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Moore H, Bablitz C, Santos Salas A, Morris H, Sinnarajah A, Watanabe SM. Describing the characteristics and symptom profile of a group of urban patients experiencing socioeconomic inequity and receiving palliative care: a descriptive exploratory analysis. Palliat Care Soc Pract 2024; 18:26323524241264880. [PMID: 39099621 PMCID: PMC11295232 DOI: 10.1177/26323524241264880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 06/11/2024] [Indexed: 08/06/2024] Open
Abstract
Background Individuals experiencing socioeconomic inequity have worse health outcomes and face barriers to palliative and end-of-life care. There is a need to develop palliative care programs tailored to this underserved population. Objectives To understand the characteristics and symptom profiles of a group of urban patients experiencing socioeconomic inequity and receiving palliative care. Design Descriptive exploratory analysis of a patient dataset. The patient dataset was generated through a pilot research study with patients experiencing socioeconomic inequity and life-limiting illness who received a community-based palliative care intervention. Methods The intervention took place over 1 year in the Palliative Care Outreach and Advocacy Team, a community-based urban palliative care clinic in Edmonton, Alberta, Canada, serving persons experiencing socioeconomic inequity. Participants had to be at least 18 years of age, be able to communicate in English, require palliative care for a life-limiting illness, and be able to consent to inclusion in the study. Results Twenty-five participants were enrolled. Participants predominantly identified as male and Indigenous, experienced poverty and housing instability, and had metastatic cancer. Our participants rated their pain, shortness of breath, and anxiety as more severe than the broader community-based palliative care population in the same city. Most patients died in inpatient hospices (73%). Conclusion Our analysis provides an in-depth picture of an understudied, underserved population requiring palliative care. Given the higher symptom severity experienced by participants, our analysis highlights the importance of person-centered palliative care. We suggest that socioeconomic inequity should be considered in patients with life-limiting illnesses. Further research is needed to explore palliative care delivery to those facing socioeconomic inequity.
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Affiliation(s)
- Harrison Moore
- Division of Palliative Care Medicine, Department of Oncology, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, 8440 112 Street NW, Edmonton, AB T6G 2B7, Canada
| | - Cara Bablitz
- Department of Family Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta
- Family Medicine, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Anna Santos Salas
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, AB, Canada
| | - Heather Morris
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, AB, Canada
| | - Aynharan Sinnarajah
- Division of Palliative Medicine, Department of Medicine, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Sharon M. Watanabe
- Department of Symptom Control and Palliative Care Cross Cancer Institute, Edmonton, AB, Canada
- Division of Palliative Care Medicine, Department of Oncology, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, AB, Canada
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Flierman I, Gieteling E, Van Rijn M, Van Grootven B, van Doorne I, Jamaludin FS, Willems DL, Muller M, Buurman BM. Effectiveness of transmural team-based palliative care in prevention of hospitalizations in patients at the end of life: A systematic review and meta-analysis. Palliat Med 2023; 37:75-87. [PMID: 36541477 DOI: 10.1177/02692163221135616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Team-based palliative care interventions have shown positive results for patients at the end of life in both hospital and community settings. However, evidence on the effectiveness of transmural, that is, spanning hospital and home, team-based palliative care collaborations is limited. AIM To systematically review whether transmural team-based palliative care interventions can prevent hospital admissions and increase death at home. DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE (Ovid), Embase (Ovid), CINAHL (Ebsco), PsychINFO (Ovid), and Cochrane Library (Wiley) were systematically searched until January 2021. Studies incorporating teams in which hospital and community professionals co-managed patients, hospital-based teams with community follow-up, and case-management interventions led by palliative care teams were included. Data was extracted by two researchers independently. RESULTS About 19 studies were included involving 6614 patients, of whom 2202 received an intervention. The overall pooled odds ratio of at least one hospital (re)admissions was 0.46 (95% confidence interval (CI) 0.34-0.68) in favor of the intervention group. The highest reduction in admission was in the hospital-based teams with community follow-up: OR 0.21 (95% CI 0.07-0.66). The pooled effect on home deaths was 2.19 (95% CI 1.26-3.79), favoring the intervention, with also the highest in the hospital-based teams: OR 4.77 (95% CI 1.23-18.47). However, studies had high heterogeneity regarding intervention, study population, and follow-up time. CONCLUSION Transmural team-based palliative care interventions, especially hospital-based teams that follow-up patients at home, show an overall effect on lowering hospital admissions and increasing the number of patients dying at home. However, broad clinical and statistical heterogeneity of included studies results in uncertainty about the effect size.
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Affiliation(s)
- Isabelle Flierman
- Amsterdam UMC Location AMC, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam, The Netherlands.,Amsterdam UMC Location AMC, University of Amsterdam, Department of General Practice, Section of Medical Ethics, Amsterdam, The Netherlands.,Amsterdam Public Health, Aging & Later life, Amsterdam, The Netherlands
| | - Elske Gieteling
- Amsterdam Public Health, Aging & Later life, Amsterdam, The Netherlands.,Amsterdam UMC Location VUmc, Department of Medicine for Older People, Amsterdam, The Netherlands.,Amstelland Hospital, Department of Internal Medicine, Amstelveen, The Netherlands
| | - Marjon Van Rijn
- Amsterdam UMC Location AMC, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam, The Netherlands.,Amsterdam Public Health, Aging & Later life, Amsterdam, The Netherlands.,Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Science, Amsterdam, The Netherlands
| | - Bastiaan Van Grootven
- Research Foundation Flanders - FWO, Brussels, Belgium + KU Leuven, Department of Public Health and Primary Care, Leuven, Belgium
| | - Iris van Doorne
- Amsterdam UMC Location AMC, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam, The Netherlands.,Amsterdam Public Health, Aging & Later life, Amsterdam, The Netherlands
| | - Faridi S Jamaludin
- Amsterdam UMC, University of Amsterdam, Research Support, Medical Library AMC, Meibergdreef 9, Amsterdam, The Netherlands
| | - Dick L Willems
- Amsterdam UMC Location AMC, University of Amsterdam, Department of General Practice, Section of Medical Ethics, Amsterdam, The Netherlands
| | - Majon Muller
- Amsterdam UMC Location VUmc, Department of Medicine for Older People, Amsterdam, The Netherlands
| | - Bianca M Buurman
- Amsterdam UMC Location AMC, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam, The Netherlands.,Amsterdam Public Health, Aging & Later life, Amsterdam, The Netherlands.,Amsterdam UMC Location VUmc, Department of Medicine for Older People, Amsterdam, The Netherlands
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3
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The impact of specialist community palliative care teams (SCPCT) on acute hospital admission rates in adult patients requiring end of life care: A systematic. Eur J Oncol Nurs 2022; 59:102168. [DOI: 10.1016/j.ejon.2022.102168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 04/14/2022] [Accepted: 06/15/2022] [Indexed: 11/20/2022]
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4
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Measuring effectiveness in community-based palliative care programs: A systematic review. Soc Sci Med 2022; 296:114731. [DOI: 10.1016/j.socscimed.2022.114731] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/19/2021] [Accepted: 01/14/2022] [Indexed: 01/11/2023]
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A Comparison of the Survival, Place of Death, and Medical Utilization of Terminal Patients Receiving Hospital-Based and Community-Based Palliative Home Care: A Retrospective and Propensity Score Matching Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18147272. [PMID: 34299722 PMCID: PMC8307712 DOI: 10.3390/ijerph18147272] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 07/03/2021] [Accepted: 07/05/2021] [Indexed: 12/17/2022]
Abstract
Evidence shows that community-based palliative home care (PHC) provision enhances continuous care and improves patient outcomes. This study compared patient survival, place of death, and medical utilization in community- versus hospital-based PHC. A retrospective cohort study was conducted of patients aged over 18 referred to either community- or hospital-based PHC from May to December 2018 at a tertiary hospital and surrounding communities in Southern Taiwan. A descriptive analysis, Chi-square test, t-test, and Log-rank test were used for the data analysis of 131 hospital-based PHC patients and 43 community-based PHC patients, with 42 paired patient datasets analyzed after propensity score matching. More nurse visits (p = 0.02), fewer emergency-room visits (p = 0.01), and a shorter waiting time to access PHC (p = 0.02) were found in the community group. There was no difference in the duration of survival and hospitalization between groups. Most hospital-based patients (57%) died in hospice wards, while most community-based patients died at home (52%). Community-based PHC is comparable to hospital-based PHC in Taiwan. Although it has fewer staffing and training requirements, it is an alternative for terminal patients to meet the growing end-of-life care demand.
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Murtonen A, Lehto JT, Sumelahti ML. End of life in multiple sclerosis: Disability, causes and place of death among cases diagnosed from 1981 to 2010 in Pirkanmaa hospital district in Western Finland. Mult Scler Relat Disord 2021; 54:103139. [PMID: 34273609 DOI: 10.1016/j.msard.2021.103139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/29/2021] [Accepted: 07/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Mortality risk and causes of death have been widely studied in MS. Surveys on conditions related to approaching death have not been conducted before in Finland. OBJECTIVE Our aim was to sort out the possible needs for end of life (EOL) care in MS by examining causes, place of death and level of hospitalization by age and MS related disability before approaching death. MATERIALS Data included information for MS patients diagnosed from 1981 to 2010 in a Finnish university hospital district. Information on place and causes of death and care prior to death was based on death certificates from Statistics Finland. Decedents initial disease course, disease modifying treatment (DMT) use and MS related disability status by using EDSS were achieved from hospital records. RESULTS Data included 113 decedents. Level of disability showed EDSS 6.0 or higher in 54% of the patients. In relapsing onset MS (N 93, 80%) DMTs were used in 11%. Infections, respiratory or other, were the main immediate cause of death (51.3%, n 58) among cases with varying disability. Central or university hospital (42.5%) or community hospital ward (28.3%) were places of death in majority of cases and nursing home (13.3%), home (9.7%) or hospice (3.7%) less often. Place of death did not significantly differ between age-groups (Chi square p = 0.86). Mean age at death was 57 years (range 28-90, SD 13.86). Cardiovascular causes of death were reported mainly in age group 60 years or more and suicide in age group younger than 50 years. CONCLUSION The level of hospitalization was high at end of life in all age-groups. High MS related disability and immobility among decedents likely relates to infections as the most common cause of death. Along with our and earlier surveys in this field, we showed that places of death and level of disability before death share similarities in both younger and older age groups highlighting the need of palliative care and end of life care plans in all MS patients with triggers of poor survival. The recently published consensus definition featuring palliative care guideline in MS is aimed at improving end of life care in MS. Our results point at need for future studies in order to assess the impact of palliative care treatment guidelines in MS.
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Affiliation(s)
- Annukka Murtonen
- Faculty of Medicine and Health Technology, Tampere University, 33014 Finland.
| | - Juho T Lehto
- Faculty of Medicine and Health Technology, Tampere University, 33014 Finland; Palliative Care Centre and Department of Oncology, Tampere University Hospital, Tampere, Finland
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Seow H, Sutradhar R, Burge F, McGrail K, Guthrie DM, Lawson B, Oz UE, Chan K, Peacock S, Barbera L. End-of-life outcomes with or without early palliative care: a propensity score matched, population-based cancer cohort study. BMJ Open 2021; 11:e041432. [PMID: 33579764 PMCID: PMC7883853 DOI: 10.1136/bmjopen-2020-041432] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To investigate whether cancer decedents who received palliative care early (ie, >6 months before death) and not-early had different risk of using hospital care and supportive home care in the last month of life. DESIGN/SETTING We identified a population-based cohort of cancer decedents between 2004 and 2014 in Ontario, Canada using linked administrative data. Analysis occurred between August 2017 to March 2019. PARTICIPANTS We propensity-score matched decedents on receiving early or not-early palliative care using billing claims. We created two groups of matched pairs: one that had Resident Assessment Instrument (RAI) home care assessments in the exposure period (Yes-RAI group) and one that did not (No-RAI group) to control for confounders uniquely available in the assessment, such as health instability and pain. The outcomes were the absolute risk difference between matched pairs in receiving hospital care, supportive home care or hospital death. RESULTS In the No-RAI group, we identified 36 238 pairs who received early and not-early palliative care. Those in the early palliative care group versus not-early group had a lower absolute risk difference of dying in hospital (-10.0%) and receiving hospital care (-10.4%) and a higher absolute risk difference of receiving supportive home care (23.3%). In the Yes-RAI group, we identified 3586 pairs, where results were similar in magnitude and direction. CONCLUSIONS Cancer decedents who received palliative care earlier than 6 months before death compared with those who did not had a lower absolute risk difference of receiving hospital care and dying in hospital, and an increased absolute risk difference of receiving supportive home care in the last month of life.
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Affiliation(s)
- Hsien Seow
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Fred Burge
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kimberlyn McGrail
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dawn M Guthrie
- Department of Health Sciences, Wilfrid Laurier University, Waterloo, Ontario, Canada
| | - Beverley Lawson
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Urun Erbas Oz
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Kelvin Chan
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Stuart Peacock
- British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Lisa Barbera
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
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8
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Vestergaard AHS, Neergaard MA, Christiansen CF, Nielsen H, Lyngaa T, Laut KG, Johnsen SP. Hospitalisation at the end of life among cancer and non-cancer patients in Denmark: a nationwide register-based cohort study. BMJ Open 2020; 10:e033493. [PMID: 32595146 PMCID: PMC7322325 DOI: 10.1136/bmjopen-2019-033493] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES End-of-life hospitalisations may not be associated with improved quality of life. Studies indicate differences in end-of-life care for cancer and non-cancer patients; however, data on hospital utilisation are sparse. This study aimed to compare end-of-life hospitalisation and place of death among patients dying from cancer, heart failure or chronic obstructive pulmonary disease (COPD). DESIGN A nationwide register-based cohort study. SETTING Data on all in-hospital admissions obtained from nationwide Danish medical registries. PARTICIPANTS All decedents dying from cancer, heart failure or COPD disease in Denmark between 2006 and 2015. OUTCOME MEASURES Data on all in-hospital admissions within 6 months and 30 days before death as well as place of death. Comparisons were made according to cause of death while adjusting for age, sex, comorbidity, partner status and residential region. RESULTS Among 154 235 decedents, the median total bed days in hospital within 6 months before death was 19 days for cancer patients, 10 days for patients with heart failure and 11 days for patients with COPD. Within 30 days before death, this was 9 days for cancer patients, and 6 days for patients with heart failure and COPD. Compared with cancer patients, the adjusted relative bed day use was 0.65 (95% CI, 0.63 to 0.68) for heart failure patients and 0.68 (95% CI, 0.66 to 0.69) for patients with COPD within 6 months before death. Correspondingly, this was 0.65 (95% CI, 0.63 to 0.68) and 0.70 (95% CI, 0.68 to 0.71) within 30 days before death.Patients had almost the same risk of dying in hospital independently of death cause (46.2% to 56.0%). CONCLUSION Patients with cancer, heart failure and COPD all spent considerable part of their end of life in hospital. Hospital use was highest among cancer patients; however, absolute differences were small.
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Affiliation(s)
| | | | | | - Henrik Nielsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Lyngaa
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
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Hwang J, Shen JJ, Kim SJ, Chun SY, Kim PC, Lee SW, Byun D, Yoo JW. Opioid use disorders and hospital palliative care among patients with gastrointestinal cancers: Ten-year trend and associated factors in the U.S. from 2005 to 2014. Medicine (Baltimore) 2020; 99:e20723. [PMID: 32569209 PMCID: PMC7310906 DOI: 10.1097/md.0000000000020723] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This study aimed to analyze the trends of opioid use disorders, cannabis use disorders, and palliative care among hospitalized patients with gastrointestinal cancer and to identify their associated factors.We analyzed the National Inpatient Sample data from 2005 to 2014 and included hospitalized patients with gastrointestinal cancers. The trends of hospital palliative care and opioid or cannabis use disorders were analyzed using the compound annual growth rates (CAGR) with Rao-Scott correction for χ tests. Multivariate logistic regression analyses were performed to identify the associated factors.From 2005 to 2014, among 4,364,416 hospitalizations of patients with gastrointestinal cancer, the average annual rates of opioid and cannabis use disorders were 0.4% (n = 19,520), and 0.3% (n = 13,009), respectively. The utilization rate of hospital palliative care was 6.2% (n = 268,742). They all sharply increased for 10 years (CAGR = 9.61%, 22.2%, and 21.51%, respectively). The patients with a cannabis use disorder were over 4 times more likely to have an opioid use disorder (Odds ratios, OR = 4.029; P < .001). Hospital palliative care was associated with higher opioid use disorder rates, higher in-hospital mortality, shorter length of hospital stay, and lower hospital charges. (OR = 1.527, 9.980, B = -0.054 and -0.386; each of P < .001)The temporal trends of opioid use disorders and hospital palliative care use among patients with gastrointestinal cancer increased from 2005 to 2014, which is mostly attributed to patients with a higher risk of in-hospital mortality. Cannabis use disorders were associated with opioid use disorders. Palliative care was associated with both reduced lengths of stay and hospital charge.
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Affiliation(s)
- Jinwook Hwang
- Department of Thoracic and Cardiovascular Surgery, Korea University Medical Center, Ansan Hospital, Korea University College of Medicine, Ansan, South Korea
| | - Jay J. Shen
- Department of Health Care Administration and Policy School of Public Health, University of Nevada Las Vegas, Las Vegas, Nevada
| | - Sun Jung Kim
- Department of Health Administration and Management, Soonchunhyang University, Asan, South Korea
| | - Sung-Youn Chun
- Department of Health Care Administration and Policy School of Public Health, University of Nevada Las Vegas, Las Vegas, Nevada
| | - Pearl C. Kim
- Department of Health Care Administration and Policy School of Public Health, University of Nevada Las Vegas, Las Vegas, Nevada
| | - Se Won Lee
- Department of Physical Medicine and Rehabilitation, Mountain View Hospital, Las Vegas, Nevada
| | - David Byun
- Department of Internal Medicine, Southern Nevada Veterans Affairs Health System, North Las Vegas, Nevada
| | - Ji Won Yoo
- Department of Internal Medicine, University of Nevada Las Vegas, School of Medicine, Las Vegas, Nevada
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Lee KT, George M, Lowry S, Ashing KT. A Review and Considerations on Palliative Care Improvements for African Americans With Cancer. Am J Hosp Palliat Care 2020; 38:671-677. [PMID: 32489113 DOI: 10.1177/1049909120930205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hospice and Palliative care benefits are infrequently realized by African American patients with cancer. With the increasing recognition of the critical role of early utilization of palliative services for optimal and quality patient care, it is important to acknowledge disparities and barriers to access that minority patients may face. The purpose of this paper is to discuss the status of palliative care delivery for African American patients within the structure and framework of the clinical practice guideline domains established by the National Consensus Project for Palliative Care. This perspectives paper describes the different aspects of palliative care and the interplay with African American culture. Here, we also attempt to identify the multilevel barriers (health care system and provider level) to palliative care among African Americans as a required step toward decreasing the disparities in access, coverage, utilization, and benefit of palliative care. Furthermore, this paper may serve as an educational guide for health care workers who care for African American patients with cancer.
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Affiliation(s)
- Kimberley T Lee
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Marshalee George
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Sarah Lowry
- Department of Hematology/Medical Oncology, 89020School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Kimlin T Ashing
- Division of Health Equities, 20220City of Hope Medical Center, Duarte, CA, USA
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11
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Taylor R, Ellis J, Gao W, Searle L, Heaps K, Davies R, Hawksworth C, Garcia-Perez A, Colclough G, Walker S, Wee B. A scoping review of initiatives to reduce inappropriate or non-beneficial hospital admissions and bed days in people nearing the end of their life: much innovation, but limited supporting evidence. BMC Palliat Care 2020; 19:24. [PMID: 32103745 PMCID: PMC7045380 DOI: 10.1186/s12904-020-0526-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 02/12/2020] [Indexed: 11/26/2022] Open
Abstract
Background Hospitalisation during the last weeks of life when there is no medical need or desire to be there is distressing and expensive. This study sought palliative care initiatives which may avoid or shorten hospital stay at the end of life and analysed their success in terms reducing bed days. Methods Part 1 included a search of literature in PubMed and Google Scholar between 2013 and 2018, an examination of governmental and organisational publications plus discussions with external and co-author experts regarding other sources. This initial sweep sought to identify and categorise relevant palliative care initiatives. In Part 2, we looked for publications providing data on hospital admissions and bed days for each category. Results A total of 1252 abstracts were reviewed, resulting in ten broad classes being identified. Further screening revealed 50 relevant publications describing a range of multi-component initiatives. Studies were generally small and retrospective. Most researchers claim their service delivered benefits. In descending frequency, benefits identified were support in the community, integrated care, out-of-hours telephone advice, care home education and telemedicine. Nurses and hospices were central to many initiatives. Barriers and factors underpinning success were rarely addressed. Conclusions A wide range of initiatives have been introduced to improve end-of-life experiences. Formal evidence supporting their effectiveness in reducing inappropriate/non-beneficial hospital bed days was generally limited or absent. Trial registration N/A
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Affiliation(s)
| | | | - Wei Gao
- Cicely Saunders Institute, London, UK
| | | | | | - Robert Davies
- Stgilesmedical Ltd, The Vestry House, St Giles High Street, London, WC2H 8LG, UK.,Stgilesmedical GmbH, Berlin, Germany
| | - Claire Hawksworth
- Stgilesmedical Ltd, The Vestry House, St Giles High Street, London, WC2H 8LG, UK
| | - Angela Garcia-Perez
- Stgilesmedical Ltd, The Vestry House, St Giles High Street, London, WC2H 8LG, UK
| | | | - Steven Walker
- Stgilesmedical Ltd, The Vestry House, St Giles High Street, London, WC2H 8LG, UK. .,Stgilesmedical GmbH, Berlin, Germany.
| | - Bee Wee
- Harris Manchester College, University of Oxford, Oxford, UK.,Sir Michael Sobell House, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Moreton SG, Saurman E, Salkeld G, Edwards J, Hooper D, Kneen K, Rothwell G, Watson J. Economic and clinical outcomes of the nurse practitioner-led Sydney Adventist Hospital Community Palliative Care Service. AUST HEALTH REV 2020; 44:791-798. [DOI: 10.1071/ah19247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 03/11/2020] [Indexed: 11/23/2022]
Abstract
ObjectiveThe aim of this study was to assess the clinical, economic and personal impacts of the nurse practitioner-led Sydney Adventist Hospital Community Palliative Care Service (SanCPCS)
MethodsParallel economic analysis of usual care was conducted prospectively with patients from the enhanced SanCPCS. A convenient retrospective sample from the initial service was used to determine the impact of the enhanced service on patient care. A time series survey was used with patients and carers from within the expanded service group in order to measure patient outcomes and values as they approached death.
ResultsPatients of the SanCPCS were less likely to die in hospital and had fewer hospital admissions. In addition, the service halved the estimated hospitalisation cost per patient, but the length of hospital stay was not affected by the service. The SanCPCS was more beneficial for women in terms of fewer hospital admissions and lower costs. Patients’ choices regarding place of care and death and what was ‘important’ to them changed over time. For instance, patients tended to prefer being at home as they approached death, and being pain free doubled in importance.
ConclusionsNurse practitioner-led community palliative care services have the potential to result in significant economic and personal benefits for patients and their families in need of such care.
What is known about the topic?National trends show an emphasis on community services with the aim of promoting and supporting the choice of dying at home, and this coincides with drives to reduce hospital costs and length of stay. Community-based palliative care services may offer substantial economic and clinical benefits.
What does this paper add?The SanCPCS was the first nurse practitioner-led community-based palliative care service in Australia. The expansion of this service led to significantly fewer admissions and deaths in hospital, and halved the estimated hospitalisation cost per patient.
What are implications for practitioners?Nurse practitioner-led models for care in the out-patient or community setting are a logical direction for palliative services through the engagement of specialised providers uniquely trained to support, nurture, guide and educate patients and their carers.
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Stubbs JM, Assareh H, Achat HM, Jalaludin B. Inpatient palliative care of people dying in New South Wales hospitals or soon after discharge. Intern Med J 2019; 49:232-239. [PMID: 30091196 DOI: 10.1111/imj.14074] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 07/23/2018] [Accepted: 07/25/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Palliative care can benefit all patients with life-limiting diseases. AIM To describe hospital use in the final year of life, timing of palliative care and variations by age and disease for patients receiving inpatient palliative care. METHODS Retrospective cohort study of all New South Wales residents aged 50 years and older who died (decedents) between July 2010 and June 2015 in hospital or within 30 days of discharge. Care type and diagnosis codes identified decedents who received inpatient palliative care. RESULTS Of 150 770 decedents, 34.4% received palliative care a median of 10 days before death. Decedents were more likely to receive palliative care if they had cancer (64.7% vs 13.3% for those without chronic conditions) or were younger (46.3% vs 25.0% of the oldest decedents). In their last year of life, palliated decedents, on average, had three emergency department presentations and four hospital admissions - one involving surgery and one where palliation was the intent of care. Of the 30.1 days spent in hospital, 8.7 days involved palliative care. Older age and non-cancer diagnoses were associated with fewer days of inpatient palliation and shorter time between first palliative admission and death. Decedents dying out of hospital started palliative care 18 days earlier than those dying in hospital. CONCLUSION Most decedents did not receive palliative care during hospital admission, and even then only very late in life, limiting its benefits. Improved recognition of palliative need, including earlier identification regardless of age and disease, will enhance the quality of care for the dying.
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Affiliation(s)
- Joanne M Stubbs
- Epidemiology and Health Analytics, Western Sydney Local Health District, New South Wales, Australia
| | - Hassan Assareh
- Epidemiology and Health Analytics, Western Sydney Local Health District, New South Wales, Australia
| | - Helen M Achat
- Epidemiology and Health Analytics, Western Sydney Local Health District, New South Wales, Australia
| | - Bin Jalaludin
- Epidemiology, Healthy People and Places Unit, South Western Sydney Local Health District, New South Wales, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
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14
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Ragg M, Ragg J, Milnes S, Bailey M, Orford N. Patients with life-limiting illness presenting to the emergency department. Emerg Med Australas 2019; 32:288-294. [PMID: 31668017 DOI: 10.1111/1742-6723.13409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/13/2019] [Accepted: 09/25/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine characteristics, outcomes and flow for patients over the age of 45 years with a life-limiting illness (LLI) presenting to a regional ED. METHODS Retrospective, observational cohort study of patients with LLI in an Australian regional ED over a 15-day period. Eligible patients were 45 years of age or older who fulfilled criteria for having an LLI. Data included demographics, diagnosis for current presentation, presence of advance care documentation, LLI category, admission and discharge destination from ED, ED and hospital length of stay and outcome for patients admitted to the acute hospital. RESULTS A total of 152 (12%) patients had an LLI. The LLI group were older, had a significantly longer median length of stay in the ED (5.9 [interquartile range 4.0-8.4] vs 3.9 h [interquartile range 2.5-6.3], P < 0.0001) and were less likely to leave the ED within 4 h (26% vs 51.5%, P < 0.0001). Forty-six percent of patients with an LLI had some form of advanced care documentation. Patients with an LLI were more likely to require hospital admission. In relation to illness trajectory, the frailty/dementia trajectory group had comparatively the longest ED length of stay with less than 10% leaving the ED within 4 h. This group were more likely to be discharged to a residential care facility. CONCLUSION A significant proportion of patients 45 years or older had an LLI which had implications for their length of ED stay and discharge destination.
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Affiliation(s)
- Michael Ragg
- Barwon Health, University Hospital Geelong, Geelong, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - James Ragg
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Sharyn Milnes
- Barwon Health, University Hospital Geelong, Geelong, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Neil Orford
- Barwon Health, University Hospital Geelong, Geelong, Victoria, Australia.,School of Medicine, Deakin University, Geelong, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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15
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Zwicker J, Qureshi D, Talarico R, Bourque P, Scott M, Chin-Yee N, Tanuseputro P. Dying of amyotrophic lateral sclerosis. Neurology 2019; 93:e2083-e2093. [DOI: 10.1212/wnl.0000000000008582] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/19/2019] [Indexed: 12/12/2022] Open
Abstract
ObjectiveTo describe health care service utilization and cost for decedents with and without amyotrophic lateral sclerosis (ALS) in the last year of life.MethodsUsing linked health administrative data, we conducted a retrospective, population-based cohort study of Ontario, Canada, decedents from 2013 to 2015. We examined demographic data, rate of utilization, and cost of health care services in the last year of life.ResultsWe identified 283,096 decedents in Ontario, of whom 1,212 (0.42%) had ALS. Decedents with ALS spent 3 times as many days in an intensive care unit (ICU) (mean 6.3 vs 2.1, p < 0.001), and twice as many days using complex continuing care (mean 12.7 vs 6.0, p < 0.001) and home care (mean 99.1 vs 41.3, p < 0.001). A greater percentage of decedents with ALS received palliative home care (44% vs 20%, p < 0.001) and palliative physician home visits (40% vs 18%, p < 0.001) than decedents without ALS. Among decedents with ALS, a palliative physician home visit in the last year of life was associated with reduced adjusted odds of dying in hospital (odds ratio 0.65, 95% confidence interval 0.48–0.89) and fewer days spent in the ICU. Mean cost of care in the last year of life was greater for those with ALS ($68,311.98 vs $55,773.48, p < 0.001).ConclusionsIn this large population-based cohort of decedents, individuals with ALS spent more days in the ICU, received more community-based services, and incurred higher costs of care in the last year of life. A palliative care physician home visit was associated with improved end of life outcomes; however, the majority of patients with ALS did not access such services.
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16
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Goodridge D, Peters J. Palliative care as an emerging role for respiratory health professionals: Findings from a cross-sectional, exploratory Canadian survey. ACTA ACUST UNITED AC 2019; 55:73-80. [PMID: 31595226 PMCID: PMC6762004 DOI: 10.29390/cjrt-2019-010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction Respiratory Health Professionals (RHPs) with specialty training in the management of asthma and COPD, often care for patients with advanced respiratory disease, who have less access to palliative care than patients with similar disease burden. The aims of this study were to: (i) explore the current and desired roles of RHPs in terms of palliative care and (ii) examine barriers to discussions with patients about palliative care. Methods An online survey addressing the aims of this study was developed and pilot tested. The survey was distributed nationally using the database of the Lung Association's RESPTREC respiratory educator training program. Descriptive statistics were performed. Results A total of 123 completed surveys were returned, with respiratory therapists comprising the largest group of respondents. The majority indicated that end-of-life care was less than optimal for patients with advanced respiratory illnesses and agreed that palliative care should be a role of RHPs. Patient- and family-related barriers to having end-of-life discussions included: difficulty accepting prognosis, limitations and complications, and lack of capacity. For providers, the most important barriers were: lack of training, uncertainty about prognosis, and lack of time. The health care system barriers of concern were increasing demand for palliative care services and limited accessibility of palliative care for those with advanced respiratory diseases and difficulties in accurate prognostication for these conditions. Discussion Incorporating a more defined role in palliative care was generally seen as a desirable evolution of the RHP role. A number of strategies to mitigate identified barriers to discussions with the patient are described. Better alignment of the services required with the needs of patients with advanced respiratory disease can be addressed in a number of ways. Conclusions As RHP roles continue to evolve, consideration should be given to the ways in which RHPs can contribute to improving the quality of care for patients with advanced respiratory disease. Building collaborations with RHPs, palliative care, and other existing health programs can ensure high quality of care. Creating and taking advantage of learning opportunities to build skills and comfort in using a palliative approach will benefit respiratory patients.
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Affiliation(s)
- Donna Goodridge
- College of Medicine, Repiratory Research Centre, University of Saskatchewan, Saskatoon, SK
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17
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Procter S, Ooi M, Hopkins C, Moore G. A review of the literature on family decision-making at end of life precipitating hospital admission. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2019; 28:878-884. [PMID: 31303037 DOI: 10.12968/bjon.2019.28.13.878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Around 70% of people would prefer to die at home, yet around 50% die in hospital, according to Dying Matters. In collaboration with a local hospice, a literature review was undertaken to address the question: 'what factors precipitate admission to hospital in the last few days of a person's life for those who had expressed a preference to die at home?' Four electronic databases were searched, with a date range of 2008 to 2018. After 80 articles were screened, 13 were included in the review. The findings identified a number of barriers experienced by people with non-cancer conditions nearing the end of life and their family carers, which inhibit the transition to end-of-life care. The findings suggest that hospice support for non-cancer patients with a deteriorating health trajectory needs to precede patient and family recognition that end-of-life care is needed.
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Affiliation(s)
- Susan Procter
- Associate Lecturer, Faculty of Society and Health, Buckinghamshire New University, High Wycombe; formerly Professor of Clinical Innovation in Nursing
| | - MuiKeow Ooi
- Formerly Senior Lecturer, Buckinghamshire New University, High Wycombe
| | - Charlotte Hopkins
- Senior Physiotherapist, Community Rehabilitation Team, Great Western Hospitals NHS Foundation Trust; formerly Physiotherapist, South Buckinghamshire Hospice, High Wycombe
| | - Geraldine Moore
- Community Hospice Nurse, Hospital In-reach Programme, St Elizabeth Hospice, Ipswich; formerly Nurse, South Buckinghamshire Hospice, High Wycombe
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18
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Gott M, Robinson J, Moeke-Maxwell T, Black S, Williams L, Wharemate R, Wiles J. 'It was peaceful, it was beautiful': A qualitative study of family understandings of good end-of-life care in hospital for people dying in advanced age. Palliat Med 2019; 33:793-801. [PMID: 31027476 DOI: 10.1177/0269216319843026] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Hospitals are important sites of end-of-life care, particularly for older people. A need has been identified to understand best practice in hospital end-of-life care from the service-user perspective. AIM The aim of this study was to identify examples of good care received in the hospital setting during the last 3 months of life for people dying in advanced age from the perspective of bereaved family members. DESIGN A social constructionist framework underpinned a qualitative research design. Data were analysed thematically drawing on an appreciative enquiry framework. SETTING/PARTICIPANTS Interviews were conducted with 58 bereaved family carers nominated by 52 people aged >80 years participating in a longitudinal study of ageing. Data were analysed for the 21 of 34 cases where family members were 'extremely' or 'very' satisfied with a public hospital admission their older relative experienced in their last 3 months of life. RESULTS Participants' accounts of good care aligned with Dewar and Nolan's relation-centred compassionate care model: (1) a relationship based on empathy; (2) effective interactions between patients/families and staff; (3) contextualised knowledge of the patient/family; and (4) patients/families being active participants in care. We extended the model to the bicultural context of Aotearoa, New Zealand. CONCLUSION We identify concrete actions that clinicians working in acute hospitals can integrate into their practice to deliver end-of-life care with which families are highly satisfied. Further research is required to support the implementation of the relation-centred compassionate care model within hospitals, with suitable adaptations for local context, and explore the subsequent impact on patients, families and staff.
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Affiliation(s)
- Merryn Gott
- 1 School of Nursing, University of Auckland, Auckland, New Zealand.,2 Te Ārai Palliative Care and End of Life Research Group, University of Auckland, Auckland, New Zealand
| | - Jackie Robinson
- 1 School of Nursing, University of Auckland, Auckland, New Zealand.,2 Te Ārai Palliative Care and End of Life Research Group, University of Auckland, Auckland, New Zealand.,3 Auckland District Health Board, Auckland, New Zealand
| | - Tess Moeke-Maxwell
- 1 School of Nursing, University of Auckland, Auckland, New Zealand.,2 Te Ārai Palliative Care and End of Life Research Group, University of Auckland, Auckland, New Zealand
| | - Stella Black
- 1 School of Nursing, University of Auckland, Auckland, New Zealand.,2 Te Ārai Palliative Care and End of Life Research Group, University of Auckland, Auckland, New Zealand
| | - Lisa Williams
- 1 School of Nursing, University of Auckland, Auckland, New Zealand.,2 Te Ārai Palliative Care and End of Life Research Group, University of Auckland, Auckland, New Zealand
| | - Rawiri Wharemate
- 2 Te Ārai Palliative Care and End of Life Research Group, University of Auckland, Auckland, New Zealand
| | - Janine Wiles
- 2 Te Ārai Palliative Care and End of Life Research Group, University of Auckland, Auckland, New Zealand.,4 School of Population Health, University of Auckland, Auckland, New Zealand
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19
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Verhoef MJ, de Nijs E, Horeweg N, Fogteloo J, Heringhaus C, Jochems A, Fiocco M, van der Linden Y. Palliative care needs of advanced cancer patients in the emergency department at the end of life: an observational cohort study. Support Care Cancer 2019; 28:1097-1107. [PMID: 31197539 PMCID: PMC6989579 DOI: 10.1007/s00520-019-04906-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/31/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Patients with advanced cancer commonly visit the emergency department (ED) during the last 3 months of life. Identification of these patients and their palliative care needs help initiating appropriate care according to patients' wishes. Our objective was to provide insight into ED visits of advanced cancer patients at the end of life. METHODS Adult palliative patients with solid tumours who died < 3 months after their ED visit were included (2011-2014). Patients, ED visits, and follow-up were described. Factors associated with approaching death were assessed using Cox proportional hazards models. RESULTS Four hundred twenty patients were included, 54.5% was male, median age 63 years. A total of 54.6% was on systemic anti-cancer treatments and 10.5% received home care ≥ 1 per day. ED visits were initiated by patients and family in 34.0% and 51.9% occurred during out-of-office hours. Dyspnoea (21.0%) or pain (18.6%) were most reported symptoms. Before the ED visit, limitations on life-sustaining treatments were discussed in 33.8%, during or after the ED visit in 70.7%. Median stay at the ED was 3:29 h (range 00:12-18:01 h), and 319 (76.0%) were hospitalized. Median survival was 18 days (IQ range 7-41). One hundred four (24.8%) died within 7 days after the ED visit, of which 71.2% in-hospital. Factors associated with approaching death were lung cancer, neurologic deterioration, dyspnoea, hypercalcemia, and jaundice. CONCLUSION ED visits of advanced cancer patients often lead to hospitalization and in-hospital deaths. Timely recognition of patients with limited life expectancies and urgent palliative care needs, and awareness among ED staff of the potential of ED-initiated palliative care may improve the end-of-life trajectory of these patients.
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Affiliation(s)
- Mary-Joanne Verhoef
- Center of Expertise Palliative Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands.
| | - Ellen de Nijs
- Center of Expertise Palliative Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Nanda Horeweg
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jaap Fogteloo
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Christian Heringhaus
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Anouk Jochems
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Medical Oncology, Haaglanden Medical Center, The Hague, the Netherlands
| | - Marta Fiocco
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands.,Mathematical Institute, Leiden University, Leiden, the Netherlands
| | - Yvette van der Linden
- Center of Expertise Palliative Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands.,Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
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20
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Morgan DD, Tieman JJ, Allingham SF, Ekström MP, Connolly A, Currow DC. The trajectory of functional decline over the last 4 months of life in a palliative care population: A prospective, consecutive cohort study. Palliat Med 2019; 33:693-703. [PMID: 30916620 DOI: 10.1177/0269216319839024] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Understanding current patterns of functional decline will inform patient care and has health service and resource implications. AIM This prospective consecutive cohort study aims to map the shape of functional decline trajectories at the end of life by diagnosis. DESIGN Changes in functional status were measured using the Australia-modified Karnofsky Performance Status Scale. Segmented regression was used to identify time points prior to death associated with significant changes in the slope of functional decline for each diagnostic cohort. Sensitivity analyses explored the impact of severe symptoms and late referrals, age and sex. SETTING/PARTICIPANTS In all, 115 specialist palliative care services submit prospectively collected patient data to the national Palliative Care Outcomes Collaboration across Australia. Data on 55,954 patients who died in the care of these services between 1 January 2013 and 31 December 2015 were included. RESULTS Two simplified functional decline trajectories were identified in the last 4 months of life. Trajectory 1 has an almost uniform slow decline until the last 14 days of life when function declines more rapidly. Trajectory 2 has a flatter more stable trajectory with greater functional impairment at 120 days before death, followed by a more rapid decline in the last 2 weeks of life. The most rapid rate of decline occurs in the last 2 weeks of life for all cohorts. CONCLUSIONS Two simplified trajectories of functional decline in the last 4 months of life were identified for five patient cohorts. Both trajectories present opportunities to plan for responsive healthcare that will support patients and families.
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Affiliation(s)
- Deidre D Morgan
- 1 Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Jennifer J Tieman
- 1 Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Samuel F Allingham
- 2 Palliative Care Outcomes Collaboration (PCOC), Australian Health Services Research Institute, University of Wollongong, Wollongong, NSW, Australia
| | - Magnus P Ekström
- 3 Division of Respiratory Medicine and Allergology, Department of Clinical Sciences, Lund University, Lund, Sweden.,4 Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Alanna Connolly
- 2 Palliative Care Outcomes Collaboration (PCOC), Australian Health Services Research Institute, University of Wollongong, Wollongong, NSW, Australia
| | - David C Currow
- 1 Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.,2 Palliative Care Outcomes Collaboration (PCOC), Australian Health Services Research Institute, University of Wollongong, Wollongong, NSW, Australia.,4 Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
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21
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Qureshi D, Tanuseputro P, Perez R, Pond GR, Seow HY. Early initiation of palliative care is associated with reduced late-life acute-hospital use: A population-based retrospective cohort study. Palliat Med 2019; 33:150-159. [PMID: 30501459 PMCID: PMC6399729 DOI: 10.1177/0269216318815794] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND: Early palliative care can reduce end-of-life acute-care use, but findings are mainly limited to cancer populations receiving hospital interventions. Few studies describe how early versus late palliative care affects end-of-life service utilization. AIM: To investigate the association between early versus late palliative care (hospital/community-based) and acute-care use and other publicly funded services in the 2 weeks before death. DESIGN: Retrospective population-based cohort study using linked administrative healthcare data. SETTING/PARTICIPANTS: Decedents (cancer, frailty, and organ failure) between 1 April 2010 and 31 December 2012 in Ontario, Canada. Initiation time before death (days): early (⩾60) and late (⩾15 and <60). ‘Acute-care settings’ included acute-hospital admissions with (‘palliative-acute-care’) and without palliative involvement (‘non-palliative-acute-care’). RESULTS: We identified 230,921 decedents. Of them, 27% were early palliative care recipients and 13% were late; 45% of early recipients had a community-based initiation and 74% of late recipients had a hospital-based initiation. Compared to late recipients, fewer early recipients used palliative-acute care (42% vs 65%) with less days (mean days: 9.6 vs 12.0). Late recipients were more likely to use acute-care settings; this was further modified by disease: comparing late to early recipients, cancer decedents were nearly two times more likely to spend >1 week in acute-care settings (odds ratio = 1.84, 95% confidence interval: 1.83–1.85), frailty decedents were three times more likely (odds ratio = 3.04, 95% confidence interval: 3.01–3.07), and organ failure decedents were four times more likely (odds ratio = 4.04, 95% confidence interval: 4.02–4.06). CONCLUSION: Early palliative care was associated with improved end-of-life outcomes. Late initiations were associated with greater acute-care use, with the largest influence on organ failure and frailty decedents, suggesting potential opportunities for improvement.
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Affiliation(s)
- Danial Qureshi
- 1 Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,3 Institute for Clinical Evaluative Sciences, McMaster University Medical Centre, Hamilton, ON, Canada
| | | | - Richard Perez
- 3 Institute for Clinical Evaluative Sciences, McMaster University Medical Centre, Hamilton, ON, Canada
| | - Greg R Pond
- 4 Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Hsien-Yeang Seow
- 3 Institute for Clinical Evaluative Sciences, McMaster University Medical Centre, Hamilton, ON, Canada.,4 Department of Oncology, McMaster University, Hamilton, ON, Canada
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22
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Spilsbury K, Rosenwax L, Brameld K, Kelly B, Arendts G. Morbidity burden and community-based palliative care are associated with rates of hospital use by people with schizophrenia in the last year of life: A population-based matched cohort study. PLoS One 2018; 13:e0208220. [PMID: 30496266 PMCID: PMC6264825 DOI: 10.1371/journal.pone.0208220] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 11/14/2018] [Indexed: 11/23/2022] Open
Abstract
Objective People with schizophrenia face an increased risk of premature death from chronic diseases and injury. This study describes the trajectory of acute care health service use in the last year of life for people with schizophrenia and how this varied with receipt of community-based specialist palliative care and morbidity burden. Method A population-based retrospective matched cohort study of people who died from 01/01/2009 to 31/12/2013 with and without schizophrenia in Western Australia. Hospital inpatient, emergency department, death and community-based care data collections were linked at the person level. Rates of emergency department presentations and hospital admissions over the last year of life were estimated. Results Of the 63508 decedents, 1196 (1.9%) had a lifetime history of schizophrenia. After adjusting for confounders and averaging over the last year of life there was no difference in the overall rate of ED presentation between decedents with schizophrenia and the matched cohort (HR 1.09; 95%CI 0.99–1.19). However, amongst the subset of decedents with cancer, choking or intentional self-harm recorded on their death certificate, those with schizophrenia presented to ED more often. Males with schizophrenia had the highest rates of emergency department use in the last year of life. Rates of hospital admission for decedents with schizophrenia were on average half (HR 0.53, 95%CI 0.44–0.65) that of the matched cohort although this varied by cause of death. Of all decedents with cancer, 27.5% of people with schizophrenia accessed community-based specialist palliative care compared to 40.4% of the matched cohort (p<0.001). Rates of hospital admissions for decedents with schizophrenia increased 50% (95% CI: 10%-110%) when enrolled in specialist palliative care. Conclusion In the last year of life, people with schizophrenia were less likely to be admitted to hospital and access community-based speciality palliative care, but more likely to attend emergency departments if male. Community-based specialist palliative care was associated with increased rates of hospital admissions.
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Affiliation(s)
- Katrina Spilsbury
- Centre for Population Health Research, Curtin University, Perth, Western Australia, Australia
- Institute for Health Research, The University of Notre Dame Australia, Perth Western Australia, Australia
| | - Lorna Rosenwax
- School of Occupational Therapy and Social Work, Curtin University, Perth, Western Australia, Australia
- * E-mail:
| | - Kate Brameld
- Centre for Population Health Research, Curtin University, Perth, Western Australia, Australia
| | - Brian Kelly
- Centre for Brain and Mental Health Research and School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Glenn Arendts
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, University of Western Australia, Perth, Western Australia, Australia
- Department of Emergency Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
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23
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Chambers S, Healy H, Hoy WE, Kark A, Ratanjee S, Mitchell G, Douglas C, Yates P, Bonner A. Health service utilisation during the last year of life: a prospective, longitudinal study of the pathways of patients with chronic kidney disease stages 3-5. BMC Palliat Care 2018; 17:57. [PMID: 29622009 PMCID: PMC5887240 DOI: 10.1186/s12904-018-0310-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 03/21/2018] [Indexed: 12/22/2022] Open
Abstract
Background Chronic kidney disease (CKD) is a growing global problem affecting around 10% of many countries’ populations. Providing appropriate palliative care services (PCS) to those with advanced kidney disease is becoming paramount. Palliative/supportive care alongside usual CKD clinical treatment is gaining acceptance in nephrology services although the collaboration with and use of PCS is not consistent. Methods The goal of this study was to track and quantify the health service utilisation of people with CKD stages 3-5 over the last 12 months of life. Patients were recruited from a kidney health service (Queensland, Australia) for this prospective, longitudinal study. Data were collected for 12 months (or until death, whichever was sooner) during 2015-17 from administrative health sources. Emergency department presentations (EDP) and inpatient admissions (IPA) (collectively referred to as critical events) were reviewed by two Nephrologists to gauge if the events were avoidable. Results Participants (n = 19) with a median age of 78 years (range 42-90), were mostly male (63%), 79% had CKD stage 5, and were heavy users of health services during the study period. Fifteen patients (79%) collectively recorded 44 EDP; 61% occurred after-hours, 91% were triaged as imminently and potentially life-threatening and 73% were admitted. Seventy-four IPA were collectively recorded across 16 patients (84%); 14% occurred on weekends or public holidays. Median length of stay was 3 days (range 1-29). The median number of EDP and IPA per patient was 1 and 2 (range 0-12 and 0-20) respectively. The most common trigger to both EDP (30%) and IPA (15%) was respiratory distress. By study end 37% of patients died, 63% were known to PCS and 11% rejected a referral to a PCS. All critical events were deemed unavoidable. Conclusions Few patients avoided using acute health care services in a 12 month period, highlighting the high service needs of this cohort throughout the long, slow decline of CKD. Proactive end-of-life care earlier in the disease trajectory through integrating renal and palliative care teams may avoid acute presentations to hospital through better symptom management and planned care pathways.
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Affiliation(s)
- Shirley Chambers
- Faculty of Health, Queensland University of Technology, Brisbane, Australia. .,National Health and Medical Research Council, Centre for Research Excellence in End of Life Care, Brisbane, Australia.
| | - Helen Healy
- Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Brisbane, Australia.,National Health and Medical Research Council, Chronic Kidney Disease Centre for Research Excellence, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Wendy E Hoy
- National Health and Medical Research Council, Chronic Kidney Disease Centre for Research Excellence, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Adrian Kark
- Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Brisbane, Australia
| | - Sharad Ratanjee
- Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Brisbane, Australia
| | - Geoffrey Mitchell
- National Health and Medical Research Council, Centre for Research Excellence in End of Life Care, Brisbane, Australia.,National Health and Medical Research Council, Chronic Kidney Disease Centre for Research Excellence, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Carol Douglas
- Palliative Care Service, Royal Brisbane and Women's Hospital, Queensland Health, Brisbane, Australia
| | - Patsy Yates
- Faculty of Health, Queensland University of Technology, Brisbane, Australia.,National Health and Medical Research Council, Centre for Research Excellence in End of Life Care, Brisbane, Australia.,Centre for Palliative Care Research and Education, Queensland Health, Brisbane, Australia
| | - Ann Bonner
- Faculty of Health, Queensland University of Technology, Brisbane, Australia.,National Health and Medical Research Council, Centre for Research Excellence in End of Life Care, Brisbane, Australia.,Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Brisbane, Australia.,National Health and Medical Research Council, Chronic Kidney Disease Centre for Research Excellence, Brisbane, Australia
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24
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Spilsbury K, Rosenwax L. Community-based specialist palliative care is associated with reduced hospital costs for people with non-cancer conditions during the last year of life. BMC Palliat Care 2017; 16:68. [PMID: 29216873 PMCID: PMC5721619 DOI: 10.1186/s12904-017-0256-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 11/30/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Community-based palliative care is associated with reduced hospital costs for people dying from cancer. It is unknown if reduced hospital costs are universal across multiple life-limiting conditions amenable to palliative care. The aim of this study was to determine if community-based palliative care provided to people dying from non-cancer conditions was associated with reduced hospital costs in the last year of life and how this compared with people dying from cancer. METHOD A retrospective population-based cohort study of all decedents in Western Australia who died January 2009 to December 2010 from a life-limiting condition considered amenable to palliative care. Hospital costs were assigned to each day of the last year of life for each decedent with a zero cost applied to days not in hospital. Day-specific hospital costs averaged over all decedents (cohort averaged) and decedents in hospital only (inpatient averaged) were estimated. Two-part models and generalised linear models were used. RESULTS The cohort comprised 12,764 decedents who, combined, spent 451,236 (9.7%) days of the last year of life in hospital. Overall, periods of time receiving community-based specialist palliative care were associated with a 27% decrease from A$112 (A$110-A$114) per decedent per day to $A82 (A$78-A$85) per decedent per day of CA hospital costs. Community-based specialist palliative care was also associated a reduction of inpatient averaged hospital costs of 9% (7%-10%) to A$1030 per hospitalised decedent per day. Hospital cost reductions were observed for decedents with organ failures, chronic obstructive pulmonary disease, Alzheimer's disease, Parkinson's disease and cancer but not for motor neurone disease. Cost reductions associated with community-based specialist palliative care were evident 4 months before death for decedents with cancer and by one to 2 months before death for decedents dying from other conditions. CONCLUSION Community-based specialist palliative care was associated with hospital cost reductions across multiple life-limiting conditions.
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Affiliation(s)
- Katrina Spilsbury
- Centre for Population Health Research, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Lorna Rosenwax
- School of Occupational Therapy and Social Work, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, 6845 Australia
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