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Bennett C, Beach S, Pacheco K, Hsu AT, Tanuseputro P, Manuel DG. Exploring perceptions of online calculators for identifying community-dwelling older people at risk of dying: A qualitative study. PEC INNOVATION 2024; 5:100313. [PMID: 39040661 PMCID: PMC11260570 DOI: 10.1016/j.pecinn.2024.100313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 05/31/2024] [Accepted: 06/24/2024] [Indexed: 07/24/2024]
Abstract
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.
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Affiliation(s)
- Carol Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Institute for Clinical Evaluative Sciences, Ottawa, Canada
| | - Sarah Beach
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Karen Pacheco
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Amy T. Hsu
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
- C.T. Lamont Primary Health Care Research Centre Program, Bruyère Research Institute, Ottawa, Canada
| | - Peter Tanuseputro
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Institute for Clinical Evaluative Sciences, Ottawa, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - Douglas G. Manuel
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Institute for Clinical Evaluative Sciences, Ottawa, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Health Analysis Division, Statistics Canada, Government of Canada, Ottawa, Canada
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2
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Ajluni V. The role of family practitioners in early identification, referral, and co-management of depression. J Family Med Prim Care 2024; 13:1141-1142. [PMID: 38736783 PMCID: PMC11086798 DOI: 10.4103/jfmpc.jfmpc_1741_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 11/22/2023] [Indexed: 05/14/2024] Open
Affiliation(s)
- Victor Ajluni
- Wayne State University, 16836 Newburgh Rd, Livonia, MI 48154, USA
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3
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Leniz J, Higginson IJ, Yi D, Ul-Haq Z, Lucas A, Sleeman KE. Identification of palliative care needs among people with dementia and its association with acute hospital care and community service use at the end-of-life: A retrospective cohort study using linked primary, community and secondary care data. Palliat Med 2021; 35:1691-1700. [PMID: 34053356 PMCID: PMC8532216 DOI: 10.1177/02692163211019897] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospital admissions among people dying with dementia are common. It is not known whether identification of palliative care needs could help prevent unnecessary admissions. AIM To examine the proportion of people with dementia identified as having palliative care needs in their last year of life, and the association between identification of needs and primary, community and hospital services in the last 90 days. DESIGN Retrospective cohort study using Discover, an administrative and clinical dataset from 365 primary care practices in London with deterministic individual-level data linkage to community and hospital records. SETTING/PARTICIPANTS People diagnosed with dementia and registered with a general practitioner in North West London (UK) who died between 2016 and 2019. The primary outcome was multiple non-elective hospital admissions in the last 90 days of life. Secondary outcomes included contacts with primary and community care providers. We examined the association between identification of palliative care needs with outcomes. RESULTS Among 5804 decedents with dementia, 1953 (33.6%) were identified as having palliative care needs, including 1141 (19.7%) identified before the last 90 days of life. Identification of palliative care needs before the last 90 days was associated with a lower risk of multiple hospital admissions (Relative Risk 0.70, 95% CI 0.58-0.85) and more contacts with the primary care practice, community nurses and palliative care teams in the last 90 days. CONCLUSIONS Further investigation of the mechanisms underlying the association between identification of palliative care needs and reduced hospital admissions could help reduce reliance on acute care for this population.
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Affiliation(s)
- Javiera Leniz
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Zia Ul-Haq
- Discover-Now, Imperial College Health Partners, London, UK
| | - Amanda Lucas
- Discover-Now, Imperial College Health Partners, London, UK
| | - Katherine E Sleeman
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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4
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Comparison of Two Methods for Implementing Comfort Care Order Sets in the Inpatient Setting: a Cluster Randomized Trial. J Gen Intern Med 2021; 36:1928-1936. [PMID: 33547573 PMCID: PMC8298677 DOI: 10.1007/s11606-020-06482-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND There is an ongoing need for interventions to improve quality of end-of-life care for patients in inpatient settings. OBJECTIVE To compare two methods for implementing a Comfort Care Education Intervention for Palliative Care Consultation Teams (PCCT) in Veterans Affairs Medical Centers (VAMCs). DESIGN Cluster randomized implementation trial conducted March 2015-April 2019. PCCTs were assigned to a traditional implementation approach using a teleconference or to an in-person, train-the-champion workshop to prepare PCCTs to be clinical champions at their home sites. PARTICIPANTS One hundred thirty-two providers from PCCTs at 47 VAMCs. INTERVENTIONS Both training modalities involved review of educational materials, instruction on using an electronic Comfort Care Order Set, and coaching to deliver the intervention to other providers. MAIN MEASUREMENTS Several processes of care were identified a priori as quality endpoints for end-of-life care (last 7 days) and abstracted from medical records of veterans who died within 9 months before or after implementation (n = 6,491). The primary endpoint was the presence of an active order for opioid medication at time of death. Secondary endpoints were orders/administration of antipsychotics, benzodiazepines, and scopolamine, do-not-resuscitate orders, advance directives, locations of death, palliative care consultations, nasogastric tubes, intravenous lines, physical restraints, pastoral care visits, and family presence at/near time of death. Generalized estimating equations were conducted adjusting for potential covariates. KEY RESULTS Eighty-eight providers from 23 VAMCs received teleconference training; 44 providers from 23 VAMCs received in-person workshop training. Analyses found no significant differences between intervention groups in any process-of-care endpoints (primary endpoint AOR (CI) = 1.18 (0.74, 1.89). Furthermore, pre-post changes were not significant for any endpoints (primary endpoint AOR (CI) = 1.16 (0.92, 1.46). Analyses may have been limited by high baseline values on key endpoints with little room for improvement. CONCLUSION Findings suggest the clinical effectiveness of palliative care educational intervention was not dependent on which of the two implementation methods was used. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02383173.
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5
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Onwuteaka-Philipsen BD, Pasman HRW, Korfage IJ, Witkamp E, Zee M, van Lent LG, Goossensen A, van der Heide A. Dying in times of the coronavirus: An online survey among healthcare professionals about end-of-life care for patients dying with and without COVID-19 (the CO-LIVE study). Palliat Med 2021; 35:830-842. [PMID: 33825567 PMCID: PMC8114455 DOI: 10.1177/02692163211003778] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND During the COVID-19 outbreak restricting measures may have affected the provision of good end-of-life care for patients with and without COVID-19. AIM To describe characteristics of patients who died and the care they received, and to examine how patient characteristics, setting and visiting restrictions are related to provided care and evaluation of the dying process. DESIGN An open observational online survey among healthcare professionals about their experience of end-of-life care that was provided to a patient with or without COVID-19 who died between March and July 2020. SETTING/PARTICIPANTS Healthcare professionals (nurses, physicians and others) in the Netherlands from all settings: home (n = 163), hospital (n = 249), nursing home (n = 192), hospice (n = 89) or elsewhere (n = 68). RESULTS Of patients reported on, 56% had COVID-19. Among these patients, 358 (84.4%) also had a serious chronic illness. Having COVID-19 was negatively, and having a serious chronic illness was positively associated with healthcare staff's favourable appreciation of end-of-life care. Often there had been visiting restrictions in the last 2 days of life (75.8%). This was negatively associated with appreciation of care at the end of life and the dying process. Finally, care at the end of life was less favourably appreciated in hospitals and especially nursing homes, and more favourably in home settings and especially hospices. CONCLUSIONS Our study suggests that end-of-life care during the COVID-19 pandemic may be further optimised, especially in nursing homes and hospitals. Allowing at least some level of visits of relatives seems a key component.
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Affiliation(s)
- Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - H Roeline W Pasman
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Erica Witkamp
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Research Center Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
| | - Masha Zee
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Expertise Center for Palliative Care, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Liza Gg van Lent
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Agnes van der Heide
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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6
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Ermers DJM, Kuip EJM, Veldhoven CMM, Schers HJ, Perry M, Bronkhorst EM, Vissers KCP, Engels Y. Timely identification of patients in need of palliative care using the Double Surprise Question: A prospective study on outpatients with cancer. Palliat Med 2021; 35:592-602. [PMID: 33423610 PMCID: PMC7975860 DOI: 10.1177/0269216320986720] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The Surprise Question ("Would I be surprised if this patient were to die within the next 12 months?") is widely used to identify palliative patients, though with low predictive value. To improve timely identification of palliative care needs, we propose an additional Surprise Question ("Would I be surprised if this patient is still alive after 12 months?") if the original Surprise Question is answered with "no." The combination of the two questions is called the Double Surprise Question. AIM To examine the prognostic accuracy of the Double Surprise Question in outpatients with cancer. DESIGN A prospective study. PARTICIPANTS Twelve medical oncologists completed the Double Surprise Question for 379 patients. RESULTS In group 1 (original Surprise Question "yes": surprised if dead) 92.1% (176/191) of the patients were still alive after 1 year, in group 2a (original and additional Surprise Question "no": not surprised if dead and not surprised if alive) 60.0% (63/105), and in group 2b (original Surprise Question "no," additional Surprise Question "yes": surprised if alive) 26.5% (22/83) (p < 0.0001). The positive predictive value increased by using the Double Surprise Question; 74% (61/83) vs 55% (103/188). Anticipatory palliative care provision and Advance Care Planning items were most often documented in group 2b. CONCLUSIONS The Double Surprise Question is a promising tool to more accurately identify outpatients with cancer at risk of dying within 1 year, and therefore, those in need of palliative care. Studies should reveal whether the implementation of the Double Surprise Question leads to more timely palliative care.
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Affiliation(s)
- Daisy JM Ermers
- Department of Anesthesiology, Pain and
Palliative Medicine, Radboud University Medical Center, Nijmegen, The
Netherlands
| | - Evelien JM Kuip
- Department of Anesthesiology, Pain and
Palliative Medicine, Radboud University Medical Center, Nijmegen, The
Netherlands
- Department of Medical Oncology, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - CMM Veldhoven
- Department of Anesthesiology, Pain and
Palliative Medicine, Radboud University Medical Center, Nijmegen, The
Netherlands
- General Practice Berg en Dal, Berg en
Dal, The Netherlands
| | - Henk J Schers
- Department of Primary and Community
Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marieke Perry
- Department of Primary and Community
Care, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Geriatrics, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - Ewald M Bronkhorst
- Department of Health Evidence, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - Kris CP Vissers
- Department of Anesthesiology, Pain and
Palliative Medicine, Radboud University Medical Center, Nijmegen, The
Netherlands
| | - Yvonne Engels
- Department of Anesthesiology, Pain and
Palliative Medicine, Radboud University Medical Center, Nijmegen, The
Netherlands
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7
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Kjellstadli C, Allore H, Husebo BS, Flo E, Sandvik H, Hunskaar S. General practitioners' provision of end-of-life care and associations with dying at home: a registry-based longitudinal study. Fam Pract 2020; 37:340-347. [PMID: 31995182 PMCID: PMC7377342 DOI: 10.1093/fampra/cmz059] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND General practitioners (GPs) may play an important role in providing end-of-life care to community-dwelling people. OBJECTIVE To investigate patients' contacts with GPs, GPs' interdisciplinary collaboration, out-of-hours services and hospitalizations in the last 13 weeks of life and associations with dying at home. Second, investigate whether GP contacts were associated with fewer out-of-hours contacts or days hospitalized. METHODS Individually linked data from the Norwegian Cause of Death Registry, Norwegian Patient Registry, Statistics Norway and Control and Payment of Reimbursement to Health Service Providers database for all 80 813 deceased people in Norway within 2012-13. Outcomes were analyzed with logistic regression and negative binomial multilevel mixed-effect models. RESULTS Overall, 1% of people received GP home visits in Week 13 and 4.6% in the last week before death. During the last 4 weeks of life, 9.2% received one or more GP home visits. Altogether, 6.6% received one or more home visits when the GP had one or more interdisciplinary collaborations during the last 4 weeks, of which <3% died at home. GP office consultations decreased towards the end of life. The likelihood of home death versus another location increased in relation to GP home visits [one home visit odds ratio (OR) 1.92, confidence interval (CI) 1.71-2.15; two or more OR 3.49, CI 3.08-3.96] and GP interdisciplinary collaboration (one contact OR 1.76, CI 1.59-1.96; two or more OR 2.52, CI 2.32-2.74). CONCLUSIONS GPs play a role in enabling people to die at home by performing home visits and collaborating with other health care personnel. Only a minority received such services in Norway.
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Affiliation(s)
- Camilla Kjellstadli
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Heather Allore
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Bettina S Husebo
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Municipality of Bergen, Bergen, Norway
| | - Elisabeth Flo
- Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Hogne Sandvik
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Steinar Hunskaar
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
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8
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Kendell C, Kotecha J, Martin M, Han H, Jorgensen M, Urquhart R. Patient and caregiver perspectives on early identification for advance care planning in primary healthcare settings. BMC FAMILY PRACTICE 2020; 21:136. [PMID: 32646380 PMCID: PMC7350686 DOI: 10.1186/s12875-020-01206-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 06/23/2020] [Indexed: 12/03/2022]
Abstract
Background As part of a broader study to improve the capacity for advance care planning (ACP) in primary healthcare settings, the research team set out to develop and validate a computerized algorithm to help primary care physicians identify individuals at risk of death, and also carried out focus groups and interviews with relevant stakeholder groups. Interviews with patients and family caregivers were carried out in parallel to algorithm development and validation to examine (1) views on early identification of individuals at risk of deteriorating health or dying; (2) views on the use of a computerized algorithm for early identification; and (3) preferences and challenges for ACP. Methods Fourteen participants were recruited from two Canadian provinces. Participants included individuals aged 65 and older with declining health and self-identified caregivers of individuals aged 65 and older with declining health. Semi-structured interviews were conducted via telephone. A qualitative descriptive analytic approach was employed, which focused on summarizing and describing the informational contents of the data. Results Participants supported the early identification of patients at risk of deteriorating health or dying. Early identification was viewed as conducive to planning not only for death, but for the remainder of life. Participants were also supportive of the use of a computerized algorithm to assist with early identification, although limitations were recognized. While participants felt that having family physicians assume responsibility for early identification and ACP was appropriate, questions arose around feasibility, including whether family physicians have sufficient time for ACP. Preferences related to the content of and approach to ACP discussions were highly individualized. Required supports during ACP include informational and emotional supports. Conclusions This work supports the role of primary care providers in the early identification of individuals at risk of deteriorating health or death and the process of ACP. To improve ACP capacity in primary healthcare settings, compensation systems for primary care providers should be adjusted to ensure appropriate compensation and to accommodate longer ACP appointments. Additional resources and more established links to community organizations and services will also be required to facilitate referrals to relevant community services as part of the ACP process.
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Affiliation(s)
- Cynthia Kendell
- Cancer Outcomes Research Program, Department of Surgery, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.
| | - Jyoti Kotecha
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Mary Martin
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Han Han
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Margaret Jorgensen
- Cancer Outcomes Research Program, Department of Surgery, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Robin Urquhart
- Cancer Outcomes Research Program, Department of Surgery, Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.,Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
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9
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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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10
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Veldhoven CMM, Nutma N, De Graaf W, Schers H, Verhagen CAHHVM, Vissers KCP, Engels Y. Screening with the double surprise question to predict deterioration and death: an explorative study. BMC Palliat Care 2019; 18:118. [PMID: 31881958 PMCID: PMC6935168 DOI: 10.1186/s12904-019-0503-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 12/09/2019] [Indexed: 12/25/2022] Open
Abstract
Background Early identification of palliative patients is challenging. The Surprise Question (SQ1; Would I be surprised if this patient were to die within 12 months?) is widely used to identify palliative patients. However, its predictive value is low. Therefore, we added a second question (SQ2) to SQ1: ‘Would I be surprised if this patient is still alive after 12 months?’ We studied the accuracy of this double surprise question (DSQ) in a general practice. Methods We performed a prospective cohort study with retrospective medical record review in a general practice in the eastern part of the Netherlands. Two general practitioners (GPs) answered both questions for all 292 patients aged ≥75 years (mean age 84 years). Primary outcome was 1-year death, secondary outcomes were aspects of palliative care. Results SQ1 was answered with ‘no‘ for 161/292 patients. Of these, SQ2 was answered with ‘yes’ in 22 patients. Within 12 months 26 patients died, of whom 24 had been identified with SQ1 (sensitivity: 92%, specificity: 49%). Ten of them were also identified with SQ2 (sensitivity: 42%, specificity: 91%). The latter group had more contacts with their GP and more palliative care aspects were discussed. Conclusions The DSQ appears a feasible and easy applicable screening tool in general practice. It is highly effective in predicting patients in high need for palliative care and using it helps to discriminate between patients with different life expectancies and palliative care needs. Further research is necessary to confirm the findings of this study.
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Affiliation(s)
- C M M Veldhoven
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands. .,General practice Berg en Dal, Oude Kleefsebaan 96, 6571, BJ, Berg en Dal, the Netherlands.
| | - N Nutma
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - W De Graaf
- General practice Berg en Dal, Oude Kleefsebaan 96, 6571, BJ, Berg en Dal, the Netherlands
| | - H Schers
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - C A H H V M Verhagen
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - K C P Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Y Engels
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
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11
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How do hospital-based nurses and physicians identify the palliative phase in their patients and what difficulties exist? A qualitative interview study. BMC Palliat Care 2019; 18:54. [PMID: 31288816 PMCID: PMC6617645 DOI: 10.1186/s12904-019-0439-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 07/01/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Early start of palliative care improves the quality of life of eligible patients and their relatives. However, in hospital, patients who could benefit from palliative care are often not identified timely. The aim of this study is to assess how hospital-based nurses and physicians define the palliative phase, how they identify the palliative phase and what difficulties they face. METHODS Semi-structured interviews were held with ten nurses and 18 physicians working at seven hospitals in the Netherlands. Data was analysed using thematic analysis. RESULTS Nurses and physicians feel insecure about how to define the palliative phase and differentiate between an acute and extended phase. Great variation existed in what life expectancy is attributed to each phase. A variety of ways to identify the palliative phase were described: 1) Prognostication. 2) Treatment trade-off. 3) Assessment of patients' preferences and needs. 4) Interprofessional collaboration. Professionals base prognostication on their experience but also search for clinical indicators. When benefits of treatment no longer outweigh the negatives, this was considered an, albeit late, identification point. To start a conversation on a patients' palliative care needs was found to be difficult. Therefore, some respondents wait for patients to vocalize preferences themselves. Many professionals rely on interprofessional collaboration for identification, however uncertainty exist about responsibilities. Difficulties in identification occurred because of variance in definitions, unpredictability of non-oncological diseases, focus on treatment and difficulties in communication and collaboration. CONCLUSION These results provide insight into the challenges and difficulties hospital-based professionals experience in timely identification of patients with palliative care needs.
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12
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Ding J, Johnson CE, Cook A. How We Should Assess the Delivery of End-Of-Life Care in General Practice? A Systematic Review. J Palliat Med 2018; 21:1790-1805. [PMID: 30129811 DOI: 10.1089/jpm.2018.0194] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The majority of end-of-life (EOL) care occurs in general practice. However, we still have little knowledge about how this care is delivered or how it can be assessed and supported. AIM (i) To review the existing evaluation tools used for assessment of the delivery of EOL care from the perspective of general practice; (ii) To describe how EOL care is provided in general practice; (iii) To identify major areas of concern in providing EOL care in this context. DESIGN A systematic review. DATA SOURCES Systematic searches of major electronic databases (Medline, EMBASE, PsycINFO, and CINAHL) from inception to 2017 were used to identify evaluation tools focusing on organizational structures/systems and process of end-of-life care from a general practice perspective. RESULTS A total of 43 studies representing nine evaluation tools were included. A relatively restricted focus and lack of validation were common limitations. Key general practitioner (GP) activities assessed by the evaluation tools were summarized and the main issues in current GP EOL care practice were identified. CONCLUSIONS The review of evaluation tools revealed that GPs are highly involved in management of patients at the EOL, but there are a range of issues relating to the delivery of care. An EOL care registration system integrated with electronic health records could provide an optimal approach to address the concerns about recall bias and time demands in retrospective analyses. Such a system should ideally capture the core GP activities and any major issues in care provision on a case-by-case basis.
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Affiliation(s)
- Jinfeng Ding
- 1 School of Population and Global Health, University of Western Australia , Perth, Western Australia, Australia
| | - Claire E Johnson
- 2 Cancer and Palliative Care Research and Evaluation Unit (CaPCREU), Medical School, University of Western Australia , Perth, Western Australia, Australia
- 3 School of Nursing and Midwifery, Monash University , Melbourne, Victoria, Australia
| | - Angus Cook
- 1 School of Population and Global Health, University of Western Australia , Perth, Western Australia, Australia
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Stakeholders' views on identifying patients in primary care at risk of dying: a qualitative descriptive study using focus groups and interviews. Br J Gen Pract 2018; 68:e612-e620. [PMID: 30104331 DOI: 10.3399/bjgp18x698345] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 04/30/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Strategies have been developed for use in primary care to identify patients at risk of declining health and dying, yet little is known about the perceptions of doing so or the broader implications and impacts. AIM To explore the acceptability and implications of using a primary care-based electronic medical record algorithm to help providers identify patients in their practice at risk of declining health and dying. DESIGN AND SETTING Qualitative descriptive study in Ontario and Nova Scotia, Canada. METHOD Six focus groups were conducted, supplemented by one-on-one interviews, with 29 healthcare providers, managers, and policymakers in primary care, palliative care, and geriatric care. Participants were purposively sampled to achieve maximal variation. Data were analysed using a constant comparative approach. RESULTS Six themes were prevalent across the dataset: early identification is aligned with the values, aims, and positioning of primary care; providers have concerns about what to do after identification; how we communicate about the end of life requires change; early identification and subsequent conversations require an integrated team approach; for patients, early identification will have implications beyond medical care; and a public health approach is needed to optimise early identification and its impact. CONCLUSION Stakeholders were much more concerned with how primary care providers would navigate the post-identification period than with early identification itself. Implications of early identification include the need for a team-based approach to identification and to engage broader communities to ensure people live and die well post-identification.
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Winthereik AK, Neergaard MA, Jensen AB, Vedsted P. Development, modelling, and pilot testing of a complex intervention to support end-of-life care provided by Danish general practitioners. BMC FAMILY PRACTICE 2018; 19:91. [PMID: 29925332 PMCID: PMC6011239 DOI: 10.1186/s12875-018-0774-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 05/25/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Most patients in end-of-life with life-threatening diseases prefer to be cared for and die at home. Nevertheless, the majority die in hospitals. GPs have a pivotal role in providing end-of-life care at patients' home, and their involvement in the palliative trajectory enhances the patient's possibility to stay at home. The aim of this study was to develop and pilot-test an intervention consisting of continuing medical education (CME) and electronic decision support (EDS) to support end-of-life care in general practice. METHODS We developed an intervention in line with the first phases of the guidelines for complex interventions drawn up by the Medical Research Council. Phase 1 involved the development of the intervention including identification of key barriers to provision of end-of-life care for GPs and of facilitators of change. Furthermore the actual modelling of two components: CME meeting and EDS. Phase 2 focused on pilot-testing and intervention assessment by process evaluation. RESULTS In phase 1 lack of identification of patients at the end of life and limited palliative knowledge among GPs were identified as barriers. The CME meeting and the EDS were developed. The CME meeting was a four-hour educational meeting performed by GPs and specialists in palliative care. The EDS consisted of two parts: a pop-up window for each patient with palliative needs and a list of all patients with palliative needs in the practice. The pilot testing in phase 2 showed that the CME meeting was performed as intended and 120 (14%) of the GPs in the region attended. The EDS was integrated in existing electronic records but was shut down early for external reasons; 50 (5%) GPs signed up. The pilot-testing demonstrated a need to strengthen the implementation as attending rate was low in the current set-up. CONCLUSION We developed a complex intervention to support GPs in providing end-of-life care. The pilot-test showed general acceptance of the CME meetings. The EDS was shut down early and needs further evaluation before examining the whole intervention in a larger study, where evaluation could be based on patient-related outcomes and impact on end-of-life care. TRIAL REGISTRATION Clinicaltrials.gov ( NCT02050256 ) January 30, 2014.
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Affiliation(s)
- Anna Kirstine Winthereik
- Department of Oncology, Aarhus University Hospital, Noerrebrogade 44, 8000, Aarhus C, Denmark.
- Department of Clinical Medicine, Aarhus University, Noerrebrogade 44, 8000, Aarhus C, Denmark.
| | - Mette Asbjoern Neergaard
- Palliative Care Team, Department of Oncology, Aarhus University Hospital, Noerrebrogade 44, 8000, Aarhus, Denmark
| | - Anders Bonde Jensen
- Department of Oncology, Aarhus University Hospital, Noerrebrogade 44, 8000, Aarhus C, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus, Denmark
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Weijers F, Veldhoven C, Verhagen C, Vissers K, Engels Y. Adding a second surprise question triggers general practitioners to increase the thoroughness of palliative care planning: results of a pilot RCT with cage vignettes. BMC Palliat Care 2018; 17:64. [PMID: 29673361 PMCID: PMC5909217 DOI: 10.1186/s12904-018-0312-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 03/23/2018] [Indexed: 12/21/2022] Open
Abstract
Background In our aging society, palliative care should be a standard component of health care. However, currently it is only provided to a small proportion of patients, mostly to those with cancer, and restricted to the terminal phase. Many general practitioners (GPs) say that one of their most significant challenges is to assess the right moment to start anticipatory palliative care. The “Surprise Question” (SQ1: “Would I be surprised if this patient were to die in the next 12 months”?), if answered with “no”, is an easy tool to apply in identifying patients in need of palliative care. However, this tool has a low specificity. Therefore, the aim of our pilot study was to determine if adding a second, more specific “Surprise Question” (SQ2: “Would I be surprised if this patient is still alive after 12 months”?) in case SQ1 is answered in the negative, prompts GPs to plan for anticipatory palliative care. Methods By randomization, 28 GPs in the south-eastern part of the Netherlands were allocated to three different groups. They all received a questionnaire with four vignettes, respectively representing patients with advanced organ failure (A), end stage cancer (B), frailty (C), and recently diagnosed cancer (D). GPs in the first group did not receive additional information, the second group received SQ1 after each vignette, and the third group received SQ1 and SQ2 after each vignette. We rated their answers based on essential components of palliative care (here called RADIANT score). Results GPs in group 3 gave higher RADIANT scores to those vignettes in which they would be surprised if the patients were still alive after 12 months. In all groups, vignette B had the highest mean RADIANT score, followed by vignettes A and C, and the lowest on vignette D. Seventy-one percent of GPs in groups 2 and 3 considered SQ1 a helpful tool, and 75% considered SQ2 helpful. Conclusions This innovative pilot study indicates that the majority of GPs think SQ2 is a helpful additional tool. The combination of the two “Surprise Questions” encourages GPs to make more specific plans for anticipatory palliative care. Electronic supplementary material The online version of this article (10.1186/s12904-018-0312-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- F Weijers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Postbox 9101, internal code 549, 6500, HB, Nijmegen, the Netherlands
| | - C Veldhoven
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Postbox 9101, internal code 549, 6500, HB, Nijmegen, the Netherlands
| | - C Verhagen
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Postbox 9101, internal code 549, 6500, HB, Nijmegen, the Netherlands
| | - K Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Postbox 9101, internal code 549, 6500, HB, Nijmegen, the Netherlands
| | - Y Engels
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud university medical center, Postbox 9101, internal code 549, 6500, HB, Nijmegen, the Netherlands.
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Hamano J, Oishi A, Kizawa Y. Identified Palliative Care Approach Needs with SPICT in Family Practice: A Preliminary Observational Study. J Palliat Med 2018; 21:992-998. [PMID: 29425053 DOI: 10.1089/jpm.2017.0491] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Identifying patients who require palliative care approach is challenging for family physicians, even though several identification tools have been developed for this purpose. OBJECTIVE To explore the prevalence and characteristics of family practice patients who need palliative care approach as determined using Supportive and Palliative Care Indicators Tool (SPICT™, April 2015) in Japan. DESIGN Single-center cross-sectional study. SETTING/SUBJECTS We enrolled all patients ≥65 years of age who visited the chief researcher's outpatient clinic in October 2016. MEASUREMENTS We used Japanese version of SPICT (SPICT-J) to identify patients who need palliative care approach. We assessed patients' backgrounds and whether they had undergone advance care planning with their family physicians. RESULTS This study included 87 patients (61 females) with a mean age of 79.0 ± 7.4 years. Eight patients (9.2%) were identified as needing palliative care approach. The mean age of patients who needed this approach was 82.3 ± 8.3 years and main underlying conditions were heart/vascular disease (37.5%), dementia/frailty (25.0%), and respiratory disease (12.5%). Only two of eight patients identified as needing palliative care approach had discussed advance care planning with their family physicians. CONCLUSIONS In family practice, 9.2% of outpatients ≥65 years of age were identified as needing palliative care approach. Family physicians should carefully evaluate whether outpatients need palliative care approach.
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Affiliation(s)
- Jun Hamano
- 1 Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba , Tsukuba, Japan
| | - Ai Oishi
- 2 Primary Palliative Care Research Group, Usher Institute of Population Health Sciences and Informatics University of Edinburgh , Edinburgh, United Kingdom
| | - Yoshiyuki Kizawa
- 3 Department of Palliative Medicine, Kobe University Graduate School of Medicine , Kobe, Japan
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Lakkappa B, Shah S, Rogers S, Holman LH. Mortality among referrals to a community-based intermediate care team. BMJ Support Palliat Care 2017; 9:263-266. [PMID: 29151044 DOI: 10.1136/bmjspcare-2017-001364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 08/12/2017] [Accepted: 10/25/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Intermediate care services have been introduced to help mitigate unnecessary hospital demand and premature placement in long-term residential care. Many patients are elderly and/or with complex comorbidities, but little consideration has been given to the palliative care needs of patients referred to intermediate care services. The objective of this study is to determine the proportion of patients referred to a community-based intermediate care team who died during care and up to 24 months after discharge and so to help inform the development of supportive and palliative care in this setting. METHODS A retrospective cohort study of all 4770 adult patients referred to Northamptonshire Intermediate Care Team (ICT) between 11 April 2010 and 10 April 2011. RESULTS Of 4770 patients referred, 60% were 75 years or older and 32% were 85 years of age or older. 4.0% of patients died during their ICT stay and 11% within 30 days of discharge. At the end of 12 months, 25% of the patients had died, increasing to 32% before the end of the second year. About 34% of all deaths occurred during the ICT stay or within 30 days of discharge, and a further 46% by the end of the first year. Male gender and higher age were associated with greater likelihood of death. CONCLUSIONS It is important for ICT clinicians to consider immediate and longer-term palliative care needs among patients referred to ICTs. Care models involving ICTs and palliative care teams working together could enable more people with end-stage non-cancer illnesses to die at home.
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Affiliation(s)
- Bharath Lakkappa
- Intermediate Care Team, Northamptonshire Healthcare NHS Foundation Trust, Northampton, UK
| | - Sanjay Shah
- Palliative Care, Northamptonshire Healthcare NHS Foundation Trust, Northampton, UK
| | - Stephen Rogers
- Research and Development, Northamptonshire Healthcare NHS Foundation Trust, Northampton, UK
| | - Leanne Helen Holman
- Research and Development, Northamptonshire Healthcare NHS Foundation Trust, Northampton, UK
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Gallais Sérézal I, Beaussant Y, Rochigneux P, Tournigand C, Aubry R, Lindelöf B, Morin L. End-of-life care for hospitalized patients with metastatic melanoma in France: a nationwide, register-based study. Br J Dermatol 2016; 175:583-92. [DOI: 10.1111/bjd.14631] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2016] [Indexed: 11/29/2022]
Affiliation(s)
- I. Gallais Sérézal
- Department of Dermatovenereology; Karolinska Hospital and Department of Medicine; Karolinska Institutet; Stockholm Sweden
| | - Y. Beaussant
- Department of Palliative Care; Besançon University Hospital; Besançon France
- INSERM CIT808; Besançon University Hospital; Besançon France
| | - P. Rochigneux
- Medical Oncology; Institut Paoli-Calmettes; Marseille France
| | - C. Tournigand
- Oncology Department; Hôpital Henri Mondor; Assistance Publique Hôpitaux de Paris; Créteil France
- Paris-Est Créteil University; Créteil France
| | - R. Aubry
- Department of Palliative Care; Besançon University Hospital; Besançon France
- INSERM CIT808; Besançon University Hospital; Besançon France
| | - B. Lindelöf
- Department of Dermatovenereology; Karolinska Hospital and Department of Medicine; Karolinska Institutet; Stockholm Sweden
| | - L. Morin
- Aging Research Center; Karolinska Institutet and Stockholm University; Gävlegatan 16 11330 Stockholm Sweden
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Birchley G, Jones K, Huxtable R, Dixon J, Kitzinger J, Clare L. Dying well with reduced agency: a scoping review and thematic synthesis of the decision-making process in dementia, traumatic brain injury and frailty. BMC Med Ethics 2016; 17:46. [PMID: 27461340 PMCID: PMC4962460 DOI: 10.1186/s12910-016-0129-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/13/2016] [Indexed: 12/02/2022] Open
Abstract
Background In most Anglophone nations, policy and law increasingly foster an autonomy-based model, raising issues for large numbers of people who fail to fit the paradigm, and indicating problems in translating practical and theoretical understandings of ‘good death’ to policy. Three exemplar populations are frail older people, people with dementia and people with severe traumatic brain injury. We hypothesise that these groups face some over-lapping challenges in securing good end-of-life care linked to their limited agency. To better understand these challenges, we conducted a scoping review and thematic synthesis. Methods To capture a range of literature, we followed established scoping review methods. We then used thematic synthesis to describe the broad themes emerging from this literature. Results Initial searches generated 22,375 references, and screening yielded 49, highly heterogeneous, studies that met inclusion criteria, encompassing 12 countries and a variety of settings. The thematic synthesis identified three themes: the first concerned the processes of end-of-life decision-making, highlighting the ambiguity of the dominant shared decision-making process, wherein decisions are determined by families or doctors, sometimes explicitly marginalising the antecedent decisions of patients. Despite this marginalisation, however, the patient does play a role both as a social presence and as an active agent, by whose actions the decisions of those with authority are influenced. The second theme examined the tension between predominant notions of a good death as ‘natural’ and the drive to medicalise death through the lens of the experiences and actions of those faced with the actuality of death. The final theme considered the concept of antecedent end-of-life decision-making (in all its forms), its influence on policy and decision-making, and some caveats that arise from the studies. Conclusions Together these three themes indicate a number of directions for future research, which are likely to be applicable to other conditions that result in reduced agency. Above all, this review emphasises the need for new concepts and fresh approaches to end of life decision-making that address the needs of the growing population of frail older people, people with dementia and those with severe traumatic brain injury. Electronic supplementary material The online version of this article (doi:10.1186/s12910-016-0129-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Giles Birchley
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK.
| | - Kerry Jones
- Faculty of Health and Social Care, The Open University, Milton Keynes, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | - Jeremy Dixon
- Department of Social and Policy Sciences, University of Bath, Bath, UK
| | - Jenny Kitzinger
- Coma and Disorders of Consciousness Research Centre, Cardiff University, Cardiff, UK
| | - Linda Clare
- REACH: The Centre for Research in Ageing and Cognitive Health, University of Exeter, Exeter, UK
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Perkins GD, Griffiths F, Slowther AM, George R, Fritz Z, Satherley P, Williams B, Waugh N, Cooke MW, Chambers S, Mockford C, Freeman K, Grove A, Field R, Owen S, Clarke B, Court R, Hawkes C. Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04110] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundCardiac arrest is the final common step in the dying process. In the right context, resuscitation can reverse the dying process, yet success rates are low. However, cardiopulmonary resuscitation (CPR) is a highly invasive medical treatment, which, if applied in the wrong setting, can deprive the patient of dignified death. Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) decisions provide a mechanism to withhold CPR. Recent scientific and lay press reports suggest that the implementation of DNACPR decisions in NHS practice is problematic.Aims and objectivesThis project sought to identify reasons why conflict and complaints arise, identify inconsistencies in NHS trusts’ implementation of national guidelines, understand health professionals’ experience in relation to DNACPR, its process and ethical challenges, and explore the literature for evidence to improve DNACPR policy and practice.MethodsA systematic review synthesised evidence of processes, barriers and facilitators related to DNACPR decision-making and implementation. Reports from NHS trusts, the National Reporting and Learning System, the Parliamentary and Health Service Ombudsman, the Office of the Chief Coroner, trust resuscitation policies and telephone calls to a patient information line were reviewed. Multiple focus groups explored service-provider perspectives on DNACPR decisions. A stakeholder group discussed the research findings and identified priorities for future research.ResultsThe literature review found evidence that structured discussions at admission to hospital or following deterioration improved patient involvement and decision-making. Linking DNACPR to overall treatment plans improved clarity about goals of care, aided communication and reduced harms. Standardised documentation improved the frequency and quality of recording decisions. Approximately 1500 DNACPR incidents are reported annually. One-third of these report harms, including some instances of death. Problems with communication and variation in trusts’ implementation of national guidelines were common. Members of the public were concerned that their wishes with regard to resuscitation would not be respected. Clinicians felt that DNACPR decisions should be considered within the overall care of individual patients. Some clinicians avoid raising discussions about CPR for fear of conflict or complaint. A key theme across all focus groups, and reinforced by the literature review, was the negative impact on overall patient care of having a DNACPR decision and the conflation of ‘do not resuscitate’ with ‘do not provide active treatment’.LimitationsThe variable quality of some data sources allows potential overstatement or understatement of findings. However, data source triangulation identified common issues.ConclusionThere is evidence of variation and suboptimal practice in relation to DNACPR decisions across health-care settings. There were deficiencies in considering, discussing and implementing the decision, as well as unintended consequences of DNACPR decisions being made on other aspects of patient care.Future workRecommendations supported by the stakeholder group are standardising NHS policies and forms, ensuring cross-boundary recognition of DNACPR decisions, integrating decisions with overall treatment plans and developing tools and training strategies to support clinician and patient decision-making, including improving communication.Study registrationThis study is registered as PROSPERO CRD42012002669.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Gavin D Perkins
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Frances Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Anne-Marie Slowther
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Robert George
- Cicely Saunders Institute, King’s College London, London, UK
- Palliative Care, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - Zoe Fritz
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Barry Williams
- Patient and Relative Committee, The Intensive Care Foundation, London, UK
| | - Norman Waugh
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Matthew W Cooke
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Sue Chambers
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Carole Mockford
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Karoline Freeman
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Amy Grove
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Richard Field
- Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Sarah Owen
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Ben Clarke
- Medical School, University of Glasgow, Glasgow, UK
| | - Rachel Court
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Claire Hawkes
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Vrijmoeth C, Christians MGM, Festen DAM, Groot M, Tonino M, Echteld MA. Physicians' recognition of death in the foreseeable future in patients with intellectual disabilities. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2016; 60:207-217. [PMID: 26757410 DOI: 10.1111/jir.12240] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 10/01/2015] [Accepted: 10/07/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Physicians are increasingly confronted with people with intellectual disabilities (ID) who are facing life-threatening diseases. We aimed to explore when and based on which information sources and signals physicians recognised that a patient with ID would die in the foreseeable future. Insights may help in identifying patients in need of palliative care. METHOD In this study, 81 physicians for people with ID and 16 general practitioners completed a retrospective survey about their last case of a patient with ID with a non-sudden death. RESULTS More than 20% of all physicians foresaw death not until the last week of life. In 30% of all patients, the physician did not discuss the start of the palliative care phase until the last week. The most reported information sources based on which physicians foresaw death were the physicians themselves and professional caregivers. We found 40 different signals that lead to physicians' foreseeing death. These were not only medical signals but also behavioural and physical signals. CONCLUSIONS Results indicate that the physicians' ability to foresee death is a result of a process of growing awareness in which multiple signals from different information sources converge. This demands continuous multi-disciplinary communication because people involved have their own unique interactions with the patient and can therefore contribute to a growing and timely awareness of patients' death in the future.
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Affiliation(s)
- C Vrijmoeth
- Intellectual Disabilities and Health, Department of Primary and Community Health Care, Radboud University Medical Centre, Nijmegen, Netherlands
- Intellectual Disability Medicine, Department of General Practice, Erasmus Medical Centre, Rotterdam, Netherlands
| | - M G M Christians
- Intellectual Disabilities and Health, Department of Primary and Community Health Care, Radboud University Medical Centre, Nijmegen, Netherlands
| | - D A M Festen
- Intellectual Disability Medicine, Department of General Practice, Erasmus Medical Centre, Rotterdam, Netherlands
| | - M Groot
- Department of Anesthesiology, Pain and Palliative Care/Expertise Centre for Palliative Care, Radboud University Medical Center, Nijmegen, Netherlands
| | - M Tonino
- Prisma Foundation, Biezenmortel, Netherlands
| | - M A Echteld
- Prisma Foundation, Biezenmortel, Netherlands
- Science in Balance Foundation, Rotterdam, Netherlands
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Rubin G, Berendsen A, Crawford SM, Dommett R, Earle C, Emery J, Fahey T, Grassi L, Grunfeld E, Gupta S, Hamilton W, Hiom S, Hunter D, Lyratzopoulos G, Macleod U, Mason R, Mitchell G, Neal RD, Peake M, Roland M, Seifert B, Sisler J, Sussman J, Taplin S, Vedsted P, Voruganti T, Walter F, Wardle J, Watson E, Weller D, Wender R, Whelan J, Whitlock J, Wilkinson C, de Wit N, Zimmermann C. The expanding role of primary care in cancer control. Lancet Oncol 2015; 16:1231-72. [PMID: 26431866 DOI: 10.1016/s1470-2045(15)00205-3] [Citation(s) in RCA: 355] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 07/25/2015] [Accepted: 07/27/2015] [Indexed: 12/21/2022]
Abstract
The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.
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Affiliation(s)
- Greg Rubin
- School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK.
| | - Annette Berendsen
- Department of General Practice, University of Groningen, Groningen, Netherlands
| | | | - Rachel Dommett
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Craig Earle
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Jon Emery
- Department of General Practice, University of Melbourne, Melbourne, VIC, Australia
| | - Tom Fahey
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Luigi Grassi
- Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy
| | - Eva Grunfeld
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Sumit Gupta
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | | | | | - David Hunter
- School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK
| | | | - Una Macleod
- Hull-York Medical School, University of Hull, Hull, UK
| | - Robert Mason
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Geoffrey Mitchell
- Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, QLD, Australia
| | - Richard D Neal
- North Wales Centre for Primary Care Research, Bangor University, Bangor, Wales
| | | | - Martin Roland
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Bohumil Seifert
- Department of General Practice, Charles University, Prague, Czech Republic
| | - Jeff Sisler
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Stephen Taplin
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Peter Vedsted
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Teja Voruganti
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Fiona Walter
- Department of General Practice, University of Groningen, Groningen, Netherlands
| | - Jane Wardle
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Eila Watson
- Department of Clinical Health Care, Oxford Brookes University, Oxford, UK
| | - David Weller
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Jeremy Whelan
- Research Department of Oncology, University College London, London, UK
| | - James Whitlock
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research, Bangor University, Bangor, Wales
| | - Niek de Wit
- Department of General Practice, University Medical Center Utrecht, Utrecht, Netherlands
| | - Camilla Zimmermann
- Division of Medical Oncology and Haematology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Moroni M, Zocchi D, Bolognesi D, Abernethy A, Rondelli R, Savorani G, Salera M, Dall'Olio FG, Galli G, Biasco G. The 'surprise' question in advanced cancer patients: A prospective study among general practitioners. Palliat Med 2014; 28:959-964. [PMID: 24662237 DOI: 10.1177/0269216314526273] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Using the 'surprise' question 'Would you be surprised if this patient died in the next year?' may improve physicians' prognostic accuracy and identify people appropriate for palliative care. AIM Determine the prognostic accuracy of general practitioners asking the 'surprise' question about their patients with advanced (stage IV) cancer. DESIGN Prospective cohort study. SETTING/PARTICIPANTS Between December 2011 and February 2012, 42 of 50 randomly selected general practitioners (Bologna area, Italy) prospectively classified 231 patients diagnosed with advanced cancer according to the 'surprise' question and supplied the status of each patient 1 year later. RESULTS Of the 231 patients, general practitioners responded 'No' to the 'surprise' question for 126 (54.5%) and 'Yes' for 105 (45.5%). After 12 months, 104 (45.0%) patients had died; 87 (83.7%) were in the 'No' group. The sensitivity of the 'surprise' question was 69.3%; the specificity was 83.6%. Positive predictive value was 83.8%; negative predictive value was 69.0%. The answer to the 'surprise' question was significantly correlated with survival at 1 year. Patients in the 'No' group had an odds ratio of 11.55 (95% confidence interval: 5.83-23.28) and a hazard ratio of 6.99 (95% confidence interval: 3.75-13.03) of being dead in the next year compared to patients in the 'Yes' group (p = 0.000 for both odds ratio and hazard ratio). CONCLUSION When general practitioners used the 'surprise' question for their patients with advanced cancer, the accuracy of survival prognosis was very high. This has clinical potential as a method to identify patients who might benefit from palliative care.
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Affiliation(s)
- Matteo Moroni
- "MariaTeresa Chiantore Seràgnoli" Hospice Foundation, Bologna, Italy Academy of Sciences of Palliative Medicine, Bologna, Italy
| | - Donato Zocchi
- Regional Health System, Emilia-Romagna Region, Italy
| | | | - Amy Abernethy
- Center for Learning Health Care, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Roberto Rondelli
- Pediatric Oncology and Haematology Unit "Lalla Seràgnoli", University of Bologna, S. Orsola Malpighi Hospital, Bologna, Italy
| | | | | | - Filippo G Dall'Olio
- "Giorgio Prodi" Center for Cancer Research, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Giulia Galli
- "Giorgio Prodi" Center for Cancer Research, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Guido Biasco
- Academy of Sciences of Palliative Medicine, Bologna, Italy "Giorgio Prodi" Center for Cancer Research, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Bailey FA, Williams BR, Woodby LL, Goode PS, Redden DT, Houston TK, Granstaff US, Johnson TM, Pennypacker LC, Haddock KS, Painter JM, Spencer JM, Hartney T, Burgio KL. Intervention to improve care at life's end in inpatient settings: the BEACON trial. J Gen Intern Med 2014; 29:836-43. [PMID: 24449032 PMCID: PMC4026508 DOI: 10.1007/s11606-013-2724-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Widespread implementation of palliative care treatment plans could reduce suffering in the last days of life by adopting best practices of traditionally home-based hospice care in inpatient settings. OBJECTIVE To evaluate the effectiveness of a multi-modal intervention strategy to improve processes of end-of-life care in inpatient settings. DESIGN Implementation trial with an intervention staggered across hospitals using a multiple-baseline, stepped wedge design. PARTICIPANTS Six Veterans Affairs Medical Centers (VAMCs). INTERVENTION Staff training was targeted to all hospital providers and focused on identifying actively dying patients and implementing best practices from home-based hospice care, supported with an electronic order set and paper-based educational tools. MAIN MEASURES Several processes of care were identified as quality endpoints for end-of-life care (last 7 days) and abstracted from electronic medical records of veterans who died before or after intervention (n = 6,066). Primary endpoints were proportion with an order for opioid pain medication at time of death, do-not-resuscitate order, location of death, nasogastric tube, intravenous line infusing, and physical restraints. Secondary endpoints were administration of opioids, order/administration of antipsychotics, benzodiazepines, and scopolamine (for death rattle); sublingual administration; advance directives; palliative care consultations; and pastoral care services. Generalized estimating equations were conducted adjusting for longitudinal trends. KEY RESULTS Significant intervention effects were observed for orders for opioid pain medication (OR: 1.39), antipsychotic medications (OR: 1.98), benzodiazepines (OR: 1.39), death rattle medications (OR: 2.77), sublingual administration (OR: 4.12), nasogastric tubes (OR: 0.71), and advance directives (OR: 1.47). Intervention effects were not significant for location of death, do-not-resuscitate orders, intravenous lines, or restraints. CONCLUSIONS This broadly targeted intervention strategy led to modest but statistically significant changes in several processes of care, indicating its potential for widespread dissemination to improve end-of-life care for thousands of patients who die each year in inpatient settings.
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Affiliation(s)
- F. Amos Bailey
- />Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), 11G, 700 South 19th Street, Birmingham, AL 35233 USA
- />University of Alabama at Birmingham, Birmingham, AL USA
| | - Beverly R. Williams
- />Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), 11G, 700 South 19th Street, Birmingham, AL 35233 USA
- />University of Alabama at Birmingham, Birmingham, AL USA
| | - Lesa L. Woodby
- />Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), 11G, 700 South 19th Street, Birmingham, AL 35233 USA
- />University of Alabama at Birmingham, Birmingham, AL USA
| | - Patricia S. Goode
- />Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), 11G, 700 South 19th Street, Birmingham, AL 35233 USA
- />University of Alabama at Birmingham, Birmingham, AL USA
| | - David T. Redden
- />Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), 11G, 700 South 19th Street, Birmingham, AL 35233 USA
- />University of Alabama at Birmingham, Birmingham, AL USA
| | - Thomas K. Houston
- />Department of Veterans Affairs, VA eHealth Quality Enhancement Research Initiative, Bedford, MA USA
- />University of Massachusetts Medical School, Worcester, MA USA
| | - U. Shanette Granstaff
- />Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), 11G, 700 South 19th Street, Birmingham, AL 35233 USA
- />University of Alabama at Birmingham, Birmingham, AL USA
| | - Theodore M. Johnson
- />Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Decatur, GA USA
- />Emory University, Atlanta, GA USA
| | | | - K. Sue Haddock
- />William Jennings Bryan Dorn VA Medical Center, Columbia, SC USA
| | | | | | | | - Kathryn L. Burgio
- />Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), 11G, 700 South 19th Street, Birmingham, AL 35233 USA
- />University of Alabama at Birmingham, Birmingham, AL USA
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Evans CJ, Ho Y, Daveson BA, Hall S, Higginson IJ, Gao W. Place and cause of death in centenarians: a population-based observational study in England, 2001 to 2010. PLoS Med 2014; 11:e1001653. [PMID: 24892645 PMCID: PMC4043499 DOI: 10.1371/journal.pmed.1001653] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 04/17/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Centenarians are a rapidly growing demographic group worldwide, yet their health and social care needs are seldom considered. This study aims to examine trends in place of death and associations for centenarians in England over 10 years to consider policy implications of extreme longevity. METHODS AND FINDINGS This is a population-based observational study using death registration data linked with area-level indices of multiple deprivations for people aged ≥100 years who died 2001 to 2010 in England, compared with those dying at ages 80-99. We used linear regression to examine the time trends in number of deaths and place of death, and Poisson regression to evaluate factors associated with centenarians' place of death. The cohort totalled 35,867 people with a median age at death of 101 years (range: 100-115 years). Centenarian deaths increased 56% (95% CI 53.8%-57.4%) in 10 years. Most died in a care home with (26.7%, 95% CI 26.3%-27.2%) or without nursing (34.5%, 95% CI 34.0%-35.0%) or in hospital (27.2%, 95% CI 26.7%-27.6%). The proportion of deaths in nursing homes decreased over 10 years (-0.36% annually, 95% CI -0.63% to -0.09%, p = 0.014), while hospital deaths changed little (0.25% annually, 95% CI -0.06% to 0.57%, p = 0.09). Dying with frailty was common with "old age" stated in 75.6% of death certifications. Centenarians were more likely to die of pneumonia (e.g., 17.7% [95% CI 17.3%-18.1%] versus 6.0% [5.9%-6.0%] for those aged 80-84 years) and old age/frailty (28.1% [27.6%-28.5%] versus 0.9% [0.9%-0.9%] for those aged 80-84 years) and less likely to die of cancer (4.4% [4.2%-4.6%] versus 24.5% [24.6%-25.4%] for those aged 80-84 years) and ischemic heart disease (8.6% [8.3%-8.9%] versus 19.0% [18.9%-19.0%] for those aged 80-84 years) than were younger elderly patients. More care home beds available per 1,000 population were associated with fewer deaths in hospital (PR 0.98, 95% CI 0.98-0.99, p<0.001). CONCLUSIONS Centenarians are more likely to have causes of death certified as pneumonia and frailty and less likely to have causes of death of cancer or ischemic heart disease, compared with younger elderly patients. To reduce reliance on hospital care at the end of life requires recognition of centenarians' increased likelihood to "acute" decline, notably from pneumonia, and wider provision of anticipatory care to enable people to remain in their usual residence, and increasing care home bed capacity.
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Affiliation(s)
- Catherine J. Evans
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King’s College London, United Kingdom
- Sussex Community NHS Trust, Brighton and Hove, United Kingdom
- * E-mail:
| | - Yuen Ho
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King’s College London, United Kingdom
| | - Barbara A. Daveson
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King’s College London, United Kingdom
| | - Sue Hall
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King’s College London, United Kingdom
| | - Irene J. Higginson
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King’s College London, United Kingdom
| | - Wei Gao
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King’s College London, United Kingdom
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Evans N, Costantini M, Pasman HR, Van den Block L, Donker GA, Miccinesi G, Bertolissi S, Gil M, Boffin N, Zurriaga O, Deliens L, Onwuteaka-Philipsen B. End-of-life communication: a retrospective survey of representative general practitioner networks in four countries. J Pain Symptom Manage 2014; 47:604-619.e3. [PMID: 23932176 DOI: 10.1016/j.jpainsymman.2013.04.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 04/22/2013] [Accepted: 05/02/2013] [Indexed: 11/25/2022]
Abstract
CONTEXT Effective communication is central to high-quality end-of-life care. OBJECTIVES This study examined the prevalence of general practitioner (GP)-patient discussion of end-of-life topics (according to the GP) in Italy, Spain, Belgium, and The Netherlands and associated patient and care characteristics. METHODS This cross-sectional, retrospective survey was conducted with representative GP networks. Using a standardized form, GPs recorded the health and care characteristics in the last three months of life, and the discussion of 10 end-of-life topics, of all patients who died under their care. The mean number of topics discussed, the prevalence of discussion of each topic, and patient and care characteristics associated with discussions were estimated per country. RESULTS In total, 4396 nonsudden deaths were included. On average, more topics were discussed in The Netherlands (mean=6.37), followed by Belgium (4.45), Spain (3.32), and Italy (3.19). The topics most frequently discussed in all countries were "physical complaints" and the "primary diagnosis," whereas "spiritual and existential issues" were the least frequently discussed. Discussions were most prevalent in The Netherlands, followed by Belgium. The GPs from all countries tended to discuss fewer topics with older patients, noncancer patients, patients with dementia, patients for whom palliative care was not an important treatment aim, and patients for whom their GP had not provided palliative care. CONCLUSION The prevalence of end-of-life discussions varied across the four countries. In all countries, training priorities should include the identification and discussion of spiritual and social problems and early end-of-life discussions with older patients, those with cognitive decline if possible, and those with non-malignant diseases.
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Affiliation(s)
- Natalie Evans
- Department of Public and Occupational Health, EMGO Institute, VU University Medical Center, Amsterdam, The Netherlands.
| | - Massimo Costantini
- Regional Palliative Care Network, IRCCS AOU San Martino-IST, Genoa, Italy
| | - H R Pasman
- Department of Public and Occupational Health, EMGO Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Lieve Van den Block
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium
| | - Gé A Donker
- Netherlands Institute of Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Guido Miccinesi
- Clinical and Descriptive Epidemiology Unit, ISPO Cancer Prevention and Research Institute, Florence, Italy
| | | | - Milagros Gil
- Public Health Directorate, Ministry of Health, Castille and León, Spain
| | - Nicole Boffin
- Scientific Institute of Public Health, Brussels, Belgium
| | - Oscar Zurriaga
- Public Health and Research General Directorate, Valencian Regional Health Administration, Valencia, Spain; Higher Public Health Research Centre, Valencia, Madrid, Spain; Spanish Consortium for Research on Epidemiology and Public Health, Madrid, Spain
| | - Luc Deliens
- Department of Public and Occupational Health, EMGO Institute, VU University Medical Center, Amsterdam, The Netherlands; End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Brussels, Belgium
| | - Bregje Onwuteaka-Philipsen
- Department of Public and Occupational Health, EMGO Institute, VU University Medical Center, Amsterdam, The Netherlands
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Maas EAT, Murray SA, Engels Y, Campbell C. What tools are available to identify patients with palliative care needs in primary care: a systematic literature review and survey of European practice. BMJ Support Palliat Care 2013; 3:444-51. [DOI: 10.1136/bmjspcare-2013-000527] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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De Korte-Verhoef MC, Pasman HRW, Schweitzer BPM, Francke AL, Onwuteaka-Philipsen BD, Deliens L. Reasons for hospitalisation at the end of life: differences between cancer and non-cancer patients. Support Care Cancer 2013; 22:645-52. [PMID: 24146344 DOI: 10.1007/s00520-013-2019-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 10/08/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE Many patients are hospitalised during the final phase of life, even though most prefer to receive care at home until the end. This study aimed to explore the reasons and characteristics of hospitalisation in the final 3 months of life for patients who died non-suddenly, with a comparison between cancer patients and non-cancer patients. METHODS This study used a nationwide retrospective cross-sectional survey among Dutch general practitioners. RESULTS Of the 317 hospitalised patients, 65 % had cancer. Most common reasons for hospitalisation in the final 3 months of life were respiratory symptoms (31 %), digestive symptoms (17 %), and cardiovascular symptoms (17 %). Seventy-three percent of patients experienced an acute episode before hospitalisation, and for 46 % of patients, their own GP initiated the hospitalisation. Compared to non-cancer patients, cancer patients were significantly more likely to be aged less than 80 (81 versus 46 %), were more likely to be hospitalised because of digestive symptoms (22 versus 7 %), were less likely to have a curative treatment goal before the last hospitalisation (6 versus 22 %) and were less likely to die in hospital (22 versus 49 %). CONCLUSIONS Respiratory problems were the most common reasons for hospitalisation in the group of patients as a whole. Digestive problems were a frequent reason for hospitalisation in cancer patients and cardiovascular symptoms in non-cancer patients. Hospitalisation can therefore be anticipated by monitoring these relatively common symptoms. Also, timely communication with the patient is recommended about their preferences for hospital or home treatment in the case of an acute episode.
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Affiliation(s)
- Maria C De Korte-Verhoef
- Department of Public and Occupational Health and Expertise Center Palliative Care VUmc, VU University Medical Center (VUmc), EMGO Institute for Health and Care Research, Amsterdam, The Netherlands,
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GPs' recognition of death in the foreseeable future and diagnosis of a fatal condition: a national survey. BMC FAMILY PRACTICE 2013; 14:104. [PMID: 23870615 PMCID: PMC3722000 DOI: 10.1186/1471-2296-14-104] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 06/18/2013] [Indexed: 12/04/2022]
Abstract
Background Nowadays, palliative care is considered as a care continuum that may start early in the course of the disease. In order to address the evolving needs of patients for palliative care in time, GPs should be aware in good time of the diagnosis and of the imminence of death. The aim of the study was to gain insight into how long before a non-sudden death the diagnosis of the disease ultimately leading to death is made and on what kind of information the diagnosis is based. In addition, we aimed to explore when, and based on what kind of information, GPs become aware that death of a patient will be in the foreseeable future. Methods A written questionnaire focusing on the GPs’ experiences with their last patient who died non-suddenly was sent to a random representative sample of 850 GPs in the Netherlands. Results The data were analysed of the 297 GPs who responded. 76% of the reported cases were cancer patients and 24% were patients with another non-sudden cause of death. The diagnosis was made only in the last week of life for 15% of the non-cancer patients and 1% of the patients with cancer. GPs were most likely to have been informed of the diagnosis by the medical specialist, although particularly in the case of non-cancer patients GPs also relied on their own assessment of the diagnosis or on other information sources. The GP remained unaware that the patient would die in the foreseeable future until the last week of life in 26% of the non-cancer group, while this was the case for only 6% of the cancer patients. GP’s awareness was most likely to be based on the GP’s own observations of problems and/or symptoms. Conclusions The GP often only becomes aware of a fatal diagnosis and of death in the foreseeable future at a late stage in the disease trajectory, particularly in the case of non-cancer patients. It can be assumed that if the diagnosis and the nearing death are only recognised at a late stage, palliative care is either started at a very late stage or not at all.
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Pennec S, Gaymu J, Monnier A, Riou F, Aubry R, Pontone S, Cases C. Le dernier mois de l'existence : les lieux de fin de vie et de décès en France. POPULATION 2013. [DOI: 10.3917/popu.1304.0585] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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