 hospitals. Two outcomes were examined: the percent of patients who (1) died in the hospital, and (2) were enrolled in hospice. Ordinary least squares regression was used to measure the association between the provision of chaplaincy services and each of the outcomes, controlling for six factors associated with hospital death rates.

RESULTS AND DISCUSSION

The analyses found significantly lower rates of hospital deaths (β = .04, p < .05) and higher rates of hospice enrollment (β = .06, p < .001) for patients cared for in hospitals that provided chaplaincy services compared to hospitals that did not.

CONCLUSIONS

The findings suggest that chaplaincy services may play a role in increasing hospice enrollment. This may be attributable to chaplains' assistance to patients and families in making decisions about care at the end-of-life, perhaps by aligning their values and wishes with actual treatment plans. Additional research is warranted.

The importance of end-of-life care in nursing home settings is not diminished by a disaster

The emphasis in disaster situations is on preserving life, and this goal is both appropriate and laudable. There is a risk, however, that the needs of people who are dying can become lost when there is a sudden surge of people needing acute intervention. There are significant ethical considerations inherent in society's prioritization of care needs across the acute, rehabilitative, and palliative spectrum in general, let alone in a disaster situation. These ethical conundrums are not the focus of this article. Rather, we anchor our discussion on the assumption that care needs are equally valid, and our purpose is to explore the issues that impact the provision of quality end-of-life care in nursing home settings for those who require this care when a disaster occurs. Nursing home residents, in particular, are at heightened risk for experiencing negative disaster-related outcomes due to compromised physical or mental health that requires skilled nursing care. Moreover, within the already vulnerable nursing home population are many people who are receiving palliative end-of-life services when a disaster strikes. Education and training in end-of-life services for nursing home staff, disaster emergency responders, and other lay people is vital to build capacity for adapting the delivery of these services in disaster situations in the interest of equity and human rights. Given the present lack of guidance in the literature as to what end-of-life care looks like when adapted to the context of disaster response, there is also a pressing need for research to inform this discussion. The purpose of this article is to draw attention to this topic and highlight some of the critical issues, gaps, and opportunities.

Dying in the margins: understanding palliative care and socioeconomic deprivation in the developed world

CONTEXT

Individuals from low socioeconomic (SE) groups have less resources and poorer health outcomes. Understanding the nature of access to appropriate end-of-life care services for this group is important.

OBJECTIVES

To evaluate the literature in the developed world for barriers to access for low SE groups.

METHODS

Electronic databases searched in the review included MEDLINE (1996-2010), CINAHL (1996-2010), PsychINFO (2000-2010), Cochrane Library (2010), and EMBASE (1996-2010). Publications were searched for key terms "socioeconomic disadvantage," "socioeconomic," "poverty," "poor" paired with "end-of-life care," "palliative care," "dying," and "terminal Illness." Articles were analyzed using existing descriptions for dimensions of access to health services, which include availability, affordability, acceptability, and geographical access.

RESULTS

A total of 67 articles were identified for the literature review. Literature describing end-of-life care and low SE status was limited. Findings from the review were summarized under the headings for dimensions of access.

CONCLUSION

Low SE groups experience barriers to access in palliative care services. Identification and evaluation of interventions aimed at reducing this disparity is required.

Using more end-of-life homecare services is associated with using fewer acute care services: a population-based cohort study

BACKGROUND

Healthcare systems are investing in end-of-life homecare to reduce acute care use. However, little evidence exists on the timing and amount of homecare services necessary to reduce acute care utilization.

OBJECTIVES

To investigate whether admission time to homecare and the amount of services, as measured by average nursing and personal support and homemaking (PSH) hours/week (h/wk), are associated with using acute care services at end-of-life.

RESEARCH DESIGN

Retrospective observational cohort study.

SUBJECTS

Decedents admitted to end-of-life homecare in Ontario, Canada.

MEASURES

The odds ratios (OR) of having a hospitalization or emergency room visit in the 2 weeks before death and dying in a hospital.

RESULTS

The cohort (n = 9018) used an average of 3.11 (SD = 4.87) nursing h/wk, 3.18 (SD = 6.89) PSH h/wk, and 18% were admitted to homecare for <1 month. As admission time to death and homecare services increased, the adjusted OR of an outcome decreased in a dose response manner. Patients admitted earlier than 6 months before death had a 35% (95% CI: 25%-44%) lower OR of hospitalization than those admitted 3 to 4 weeks before death; patients using more than 7 nursing h/wk and more than 7 PSH h/wk had a 50% (95% CI: 37%-60%) and 35% (95% CI: 21%-47%) lower OR of a hospitalization, respectively, than patients using 1 h/wk, controlling for other covariates. Other outcomes had similar results.

CONCLUSION

These results suggest that early homecare admission and increased homecare services will help alleviate the demand for hospital resources at end-of-life.

The rapidly changing location of death in Canada, 1994-2004

This 2008 study assessed location-of-death changes in Canada during 1994-2004, after previous research had identified a continuing increase to 1994 in hospital deaths. The most recent (1994-2004) complete population and individual-level Statistics Canada mortality data were analyzed, involving 1,806,318 decedents of all Canadian provinces and territories except Quebec. A substantial and continuing decline in hospitalized deaths was found (77.7%-60.6%). This decline was universal among decedents regardless of age, gender, marital status, whether they were born in Canada or not, across urban and rural provinces, and for all but two (infrequent) causes of death. This shift occurred in the absence of policy or purposive healthcare planning to shift death or dying out of hospital. In the developed world, recent changing patterns in the place of death, as well as the location and type of care provided near death appear to be occurring, making location-of-death trends an important topic of investigation. Canada is an important case study for highlighting the significance of location-of-death trends, and suggesting important underlying causal relationships and implications for end-of-life policies and practices.

Staff opinions about the components of a good death in long-term care

AIM

The aim of this study was to identify differences of opinion about the relative importance of different components of a good death among care providers in a long-term care home serving Canadian war veterans.

METHODS

The Concept of a Good Death scale (Swartz et al, 2003), with slight adaptations to fit the long-term care context, was made available to all staff. Responses were accepted for a one-month period.

FINDINGS

Survey return rate was 30.4%. There was a majority (greater than 50%) opinion that 12 of the 20 items were essential or important to a good death, and that three items were not necessary: 'that death is sudden and unexpected' (64.5%), 'that there be control of bodily functions to the end' (61.8%) and 'that there be mental alertness to the end' (55.3%). There was not a majority opinion on the five remaining items: 'that the dying period be short', 'that death occurs naturally without technical equipment', 'that the person lived until a key event', 'that the ability to communicate be present until death', and 'that death occurs during sleep'.

CONCLUSIONS

Detailed analysis of survey results identified differences of opinion that could have implications for consistency and quality of care. The findings suggest ways in which the unique characteristics of the long-term care environment and population influence opinions about the components of a good death.

Hospitalizations at the end of life among long-term care residents

BACKGROUND

Concerns have been raised over transfers into acute care hospitals at the end of life. The objective of this study was to examine (a) the extent of and (b) factors related to hospitalization in the last 180 days before death among long-term care (LTC) residents.

METHODS

The study included all LTC residents from 60 facilities in the province of Manitoba, Canada, who died in 2003/04 (N = 2,379), with data derived from administrative health care records. Multilevel regression analyses were conducted to examine the relationship between resident and facility characteristics and the following: location of death (in hospital vs the LTC facility); whether individuals were hospitalized in the last 180 days before death; and number of hospital days in the last 180 days.

RESULTS

Overall, 19.1% of LTC residents died in hospital; however, 40.7% were hospitalized at least once in the last 6 months before death. Several resident characteristics (age, trajectory group, and level of care) were related to the outcome measures. Living in a not-for-profit LTC facility decreased the odds of dying in hospital (adjusted odds ratio [OR] = 0.589; 95% confidence interval [CI] = 0.402-0.863) or being hospitalized (adjusted OR = 0.647; 95% CI = 0.452-0.926).

CONCLUSIONS

Hospitalization at the end of life is common among LTC residents, and the likelihood of hospital transfers is increased for residents who are younger, have organ failure, lower care level needs, as well as among those who live in for-profit facilities. Particular emphasis should, therefore, be placed on targeting these groups to determine the appropriateness of hospital admission and possible ways of reducing transfers.