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Bailey S, Hodgson D, Lennie SJ, Bresnen M, Hyde P. Managing death: navigating divergent logics in end-of-life care. SOCIOLOGY OF HEALTH & ILLNESS 2020; 42:1277-1295. [PMID: 32374434 DOI: 10.1111/1467-9566.13095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Delivery of end-of-life care has gained prominence in the UK, driven by a focus upon the importance of patient choice. In practice choice is influenced by several factors, including the guidance and conduct of healthcare professionals, their different understandings of what constitutes 'a good death', and contested ideas of who is best placed to deliver this. We argue that the attempt to elicit and respond to patient choice is shaped in practice by a struggle between distinct 'institutional logics'. Drawing on qualitative data from a two-part study, we examine the tensions between different professional and organisational logics in the delivery of end-of-life care. Three broad clusters of logics are identified: finance, patient choice and professional authority. We find that the logic of finance shapes the meaning and practice of 'choice', intersecting with the logic of professional authority in order to shape choices that are in the 'best interest' of the patient. Different groups might be able to draw upon alternative forms of professionalism, and through these enact different versions of choice. However, this can resemble a struggle for ownership of patients at the end of life, and therefore, reinforce a conventional script of professional authority.
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Affiliation(s)
| | | | | | - Mike Bresnen
- Manchester Metropolitan University, Manchester, UK
| | - Paula Hyde
- University of Birmingham, Birmingham, UK
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52
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Gallagher J, Bolt T, Tamiya N. Advance care planning in the community: factors of influence. BMJ Support Palliat Care 2020; 12:bmjspcare-2020-002221. [PMID: 32513679 DOI: 10.1136/bmjspcare-2020-002221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/08/2020] [Accepted: 05/04/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES This study aims to identify factors among British community-based adults associated with advance care planning engagement. Factors are then compared among six domains of wishes: medical care, spiritual and religious needs, privacy and peace, dignified care, place of death and pain relief. METHODS Cross-sectional data were analysed from a stratified random sample of adults across Great Britain (England, Scotland and Wales) who were interviewed on their attitudes towards death and dying. Weighted multivariable logistic regression tested for associations with expressing any end-of-life wishes and then for each separate domain. RESULTS Analysis of 2042 respondents (response rate: 53.5%) revealed those less likely to have discussed their wishes were: male, younger, born in the UK, owned their residence, had no experience working in health or social care, had no chronic conditions or disabilities, had not experienced the death of a close person in the last 5 years and feel neither comfortable nor uncomfortable or uncomfortable talking about death. Additional factors among the six domains associated with having not discussed wishes include: having less and more formal education, no religious beliefs, lower household income and living with at least one other person. CONCLUSIONS This study is the first to be conducted among a sample of community-dwelling British adults and the first of its kind to compare domains of end-of-life wishes. Our findings provide an understanding of social determinants which can inform a public health approach to end-of-life care that promotes advance care planning among compassionate communities.
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Affiliation(s)
- Joshua Gallagher
- School of Global and Area Studies, University of Oxford, Oxford, UK
- Health Services Research & Development Center, University of Tsukuba, Tsukuba, Japan
| | - Timothy Bolt
- Health Services Research & Development Center, University of Tsukuba, Tsukuba, Japan
- Department of Economics, Saitama University, Saitama, Japan
| | - Nanako Tamiya
- Health Services Research & Development Center, University of Tsukuba, Tsukuba, Japan
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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53
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Fraser LK, Bluebond-Langner M, Ling J. Advances and Challenges in European Paediatric Palliative Care. Med Sci (Basel) 2020; 8:medsci8020020. [PMID: 32316401 PMCID: PMC7353522 DOI: 10.3390/medsci8020020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/10/2020] [Accepted: 04/14/2020] [Indexed: 11/16/2022] Open
Abstract
Advances in both public health and medical interventions have resulted in a reduction in childhood mortality worldwide over the last few decades; however, children still have life-threatening conditions that require palliative care. Children's palliative care is a specialty that differs from palliative care for adults in many ways. This paper discusses some of the challenges, and some of the recent advances in paediatric palliative care. Developing responsive services requires good epidemiological data, as well as a clarity on services currently available and a robust definition of the group of children who would benefit from palliative care. Once a child is diagnosed with a life-limiting condition or life-limiting illness, parents face a number of complex and difficult decisions; not only about care and treatment, but also about the place of care and ultimately, place of death. The best way to address the needs of children requiring palliative care and their families is complex and requires further research and the routine collection of high-quality data. Although research in children's palliative care has dramatically increased, there is still a dearth of evidence on key components of palliative care notably decision making, communication and pain and symptom management specifically as it relates to children. This evidence is required in order to ensure that the care that these children and their families require is delivered.
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Affiliation(s)
- Lorna K Fraser
- Martin House Research Centre, University of York, York YO10 5DD, UK;
| | - Myra Bluebond-Langner
- Palliative Care for Children and Young People, Louis Dundas Centre, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK;
| | - Julie Ling
- European Association for Palliative Care, 1800 Vilvoorde, Belgium
- Correspondence:
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Wu MP, Huang SJ, Tsao LI. The Life Experiences Among Primary Family Caregivers of Home-Based Palliative Care. Am J Hosp Palliat Care 2020; 37:816-822. [PMID: 32116010 DOI: 10.1177/1049909120907601] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND An increasing number of patients with terminal illnesses prefer to die in their own homes due to aging, high medical payments, a limited number of hospitalization days, and the ability to receive care from family members. However, few studies have been conducted on the subjective perception and value of caregivers for home-based palliative care (HBPC). OBJECTIVE To identify common themes and topics of primary family caregivers' lived experiences with HBPC when taking care of terminally ill family members. METHODS We conducted audio-recorded transcripts of one-on-one in-depth interviews of primary family caregivers of HBPC. Through a purposive sampling method, the participants were all interviewed; these interviews were transcribed verbatim and analyzed using a grounded theory approach. RESULTS A total of 22 primary family caregivers participated in the study. "Wholeheartedly accompanying one's family to the end of life at home" was the core category. Six main themes describing caregivers' experiences emerged from the interviews: (1) learning the basic skills of end-of-life home care, (2) arranging the sharing and rotation of care, (3) preparing for upcoming deaths and funerals, (4) negotiating the cultural and ethical issues of end-of-life home care, (5) ensuring a comfortable life with basic life support, and (6) maintaining care characterized by concern, perseverance, and patience. CONCLUSIONS Primary family caregivers of HBPC need support and must learn home care skills by means of the holistic approach. It is crucial to establish assessment tools for caregivers' preparedness for HBPC, including biopsychosocial and cultural considerations.
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Affiliation(s)
- Meng-Ping Wu
- Department of Nursing and Center of R/D in Community Based Palliative Care, Taipei, Taiwan.,Community Nursing Section, Department of Nursing, Taipei City Hospital, Taipei, Taiwan.,School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Sheng-Jean Huang
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Lee-Ing Tsao
- National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
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55
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Taylor R, Ellis J, Gao W, Searle L, Heaps K, Davies R, Hawksworth C, Garcia-Perez A, Colclough G, Walker S, Wee B. A scoping review of initiatives to reduce inappropriate or non-beneficial hospital admissions and bed days in people nearing the end of their life: much innovation, but limited supporting evidence. BMC Palliat Care 2020; 19:24. [PMID: 32103745 PMCID: PMC7045380 DOI: 10.1186/s12904-020-0526-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 02/12/2020] [Indexed: 11/26/2022] Open
Abstract
Background Hospitalisation during the last weeks of life when there is no medical need or desire to be there is distressing and expensive. This study sought palliative care initiatives which may avoid or shorten hospital stay at the end of life and analysed their success in terms reducing bed days. Methods Part 1 included a search of literature in PubMed and Google Scholar between 2013 and 2018, an examination of governmental and organisational publications plus discussions with external and co-author experts regarding other sources. This initial sweep sought to identify and categorise relevant palliative care initiatives. In Part 2, we looked for publications providing data on hospital admissions and bed days for each category. Results A total of 1252 abstracts were reviewed, resulting in ten broad classes being identified. Further screening revealed 50 relevant publications describing a range of multi-component initiatives. Studies were generally small and retrospective. Most researchers claim their service delivered benefits. In descending frequency, benefits identified were support in the community, integrated care, out-of-hours telephone advice, care home education and telemedicine. Nurses and hospices were central to many initiatives. Barriers and factors underpinning success were rarely addressed. Conclusions A wide range of initiatives have been introduced to improve end-of-life experiences. Formal evidence supporting their effectiveness in reducing inappropriate/non-beneficial hospital bed days was generally limited or absent. Trial registration N/A
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Affiliation(s)
| | | | - Wei Gao
- Cicely Saunders Institute, London, UK
| | | | | | - Robert Davies
- Stgilesmedical Ltd, The Vestry House, St Giles High Street, London, WC2H 8LG, UK.,Stgilesmedical GmbH, Berlin, Germany
| | - Claire Hawksworth
- Stgilesmedical Ltd, The Vestry House, St Giles High Street, London, WC2H 8LG, UK
| | - Angela Garcia-Perez
- Stgilesmedical Ltd, The Vestry House, St Giles High Street, London, WC2H 8LG, UK
| | | | - Steven Walker
- Stgilesmedical Ltd, The Vestry House, St Giles High Street, London, WC2H 8LG, UK. .,Stgilesmedical GmbH, Berlin, Germany.
| | - Bee Wee
- Harris Manchester College, University of Oxford, Oxford, UK.,Sir Michael Sobell House, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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56
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Merlane H, Booth Z. Discharge planning in end-of-life care. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2020; 29:202-203. [PMID: 32105530 DOI: 10.12968/bjon.2020.29.4.202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Helen Merlane
- Senior Lecturer, Northumbria University, Newcastle upon Tyne
| | - Zoe Booth
- Palliative Care Nurse Specialist, Royal Victoria Infirmary, The Newcastle-upon-Tyne Hospitals NHS Foundation Trust
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Quinn KL, Hsu AT, Smith G, Stall N, Detsky AS, Kavalieratos D, Lee DS, Bell CM, Tanuseputro P. Association Between Palliative Care and Death at Home in Adults With Heart Failure. J Am Heart Assoc 2020; 9:e013844. [PMID: 32070207 PMCID: PMC7335572 DOI: 10.1161/jaha.119.013844] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Palliative care is associated with improved symptom control and quality of life in people with heart failure. There is conflicting evidence as to whether it is associated with a greater likelihood of death at home in this population. The objective of this study was to describe the delivery of newly initiated palliative care services in adults who die with heart failure and measure the association between receipt of palliative care and death at home compared with those who did not receive palliative care. Methods and Results We performed a population-based cohort study using linked health administrative data in Ontario, Canada of 74 986 community-dwelling adults with heart failure who died between 2010 and 2015. Seventy-five percent of community-dwelling adults with heart failure died in a hospital. Patients who received any palliative care were twice as likely to die at home compared with those who did not receive it (adjusted odds ratio 2.12 [95% CI, 2.03-2.20]; P<0.01). Delivery of home-based palliative care had a higher association with death at home (adjusted odds ratio 11.88 [95% CI, 9.34-15.11]; P<0.01), as did delivery during transitions of care between inpatient and outpatient care settings (adjusted odds ratio 8.12 [95% CI, 6.41-10.27]; P<0.01). Palliative care was most commonly initiated late in the course of a person's disease (≤30 days before death, 45.2% of subjects) and led by nonspecialist palliative care physicians 61% of the time. Conclusions Most adults with heart failure die in a hospital. Providing palliative care near the end-of-life was associated with an increased likelihood of dying at home. These findings suggest that scaling existing palliative care programs to increase access may improve end-of-life care in people dying with chronic noncancer illness.
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Affiliation(s)
- Kieran L Quinn
- Department of Medicine University of Toronto Ontario Canada.,ICES Toronto and Ottawa Ontario Canada.,Institute of Health Policy, Management and Evaluation University of Toronto Ontario Canada.,Department of Medicine Sinai Health System Toronto Ontario Canada
| | - Amy T Hsu
- ICES Toronto and Ottawa Ontario Canada.,Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Ontario Canada.,School of Epidemiology, Public Health and Preventive Medicine University of Ottawa Ontario Canada.,Bruyère Research Institute Ottawa Ontario Canada
| | - Glenys Smith
- ICES Toronto and Ottawa Ontario Canada.,Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Ontario Canada
| | - Nathan Stall
- Institute of Health Policy, Management and Evaluation University of Toronto Ontario Canada.,Women's College Research Institute Women's College Hospital Toronto Ontario Canada.,Division of Geriatric Medicine University of Toronto Ontario Canada
| | - Allan S Detsky
- Department of Medicine University of Toronto Ontario Canada.,Institute of Health Policy, Management and Evaluation University of Toronto Ontario Canada.,Department of Medicine Sinai Health System Toronto Ontario Canada
| | | | - Douglas S Lee
- Department of Medicine University of Toronto Ontario Canada.,ICES Toronto and Ottawa Ontario Canada.,Institute of Health Policy, Management and Evaluation University of Toronto Ontario Canada
| | - Chaim M Bell
- Department of Medicine University of Toronto Ontario Canada.,ICES Toronto and Ottawa Ontario Canada.,Institute of Health Policy, Management and Evaluation University of Toronto Ontario Canada.,Department of Medicine Sinai Health System Toronto Ontario Canada
| | - Peter Tanuseputro
- ICES Toronto and Ottawa Ontario Canada.,Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Ontario Canada.,School of Epidemiology, Public Health and Preventive Medicine University of Ottawa Ontario Canada.,Bruyère Research Institute Ottawa Ontario Canada.,Department of Medicine University of Ottawa Ontario Canada
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58
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May P, Roe L, McGarrigle CA, Kenny RA, Normand C. End-of-life experience for older adults in Ireland: results from the Irish longitudinal study on ageing (TILDA). BMC Health Serv Res 2020; 20:118. [PMID: 32059722 PMCID: PMC7023768 DOI: 10.1186/s12913-020-4978-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 02/11/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND End-of-life experience is a subject of significant policy interest. National longitudinal studies offer valuable opportunities to examine individual-level experiences. Ireland is an international leader in palliative and end-of-life care rankings. We aimed to describe the prevalence of modifiable problems (pain, falls, depression) in Ireland, and to evaluate associations with place of death, healthcare utilisation, and formal and informal costs in the last year of life. METHODS The Irish Longitudinal Study on Ageing (TILDA) is a nationally representative sample of over-50-year-olds, recruited in Wave 1 (2009-2010) and participating in biannual assessment. In the event of a participant's death, TILDA approaches a close relative or friend to complete a voluntary interview on end-of-life experience. We evaluated associations using multinomial logistic regression for place of death, ordinary least squares for utilisation, and generalised linear models for costs. We identified 14 independent variables for regressions from a rich set of potential predictors. Of 516 confirmed deaths between Waves 1 and 3, the analytic sample contained 375 (73%) decedents for whom proxies completed an interview. RESULTS There was high prevalence of modifiable problems pain (50%), depression (45%) and falls (41%). Those with a cancer diagnosis were more likely to die at home (relative risk ratio: 2.5; 95% CI: 1.3-4.8) or in an inpatient hospice (10.2; 2.7-39.2) than those without. Place of death and patterns of health care use were determined not only by clinical need, but other factors including age and household structure. Unpaid care accounted for 37% of all care received but access to this care, as well as place of death, may be adversely affected by living alone or in a rural area. Deficits in unpaid care are not balanced by higher formal care use. CONCLUSIONS Despite Ireland's well-established palliative care services, clinical need is not the sole determinant of end-of-life experience. Cancer diagnosis and access to family supports were additional key determinants. Future policy reforms should revisit persistent inequities by diagnosis, which may be mitigated through comprehensive geriatric assessment in hospitals. Further consideration of policies to support unpaid carers is also warranted.
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Affiliation(s)
- Peter May
- Centre for Health Policy & Management, Trinity College Dublin, 3-4 Foster Place, Dublin 2, Ireland. .,The Irish Longitudinal study on Ageing (TILDA), Trinity College Dublin, Lincoln Gate, Dublin 2, Ireland.
| | - Lorna Roe
- Centre for Health Policy & Management, Trinity College Dublin, 3-4 Foster Place, Dublin 2, Ireland.,The Irish Longitudinal study on Ageing (TILDA), Trinity College Dublin, Lincoln Gate, Dublin 2, Ireland
| | - Christine A McGarrigle
- The Irish Longitudinal study on Ageing (TILDA), Trinity College Dublin, Lincoln Gate, Dublin 2, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal study on Ageing (TILDA), Trinity College Dublin, Lincoln Gate, Dublin 2, Ireland.,Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
| | - Charles Normand
- Centre for Health Policy & Management, Trinity College Dublin, 3-4 Foster Place, Dublin 2, Ireland.,Cicely Saunders Institute for Palliative Care, Rehabilitation and Policy, King's College London, Bessemer Road, London, SE5 9PJ, UK
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Teike Lüthi F, Bernard M, Beauverd M, Gamondi C, Ramelet AS, Borasio GD. IDentification of patients in need of general and specialised PALLiative care (ID-PALL©): item generation, content and face validity of a new interprofessional screening instrument. BMC Palliat Care 2020; 19:19. [PMID: 32050964 PMCID: PMC7017473 DOI: 10.1186/s12904-020-0522-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 02/05/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Early identification of patients requiring palliative care is a major public health concern. A growing number of instruments exist to help professionals to identify these patients, however, thus far, none have been thoroughly assessed for criterion validity. In addition, no currently available instruments differentiate between patients in need of general vs. specialised palliative care, and most are primarily intended for use by physicians. This study aims to develop and rigorously validate a new interprofessional instrument allowing identification of patients in need of general vs specialised palliative care. METHODS The instrument development involved four steps: i) literature review to determine the concept to measure; ii) generation of a set of items; iii) review of the initial set of items by experts to establish the content validity; iv) administration of the items to a sample of the target population to establish face validity. We conducted a Delphi process with experts in palliative care to accomplish step 3 and sent a questionnaire to nurses and physicians non-specialised in palliative care to complete step 4. The study was conducted in the French and Italian-speaking regions of Switzerland. An interdisciplinary committee of clinical experts supervised all steps. RESULTS The literature review confirmed the necessity of distinguishing between general and specialised palliative care needs and of adapting clinical recommendations to these different needs. Thirty-six nurses and physicians participated in the Delphi process and 28 were involved in the face validity assessment. The Delphi process resulted in two lists: a 7-item list to identify patients in need of general PC and an 8-item list to identify specialised PC needs. The content and face validity were deemed to be acceptable by both the expert and target populations. CONCLUSION This instrument makes a significant contribution to the identification of patients with palliative care needs as it has been designed to differentiate between general and specialised palliative care needs. Moreover, diagnostic data is not fundamental to the use of the instrument, thus facilitating its use by healthcare professionals other than physicians, in particular nurses. Internal and criterion validity assessments are ongoing and essential before wider dissemination of the instrument.
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Affiliation(s)
- Fabienne Teike Lüthi
- Institute of Higher Education and Research in Healthcare, University of Lausanne and Lausanne University Hospital, Lausanne, Switzerland. .,Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Mathieu Bernard
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Michel Beauverd
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Claudia Gamondi
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Palliative and Supportive Care Clinic, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, University of Lausanne and Lausanne University Hospital, Lausanne, Switzerland
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Stephens SJ, Chino F, Williamson H, Niedzwiecki D, Chino J, Mowery YM. Evaluating for disparities in place of death for head and neck cancer patients in the United States utilizing the CDC WONDER database. Oral Oncol 2020; 102:104555. [PMID: 32006782 DOI: 10.1016/j.oraloncology.2019.104555] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 12/19/2019] [Accepted: 12/21/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Evaluate trends in place of death for patients with head and neck cancers (HNC) in the U.S. from 1999 to 2017 based on the CDC WONDER (Wide-ranging Online Data for Epidemiologic Research) database. MATERIALS/METHODS Using patient-level data from 2015 and aggregate data from 1999 to 2017, multivariable logistic regression analyses (MLR) were performed to evaluate for disparities in place of death. RESULTS We obtained aggregate data for 101,963 people who died of HNC between 1999 and 2017 (25.9% oral cavity, 24.6% oropharynx/pharynx, 0.4% nasopharynx, and 49.1% larynx/hypopharynx). Most were Caucasian (92.7%) and male (87.0%). Deaths at home or hospice increased over the study period (R2 = 0.96, p < 0.05) from 29.2% in 1999 to 61.2% in 2017. On MLR of patient-level data from 2015, those who were single (ref), ages 85+ (OR 0.78; 95% CI: 0.68, 0.90), African American (OR 0.73; 95% CI: 0.65, 0.82), or Asian/Pacific Islanders (OR 0.66; 95% CI: 0.54, 0.81) were less likely to die at home or hospice. On MLR of the aggregate data (1999-2017), those who were female (OR 0.87; 95% CI: 0.83, 0.91) or ages 75-84 (OR 0.79; 95% CI: 0.76, 0.82) were also less likely to die at home or hospice. In both analyses, those who died from larynx/hypopharynx cancers were less likely to die at home or hospice. CONCLUSIONS HNC-related deaths at home or hospice increased between 1999 and 2017. Those who were single, female, African American, Asian/Pacific Islander, older (ages 75+), or those with larynx/hypopharynx cancers were less likely to die at home or hospice.
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Affiliation(s)
- Sarah J Stephens
- Department of Radiation Oncology, Duke University Medical Center, DUMC Box 3085, Durham, NC 27710, USA.
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| | - Hannah Williamson
- Biostatistics Shared Resource, Duke Cancer Institute, DUMC Box 2717, Durham, NC 27710, USA.
| | - Donna Niedzwiecki
- Biostatistics Shared Resource, Duke Cancer Institute, DUMC Box 2717, Durham, NC 27710, USA.
| | - Junzo Chino
- Department of Radiation Oncology, Duke University Medical Center, DUMC Box 3085, Durham, NC 27710, USA.
| | - Yvonne M Mowery
- Department of Radiation Oncology, Duke University Medical Center, DUMC Box 3085, Durham, NC 27710, USA.
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Moreton SG, Saurman E, Salkeld G, Edwards J, Hooper D, Kneen K, Rothwell G, Watson J. Economic and clinical outcomes of the nurse practitioner-led Sydney Adventist Hospital Community Palliative Care Service. AUST HEALTH REV 2020; 44:791-798. [DOI: 10.1071/ah19247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 03/11/2020] [Indexed: 11/23/2022]
Abstract
ObjectiveThe aim of this study was to assess the clinical, economic and personal impacts of the nurse practitioner-led Sydney Adventist Hospital Community Palliative Care Service (SanCPCS)
MethodsParallel economic analysis of usual care was conducted prospectively with patients from the enhanced SanCPCS. A convenient retrospective sample from the initial service was used to determine the impact of the enhanced service on patient care. A time series survey was used with patients and carers from within the expanded service group in order to measure patient outcomes and values as they approached death.
ResultsPatients of the SanCPCS were less likely to die in hospital and had fewer hospital admissions. In addition, the service halved the estimated hospitalisation cost per patient, but the length of hospital stay was not affected by the service. The SanCPCS was more beneficial for women in terms of fewer hospital admissions and lower costs. Patients’ choices regarding place of care and death and what was ‘important’ to them changed over time. For instance, patients tended to prefer being at home as they approached death, and being pain free doubled in importance.
ConclusionsNurse practitioner-led community palliative care services have the potential to result in significant economic and personal benefits for patients and their families in need of such care.
What is known about the topic?National trends show an emphasis on community services with the aim of promoting and supporting the choice of dying at home, and this coincides with drives to reduce hospital costs and length of stay. Community-based palliative care services may offer substantial economic and clinical benefits.
What does this paper add?The SanCPCS was the first nurse practitioner-led community-based palliative care service in Australia. The expansion of this service led to significantly fewer admissions and deaths in hospital, and halved the estimated hospitalisation cost per patient.
What are implications for practitioners?Nurse practitioner-led models for care in the out-patient or community setting are a logical direction for palliative services through the engagement of specialised providers uniquely trained to support, nurture, guide and educate patients and their carers.
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Abstract
Most people die when they are old, with multiple pathologies, and while living with frailty or dementia. These circumstances need the specialist skills of geriatric medicine. Death may not be unexpected, but survival and restoration of function are usually uncertain, influencing the approach to medical intervention. Assessment considers medical, functional, mental, social and environmental domains. Care requires a mix of acute, rehabilitation, mental health and palliative expertise, and evolves with changing circumstances. Relief of suffering and maintenance of function are key goals, but not the only ones. Mental distress is as common as physical; investigation- and treatment-burden are important; drug treatments are prone to adverse effects. A focus on person-centredness rather than the end-of-life is needed. This prioritizes respect for individual diversity in needs, assets and priorities, and rigorous decision making, to achieve what is the right intervention for that person at that time.
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Affiliation(s)
- Hannah Enguell
- Academic Clinical Fellow, Health Care of Older People, Nottingham University Hospitals NHS Trust, Nottingham
| | - Rowan H Harwood
- Professor of Palliative and End-of-Life Care and Honorary Consultant Geriatrician, School of Health Sciences, University of Nottingham, Nottingham NG7 2UH
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63
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Menon AP, Mok YH, Loh LE, Lee JH. Pediatric Palliative Transport in Critically Ill Children: A Single Center's Experience and Parents' Perspectives. J Pediatr Intensive Care 2019; 9:99-105. [PMID: 32351763 DOI: 10.1055/s-0039-3401009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 11/03/2019] [Indexed: 12/29/2022] Open
Abstract
The transfer of critically ill children from intensive care units (ICUs) to their homes for palliation is seldom described. We report our 10-year pediatric palliative transport experience and conducted a survey to gain parents' perspectives of their child's transport experience. Over the study period, eight patients were transported from our pediatric ICU to their homes or hospice facilities. There were no intratransport adverse events. Parents who participated in the survey responded positively to the transport experience. The availability of a dedicated critical care transport service allowed for palliative transfers to be performed safely. Facilitating transport to allow withdrawal of life support at home is an acceptable option to families as part of holistic end-of-life care.
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Affiliation(s)
- Anuradha P Menon
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Children's Hospital Emergency Transport Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Children's Hospital Emergency Transport Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Lik Eng Loh
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Children's Hospital Emergency Transport Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Children's Hospital Emergency Transport Service, KK Women's and Children's Hospital, Singapore, Singapore
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64
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Harwood RH, Enguell H. End-of-life care for frail older people. BMJ Support Palliat Care 2019; 12:bmjspcare-2019-001953. [PMID: 31732659 DOI: 10.1136/bmjspcare-2019-001953] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/18/2019] [Accepted: 10/21/2019] [Indexed: 11/03/2022]
Abstract
Most people die when they are old, but predicting exactly when this will occur is unavoidably uncertain. The health of older people is challenged by multimorbidity, disability and frailty. Frailty is the tendency to crises or episodes of rapid deterioration. These are often functional or non-specific in nature, such as falls or delirium, and recovery is usually expected. Health-related problems can be defined in terms of distress and disability. Distress is as often mental as physical, especially for people with delirium and dementia. Problems can be addressed using the principles of supportive and palliative care, but there is rarely a simple solution. Most problems do not have a palliative drug treatment, and the propensity to adverse effects means that drugs must be used with caution. Geriatricians use a model called comprehensive geriatric assessment, including medical, functional, mental health, social and environmental dimensions, but also use a variety of other models, such as the acute medical model, person-centred care, rehabilitation, alongside palliative care. Features such as communication, family engagement and advance planning are common to them all. These approaches are often consistent with each other, but their commonalities are not always recognised. The emphasis should be on making the right decision at a given point in time, taking account of what treatment is likely to deliver benefit, treatment burden and what is wanted. Choices are often limited by what is available and feasible. Palliative care should be integrated with all medical care for frail older people.
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Affiliation(s)
- Rowan H Harwood
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Hannah Enguell
- Healthcare of Older People, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Dong T, Zhu Z, Guo M, Du P, Wu B. Association between Dying Experience and Place of Death: Urban–Rural Differences among Older Chinese Adults. J Palliat Med 2019; 22:1386-1393. [DOI: 10.1089/jpm.2018.0583] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Tingyue Dong
- School of Sociology and Population Studies, Renmin University of China, Beijing, China
| | - Zheng Zhu
- School of Nursing, Fudan University, Shanghai, China
| | - Mengdi Guo
- School of Public Affairs, Zhejiang University, Hangzhou, China
| | - Peng Du
- School of Sociology and Population Studies, Renmin University of China, Beijing, China
| | - Bei Wu
- Rory Meyers College of Nursing and NYU Aging Incubator, New York University, New York, New York
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66
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Strupp J, Köneke V, Rietz C, Voltz R. Perceptions of and Attitudes Toward Death, Dying, Grief, and the Finitude of Life-A Representative Survey Among the General Public in Germany. OMEGA-JOURNAL OF DEATH AND DYING 2019; 84:157-176. [PMID: 31615342 DOI: 10.1177/0030222819882220] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Some end-of-life aspects have become a significant political and social issue such as elderly care and euthanasia. But hardly anything is known about how the general public in Germany thinks about death and dying more generally. Therefore, we conducted a representative online survey (N = 997) regarding 21 end-of-life aspects. Differences between subgroups were analyzed by conducting analyses of variance and Tukey honestly significance difference post hoc tests and by performing t tests. The findings revealed that the general public is open to engaging with topics of death, dying, and grief and that death education might even be promoted for children. Most participants appraised dealing with the finitude of life as part of a good life, but few have contemplated death and dying themselves so far. Attitudes and perceptions were related to age, subjective health, religious denomination, and gender. The survey provides useful implications for community palliative care, death education, and communication with dying people.
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Affiliation(s)
- Julia Strupp
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Germany
| | - Vanessa Köneke
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Germany.,Cologne Graduate School in Management, Economics and Social Sciences, University of Cologne, Germany
| | - Christian Rietz
- Department of Educational and Social Sciences, University of Education Heidelberg, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, Faculty of Medicine and University Hospital, University of Cologne, Germany.,Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital, University of Cologne, Germany.,Clinical Trials Center (ZKS), Faculty of Medicine and University Hospital, University of Cologne, Germany.,Center for Health Services Research, Faculty of Medicine and University Hospital, University of Cologne, Germany
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67
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Woodland H, Hudson B, Forbes K, McCune A, Wright M. Palliative care in liver disease: what does good look like? Frontline Gastroenterol 2019; 11:218-227. [PMID: 32419913 PMCID: PMC7223359 DOI: 10.1136/flgastro-2019-101180] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/08/2019] [Accepted: 08/11/2019] [Indexed: 02/04/2023] Open
Abstract
The mortality rate from chronic liver disease in the UK is rising rapidly, and patients with advanced disease have a symptom burden comparable to or higher than that experienced in other life-limiting illnesses. While evidence is limited, there is growing recognition that care of patients with advanced disease needs to improve. Many factors limit widespread provision of good palliative care to these patients, including the unpredictable trajectory of chronic liver disease, the misconception that palliative care and end-of-life care are synonymous, lack of confidence in prescribing and lack of time and resources. Healthcare professionals managing these patients need to develop the skills to ensure effective delivery of core palliative care, with referral to specialist palliative care services reserved for those with complex needs. Core palliative care is best delivered by the hepatology team in parallel with active disease management. This includes ensuring that discussions about disease trajectory and advance care planning occur alongside active management of disease complications. Liver disease is strongly associated with significant social, psychological and financial hardships for patients and their carers; strategies that involve the wider multidisciplinary team at an early stage in the disease trajectory help ensure proactive management of such issues. This review summarises the evidence supporting palliative care for patients with advanced chronic liver disease, presents examples of current best practice and provides pragmatic suggestions for how palliative and disease-modifying care can be run in parallel, such that patients do not miss opportunities for interventions that improve their quality of life.
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Affiliation(s)
- Hazel Woodland
- Department of Hepatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Ben Hudson
- Department of Hepatology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Karen Forbes
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Anne McCune
- Department of Liver Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Mark Wright
- Department of Hepatology, University Hospital Southampton, Southampton, UK
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Hoare S, Kelly MP, Barclay S. Home care and end-of-life hospital admissions: a retrospective interview study in English primary and secondary care. Br J Gen Pract 2019; 69:e561-e569. [PMID: 31208973 PMCID: PMC6582452 DOI: 10.3399/bjgp19x704561] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 12/24/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Enabling death at home remains an important priority in end-of-life care policy. However, hospital continues to be a more prevalent place of death than home in the UK, with admissions at the end-of-life often negatively labelled. Admissions are frequently attributed to an unsuitable home environment, associated with inadequate family care provision and insufficient professional care delivery. AIM To understand problems in professional and lay care provision that discourage death at home and lead to hospital admissions at the end of life. DESIGN AND SETTING A qualitative study of admission to a large English hospital of patients close to the end of their life. METHOD Retrospective in-depth semi-structured interviews with healthcare professionals (n = 30) and next-of-kin (n = 3) involved in an admission. Interviews addressed why older patients (>65 years) close to the end of life are admitted to hospital. Interviews were transcribed and analysed thematically. RESULTS Home-based end-of-life care appeared precarious. Hospital admission was considered by healthcare staff when there was insufficient nursing provision, or where family support, which was often extensive but under supported, was challenged. In these circumstances, home was not recognised to be a suitable place of care or death, justifying seeking care provision elsewhere. CONCLUSION Challenges in home care provision led to hospital admissions. Home end-of-life care depended on substantial input from family and professional carers, both of which were under-resourced. Where either care was insufficient to meet the needs of patients, home was no longer deemed to be desirable by healthcare staff and hospital care was sought.
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Affiliation(s)
- Sarah Hoare
- Primary Care Unit, Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Michael P Kelly
- Primary Care Unit, Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Stephen Barclay
- Primary Care Unit, Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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69
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Webber C, Viola R, Knott C, Peng Y, Groome PA. Community Palliative Care Initiatives to Reduce End-of-Life Hospital Utilization and In-Hospital Deaths: A Population-Based Observational Study Evaluating Two Home Care Interventions. J Pain Symptom Manage 2019; 58:181-189.e1. [PMID: 31022443 DOI: 10.1016/j.jpainsymman.2019.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/12/2019] [Accepted: 04/15/2019] [Indexed: 01/08/2023]
Abstract
CONTEXT The end-of-life period is characterized by increased hospital utilization despite patients' preferences to receive care and die at home. OBJECTIVES To evaluate the impact of interventions aimed at planning for a home death (Yellow Folder) and managing symptoms in the home (Symptom Response Kit) on place of death and hospital utilization among palliative home care patients. METHODS This was an ecologic and retrospective cohort study of palliative home care patients in southeastern Ontario from April 2009 to March 2014. Linked health administrative and clinical databases were used to identify palliative home care patients and their receipt of the interventions, hospitalizations, emergency department visits, and place of death. Bivariable and multivariable regressions were used to evaluate outcomes according to patients' receipt of intervention(s). RESULTS The proportion of patients who died in the community increased after implementation of the interventions, from 42.8% to 48.5% (P < 0.0001). Compared with patients who received neither intervention, patients who received the Yellow Folder or Symptom Response Kit had an increased likelihood of dying in the community, with the largest relative risk observed in patients who received both interventions (relative risk = 2.20, 95% confidence interval 2.05-2.36). Receipt of these interventions was only associated with reductions in hospitalization or emergency department visit rates in the six months before death. CONCLUSION Patients who received the Yellow Folder or Symptom Response Kit were more likely remain at home at the end of life. This association was stronger when these interventions were used together.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada.
| | - Raymond Viola
- Division of Palliative Medicine, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Christine Knott
- Centre for Health Services and Policy Research, Queen's University, Kingston, Ontario, Canada; ICES, Kingston, Ontario, Canada
| | - Yingwei Peng
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada; Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, Ontario, Canada
| | - Patti A Groome
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada; Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, Ontario, Canada
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70
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Combes S, Nicholson CJ, Gillett K, Norton C. Implementing advance care planning with community-dwelling frail elders requires a system-wide approach: An integrative review applying a behaviour change model. Palliat Med 2019; 33:743-756. [PMID: 31057042 PMCID: PMC6620766 DOI: 10.1177/0269216319845804] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Facilitating advance care planning with community-dwelling frail elders can be challenging. Notably, frail elders' vulnerability to sudden deterioration leads to uncertainty in recognising the timing and focus of advance care planning conversations. AIM To understand how advance care planning can be better implemented for community-dwelling frail elders and to develop a conceptual model to underpin intervention development. DESIGN A structured integrative review of relevant literature. DATA SOURCES CINAHL, Embase, Ovid Medline, PsycINFO, Cochrane Library, and University of York Centre for Reviews and Dissemination. Further strategies included searching for policy and clinical documents, grey literature, and hand-searching reference lists. Literature was searched from 1990 until October 2018. RESULTS From 3043 potential papers, 42 were included. Twenty-nine were empirical, six expert commentaries, four service improvements, two guidelines and one theoretical. Analysis revealed nine themes: education and training, personal ability, models, recognising triggers, resources, conversations on death and dying, living day to day, personal beliefs and experience, and relationality. CONCLUSION Implementing advance care planning for frail elders requires a system-wide approach, including providing relevant resources and clarifying responsibilities. Early engagement is key for frail elders, as is a shift from the current advance care planning model focussed on future ceilings of care to one that promotes living well now alongside planning for the future. The proposed conceptual model can be used as a starting point for professionals, organisations and policymakers looking to improve advance care planning for frail elders.
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Affiliation(s)
- Sarah Combes
- Florence Nightingale Faculty of Nursing,
Midwifery and Palliative Care, King’s College London, London, UK
- St Christopher’s Hospice, London,
UK
| | - Caroline Jane Nicholson
- Florence Nightingale Faculty of Nursing,
Midwifery and Palliative Care, King’s College London, London, UK
- St Christopher’s Hospice, London,
UK
| | - Karen Gillett
- Florence Nightingale Faculty of Nursing,
Midwifery and Palliative Care, King’s College London, London, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing,
Midwifery and Palliative Care, King’s College London, London, UK
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71
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Morgan DD, Tieman JJ, Allingham SF, Ekström MP, Connolly A, Currow DC. The trajectory of functional decline over the last 4 months of life in a palliative care population: A prospective, consecutive cohort study. Palliat Med 2019; 33:693-703. [PMID: 30916620 DOI: 10.1177/0269216319839024] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Understanding current patterns of functional decline will inform patient care and has health service and resource implications. AIM This prospective consecutive cohort study aims to map the shape of functional decline trajectories at the end of life by diagnosis. DESIGN Changes in functional status were measured using the Australia-modified Karnofsky Performance Status Scale. Segmented regression was used to identify time points prior to death associated with significant changes in the slope of functional decline for each diagnostic cohort. Sensitivity analyses explored the impact of severe symptoms and late referrals, age and sex. SETTING/PARTICIPANTS In all, 115 specialist palliative care services submit prospectively collected patient data to the national Palliative Care Outcomes Collaboration across Australia. Data on 55,954 patients who died in the care of these services between 1 January 2013 and 31 December 2015 were included. RESULTS Two simplified functional decline trajectories were identified in the last 4 months of life. Trajectory 1 has an almost uniform slow decline until the last 14 days of life when function declines more rapidly. Trajectory 2 has a flatter more stable trajectory with greater functional impairment at 120 days before death, followed by a more rapid decline in the last 2 weeks of life. The most rapid rate of decline occurs in the last 2 weeks of life for all cohorts. CONCLUSIONS Two simplified trajectories of functional decline in the last 4 months of life were identified for five patient cohorts. Both trajectories present opportunities to plan for responsive healthcare that will support patients and families.
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Affiliation(s)
- Deidre D Morgan
- 1 Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Jennifer J Tieman
- 1 Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Samuel F Allingham
- 2 Palliative Care Outcomes Collaboration (PCOC), Australian Health Services Research Institute, University of Wollongong, Wollongong, NSW, Australia
| | - Magnus P Ekström
- 3 Division of Respiratory Medicine and Allergology, Department of Clinical Sciences, Lund University, Lund, Sweden.,4 Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Alanna Connolly
- 2 Palliative Care Outcomes Collaboration (PCOC), Australian Health Services Research Institute, University of Wollongong, Wollongong, NSW, Australia
| | - David C Currow
- 1 Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.,2 Palliative Care Outcomes Collaboration (PCOC), Australian Health Services Research Institute, University of Wollongong, Wollongong, NSW, Australia.,4 Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
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Turner V, Flemming K. Socioeconomic factors affecting access to preferred place of death: A qualitative evidence synthesis. Palliat Med 2019; 33:607-617. [PMID: 30848703 DOI: 10.1177/0269216319835146] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Existing quantitative evidence suggests that at a population level, socioeconomic factors affect access to preferred place of death. However, the influence of individual and contextual socioeconomic factors on preferred place of death are less well understood. AIM To systematically synthesise the existing qualitative evidence for socioeconomic factors affecting access to preferred place of death in the United Kingdom. DESIGN A thematic synthesis of qualitative research. DATA SOURCES Cochrane Library, MEDLINE, Embase, CINAHL, ASSIA, Scopus and PsycINFO databases were searched from inception to May 2018. RESULTS A total of 13 articles, reporting on 12 studies, were included in the synthesis. Two overarching themes were identified: 'Human factors' representing support networks, interactions between people and decision-making and 'Environmental factors', which included issues around locations and resources. Few studies directly referenced socioeconomic deprivation. The main factor affecting access to preferred place of death was social support; people with fewer informal carers were less likely to die in their preferred location. Other key findings included fluidity around the concept of home and variability in preferred place of death itself, particularly in response to crises. CONCLUSION There is limited UK-based qualitative research on socioeconomic factors affecting preferred place of death. Further qualitative research is needed to explore the barriers and facilitators of access to preferred place of death in socioeconomically deprived UK communities. In practice, there needs to be more widespread discussion and documentation of preferred place of death while also recognising these preferences may change as death nears or in times of crisis.
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Affiliation(s)
| | - Kate Flemming
- Department of Health Sciences, University of York, York, UK
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73
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Haematology nurses' perspectives of their patients' places of care and death: A UK qualitative interview study. Eur J Oncol Nurs 2019; 39:70-80. [PMID: 30850141 PMCID: PMC6417764 DOI: 10.1016/j.ejon.2019.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 12/04/2018] [Accepted: 02/06/2019] [Indexed: 12/19/2022]
Abstract
Purpose Patients with haematological malignancies are more likely to die in hospital, and less likely to access palliative care than people with other cancers, though the reasons for this are not well understood. The purpose of our study was to explore haematology nurses' perspectives of their patients’ places of care and death. Method Qualitative description, based on thematic content analysis. Eight haematology nurses working in secondary and tertiary hospital settings were purposively selected and interviewed. Transcriptions were coded and analysed for themes using a mainly inductive, cross-comparative approach. Results Five inter-related factors were identified as contributing to the likelihood of patients’ receiving end of life care/dying in hospital: the complex nature of haematological diseases and their treatment; close clinician-patient bonds; delays to end of life discussions; lack of integration between haematology and palliative care services; and barriers to death at home. Conclusions Hospital death is often determined by the characteristics of the cancer and type of treatment. Prognostication is complex across subtypes and hospital death perceived as unavoidable, and sometimes the preferred option. Earlier, frank conversations that focus on realistic outcomes, closer integration of palliative care and haematology services, better communication across the secondary/primary care interface, and an increase in out-of-hours nursing support could improve end of life care and facilitate death at home or in hospice, when preferred. Patients with haematological malignancies are more likely to die in hospital than people with other cancers. No previous research has reported on UK haematology nurses' perspectives of their patients' place of care and place of death. Hospital deaths were largely attributed to disease characteristics, nature of treatment and difficulties with prognostication. However, other modifiable factors were also identified as barriers to death at home.
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74
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Lewis ET, Harrison R, Hanly L, Psirides A, Zammit A, McFarland K, Dawson A, Hillman K, Barr M, Cardona M. End-of-life priorities of older adults with terminal illness and caregivers: A qualitative consultation. Health Expect 2019; 22:405-414. [PMID: 30614161 PMCID: PMC6543262 DOI: 10.1111/hex.12860] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 12/04/2018] [Accepted: 12/04/2018] [Indexed: 12/01/2022] Open
Abstract
Background As older adults approach the end‐of‐life (EOL), many are faced with complex decisions including whether to use medical advances to prolong life. Limited information exists on the priorities of older adults at the EOL. Objective This study aimed to explore patient and family experiences and identify factors deemed important to quality EOL care. Method A descriptive qualitative study involving three focus group discussions (n = 18) and six in‐depth interviews with older adults suffering from either a terminal condition and/or caregivers were conducted in NSW, Australia. Data were analysed thematically. Results Seven major themes were identified as follows: quality as a priority, sense of control, life on hold, need for health system support, being at home, talking about death and competent and caring health professionals. An underpinning priority throughout the seven themes was knowing and adhering to patient's wishes. Conclusion Our study highlights that to better adhere to EOL patient's wishes a reorganization of care needs is required. The readiness of the health system to cater for this expectation is questionable as real choices may not be available in acute hospital settings. With an ageing population, a reorganization of care which influences the way we manage terminal patients is required.
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Affiliation(s)
- Ebony T Lewis
- Faculty of Medicine, School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Reema Harrison
- Faculty of Medicine, School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Laura Hanly
- SWS Clinical School, The Simpson Centre for Health Services Research, University of New South Wales, Sydney, New South Wales, Australia
| | - Alex Psirides
- Department of Intensive Care Medicine, Wellington Regional Hospital, Wellington, New Zealand.,University of Otago, Wellington, New Zealand
| | | | - Kathryn McFarland
- Cunningham Centre for Palliative Care, Sacred Heart Health Service, St Vincent's Health Network, Sydney, New South Wales, Australia
| | - Angela Dawson
- Faculty of Health, The Australian Centre for Public and Population Health Research, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Ken Hillman
- SWS Clinical School, The Simpson Centre for Health Services Research, University of New South Wales, Sydney, New South Wales, Australia.,Intensive Care Unit, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Margo Barr
- Centre for Primary Health Care and Equity, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Magnolia Cardona
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia.,Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
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75
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Walbert T. Maintaining quality of life near the end of life: hospice in neuro-oncology. Neuro Oncol 2018; 20:439-440. [PMID: 29390139 DOI: 10.1093/neuonc/nox236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Tobias Walbert
- Departments of Neurosurgery and Neurology, Henry Ford Health System, Detroit, Michigan
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76
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Eagar K, Clapham SP, Allingham SF. Palliative care is effective: but hospital symptom outcomes superior. BMJ Support Palliat Care 2018; 10:186-190. [PMID: 30171042 PMCID: PMC7286033 DOI: 10.1136/bmjspcare-2018-001534] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 07/25/2018] [Accepted: 08/08/2018] [Indexed: 11/29/2022]
Abstract
Objectives To explore differences in severe symptom outcomes for palliative care patients receiving hospital care compared with those receiving care at home. Methods Change in symptom distress from the start of an episode of palliative care to just prior to death was measured for 25 679 patients who died under the care of a hospital or home-based palliative care team between January 2015 and December 2016. Logistic regression models controlled for differences between hospital and home and enabled a comparison of the number of severe symptoms just prior to death. Results All symptoms improved and over 85% of all patients had no severe symptoms prior to death. Pain control illustrates this with 7.4% of patients reporting severe pain distress at episode start and 2.5% just prior to death. When comparing all symptom outcomes by place of death, hospital patients are 3.7 times more likely than home patients to have no severe symptoms. Conclusion Symptom outcomes are better for hospital patients. Patients at home have less improvement overall and some symptoms get worse. Reasons for the difference in outcomes by hospital and home are multifactorial and must be considered in relation to the patient’s right to choose their place of care.
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Affiliation(s)
- Kathy Eagar
- Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia .,Palliative Care Outcomes Collaboration, University of Wollongong, Wollongong, NSW, Australia
| | - Sabina Petranella Clapham
- Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia.,Palliative Care Outcomes Collaboration, University of Wollongong, Wollongong, NSW, Australia
| | - Samuel Frederic Allingham
- Australian Health Services Research Institute, University of Wollongong, Wollongong, New South Wales, Australia.,Palliative Care Outcomes Collaboration, University of Wollongong, Wollongong, NSW, Australia
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Adusumilli P, Nayak L, Viswanath V, Digumarti L, Digumarti RR. Palliative care and end-of-life measure outcomes: Experience of a tertiary care institute from South India. South Asian J Cancer 2018; 7:210-213. [PMID: 30112344 PMCID: PMC6069332 DOI: 10.4103/sajc.sajc_257_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Desisting from disease directed treatment in the past weeks of life is a quality criterion in oncology service. Patients with advanced cancer have unrealistic expectations from chemotherapy and hold on to it as a great source of hope. Many oncologists continue futile and unnecessary treatments, instead of conveying to the patients the lack of benefit, resulting in delayed referral for palliative care (PC). MATERIALS AND METHODS This is a retrospective analysis of case records from June 2014 to December 2015. The primary objective was to study, how far back in time terminally ill cancer patients received definitive cancer directed therapy (DCDT). Apart from patient demographics, the diagnosis, stage, and details of DCDT, and death were captured. PC referral data were recorded. DCDT to death was taken as treatment-free interval (TFI). Analysis was performed using IBM SPSS Statistics for Windows, Version 20. RESULTS A total of 292 case records were evaluated. Seventy-three had inadequate treatment details. Hence, 219 records were analyzed. PC referral was done in 78.5% of patients. Only best supportive care (BSC) without any DCDT was given in 27 patients. The most common reason for BSC was a poor performance status in 92.5%. The median time from PC referral till death was 43.5 days (range: 1-518 days). Chemotherapy was the most common DCDT in 52.9% of patients. The median time from DCDT and death was 49 days (range: 0-359 days). Cervical and ovarian cancers patients had the longest TFI; shortest in unknown primary. Most patients died at home (70.4%). Patients receiving PC preferred home or hospice as place of death. Of the 80 patients given hospice care, 39 (36.5%) died in the hospice. CONCLUSION While DCDT needs to be started at the right time, it should also be discontinued when futile. Early involvement of the PC team, even while patients are on DCDT makes the transition smoother and more meaningful.
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Affiliation(s)
- Praveen Adusumilli
- Department of Medical Oncology, Homi Bhabha Cancer Hospital and Research Centre, Aganampudi, Andhra Pradesh, India
| | - Lingaraj Nayak
- Department of Medical Oncology, Homi Bhabha Cancer Hospital and Research Centre, Aganampudi, Andhra Pradesh, India
| | - Vidya Viswanath
- Department of Palliative Medicine, Homi Bhabha Cancer Hospital and Research Centre, Aganampudi, Andhra Pradesh, India
| | - Leela Digumarti
- Department of Gynaec Oncology, Homi Bhabha Cancer Hospital and Research Centre, Aganampudi, Andhra Pradesh, India
| | - Raghunadha Rao Digumarti
- Department of Medical Oncology, Homi Bhabha Cancer Hospital and Research Centre, Aganampudi, Andhra Pradesh, India
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End-of-Life Care for Patients With Advanced Ovarian Cancer Is Aggressive Despite Hospice Intervention. Int J Gynecol Cancer 2018; 28:1183-1190. [DOI: 10.1097/igc.0000000000001285] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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79
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Damani A, Ghoshal A, Dighe M, Dhiliwal S, Muckaden M. Exploring Education and Training Needs in Palliative Care among Family Physicians in Mumbai: A Qualitative Study. Indian J Palliat Care 2018; 24:139-144. [PMID: 29736114 PMCID: PMC5915878 DOI: 10.4103/ijpc.ijpc_216_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Context: Patients with chronic life-limiting conditions on palliative care (PC) prefer to be treated at home. Medical care by family physicians (FPs) reduces demand on costly and busy hospital facilities. Working of PC team in collaboration with FPs is thus helpful in home-based management of patients. Aims: This study aimed at exploring the extent of knowledge of FPs about PC and the need for additional training. Settings and Design: Semi-structured interviews were conducted with ten FPs from two suburbs of Mumbai, currently served by home care services of a tertiary cancer care center. Subjects and Methods: Data were digitally recorded, transcribed, and analyzed using exploratory analysis followed by content analysis to develop thematic codes. Results and Conclusions: FPs perceive PC as symptom control and psychological support helpful in managing patients with advanced life-limiting illnesses. Further training would help them in PC provision. Such training programs should preferably focus on symptom management and communication skills. There is a need for further research in designing a training module for FPs to get better understanding of the principles of PC.
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Affiliation(s)
- Anuja Damani
- Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, India
| | - Arunangshu Ghoshal
- Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, India
| | - Manjiri Dighe
- Cipla Palliative Care and Training Centre, Pune, Maharashtra, India
| | - Sunil Dhiliwal
- Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, India
| | - Maryann Muckaden
- Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, India
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80
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Abstract
BACKGROUND Payment models for palliative care vary across nations, with few adopting contemporary payments designs that apply to other parts of the health system. AIM To propose optimal payment arrangements for palliative care. APPROACH Review of relevant literature on funding mechanisms in health care generally and palliative care in particular. RESULTS Payment models for palliative care should move toward activity-based funding using an agreed classification, be uncapped funding with performance monitoring, and make explicit use of performance metrics and reporting. CONCLUSIONS If palliative care is to become a universally accessible service, new approaches to funding, based on the experience of funding reforms in other parts of the health system, need to be adopted.
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Affiliation(s)
- Stephen Duckett
- Health Program, Grattan Institute, 8 Malvina Place, Carlton, VIC, 3053, Australia.
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81
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Affiliation(s)
- Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA.,San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Vyjeyanthi S Periyakoil
- Division of Primary Care and Population Health, Department of Medicine, School of Medicine, Stanford University, Palo Alto, CA.,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
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82
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Johnston B, Patterson A, Bird L, Wilson E, Almack K, Mathews G, Seymour J. Impact of the Macmillan specialist Care at Home service: a mixed methods evaluation across six sites. BMC Palliat Care 2018; 17:36. [PMID: 29475452 PMCID: PMC6389143 DOI: 10.1186/s12904-018-0281-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 01/30/2018] [Indexed: 11/25/2022] Open
Abstract
Background The Midhurst Macmillan Specialist Palliative Care at Home Service was founded in 2006 to improve community-based palliative care provision. Principal components include; early referral; home-based clinical interventions; close partnership working; and flexible teamwork. Following a successful introduction, the model was implemented in six further sites across England. This article reports a mixed methods evaluation of the implementation across these ‘Innovation Centres’. The evaluation aimed to assess the process and impact on staff, patients and carers of providing Macmillan Specialist Care at Home services across the six sites. Methods The study was set within a Realist Evaluation framework and used a longitudinal, mixed methods research design. Data collection over 15 months (2014–2016) included: Quantitative outcome measures - Palliative Performance Scale [PPS] and Palliative Prognostic Index [PPI] (n = 2711); Integrated Palliative Outcome Scales [IPOS] (n = 1157); Carers Support Needs Assessment Tool [CSNAT] (n = 241); Views of Informal Carers –Evaluation of Services [VOICES-SF] (n = 102); a custom-designed Service Data Tool [SDT] that gathered prospective data from each site (n = 88). Qualitative data methods included: focus groups with project team and staff (n = 32 groups with n = 190 participants), and, volunteers (n = 6 groups with n = 32 participants). Quantitative data were analysed using SPPS Vs. 21 and qualitative data was examined via thematic analysis. Results Comparison of findings across the six sites revealed the impact of their unique configurations on outcomes, compounded by variations in stage and mode of implementation. PPS, PPI and IPOS data revealed disparity in early referral criteria, complicated by contrasting interpretations of palliative care. The qualitative analysis, CSNAT and VOICES-SF data confirmed the value of the Macmillan model of care but uptake of specialist home-based clinical interventions was limited. The Macmillan brand engendered patient and carer confidence, bringing added value to existing services. Significant findings included better co-ordination of palliative care through project management and a single referral point and multi-disciplinary teamwork including leadership from consultants in palliative medicine, the role of health care assistants in rapid referral, and volunteer support. Conclusions Macmillan Specialist Care at Home increases patient choice about place of death and enhances the quality of end of life experience. Clarification of key components is advocated to aid consistency of implementation across different sites and support future evaluative work. Electronic supplementary material The online version of this article (10.1186/s12904-018-0281-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bridget Johnston
- Florence Nightingale Foundation Professor of Clinical Nursing Practice Research, School of Medicine, Dentistry and Nursing, University of Glasgow, 57-61 Oakfield Avenue, Room 61/504, Glasgow, G12 8LL, UK.
| | - Anne Patterson
- School of Sociology and Social Policy, University Park, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Lydia Bird
- Present address: Division of Primary Care, University of Nottingham, Queens Medical Centre, Derby Road, Nottingham, NG7 2HA, UK
| | - Eleanor Wilson
- School of Health Sciences, University of Nottingham, Queens Medical Centre, Derby Road, Nottingham, NG7 2HA, UK
| | - Kathryn Almack
- School of Health and Social Work, University of Hertfordshire, Hatfield, Hertfordshire, AL10 9AB, UK
| | - Gillian Mathews
- School of Medicine, Dentistry and Nursing, University of Glasgow, 57-61 Oakfield Avenue, Glasgow, G12 8LL, UK
| | - Jane Seymour
- School of Nursing and Midwifery, The University of Sheffield, Barber House Annex, 3a Clarkehouse Road, Sheffield, S10 2LA, UK
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83
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Buck J, Webb L, Moth L, Morgan L, Barclay S. Persistent inequalities in Hospice at Home provision. BMJ Support Palliat Care 2018; 10:e23. [PMID: 29444775 PMCID: PMC7456670 DOI: 10.1136/bmjspcare-2017-001367] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 12/20/2017] [Accepted: 01/03/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To describe the nature and scope of a new Hospice at Home (H@H) service and to identify its equality of provision. METHODS Case note review of patients supported by a H@H service for 1 year from September 2012 to August 2013 (n=321). Descriptive analysis to report frequencies and proportions of quantitative data extracted from service logs, referral forms and care records; thematic analysis of qualitative data from care record free text. RESULTS Demand outstripped supply. Twice as many night care episodes were requested (n=1237) as were provided (n=613). Inequalities in access to the service related to underlying diagnosis and socioeconomic status. 75% of patients using the service had cancer (221/293 with documented diagnosis). Of those who died at home in the areas surrounding the hospice, 53% (163/311) of people with cancer and 11% (49/431) of those without cancer received H@H support. People who received H@H care were often more affluent than the population average for the area within which they lived. Roles of the service identified included: care planning/implementation, specialist end-of-life care assessment and advice, 'holding' complex patients until hospice beds become available and clinical nursing care. CONCLUSION There is significant unmet need and potentially large latent demand for the H@H service. People without cancer or of lower socioeconomic status are less likely to access the service. Action is needed to ensure greater and more equitable service provision in this and similar services nationally and internationally.
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Affiliation(s)
- Jackie Buck
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Liz Webb
- Arthur Rank Hospice Charity, Cambridge, UK
| | | | | | - Stephen Barclay
- Primary Care Unit, Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, UK
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84
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Fraser LK, Fleming S, Parslow R. Changing place of death in children who died after discharge from paediatric intensive care units: A national, data linkage study. Palliat Med 2018; 32:337-346. [PMID: 28494634 PMCID: PMC5788081 DOI: 10.1177/0269216317709711] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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 Although child mortality is decreasing, more than half of all deaths in childhood occur in children with a life-limiting condition whose death may be expected. AIM To assess trends in place of death and identify characteristics of children who died in the community after discharge from paediatric intensive care unit. DESIGN National data linkage study. SETTING/PARTICIPANTS All children resident in England and Wales when admitted to a paediatric intensive care unit in the United Kingdom (1 January 2004 and 31 December 2014) were identified in the Paediatric Intensive Care Audit Network dataset. Linkage to death certificate data was available up to the end of 2014. Place of death was categorised as hospital (hospital or paediatric intensive care unit) or community (hospice, home or other) for multivariable logistic modelling. RESULTS The cohort consisted of 110,328 individuals. In all, 7709 deaths occurred after first discharge from paediatric intensive care unit. Among children dying, the percentage in-hospital at the time of death decreased from 83.8% in 2004 to 68.1% in 2014; 852 (0.8%) of children were discharged to palliative care. Children discharged to palliative care were eight times more likely to die in the community than children who died and had not been discharged to palliative care (odds ratio = 8.06 (95% confidence interval = 6.50-10.01)). CONCLUSIONS The proportion of children dying in hospital is decreasing, but a large proportion of children dying after discharge from paediatric intensive care unit continue to die in hospital. The involvement of palliative care at the point of discharge has the potential to offer choice around place of care and death for these children and families.
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Affiliation(s)
- Lorna K Fraser
- 1 Department of Health Sciences, University of York, York, UK
| | - Sarah Fleming
- 2 Division of Epidemiology & Biostatistics, LICAMM, University of Leeds, Leeds, UK
| | - Roger Parslow
- 2 Division of Epidemiology & Biostatistics, LICAMM, University of Leeds, Leeds, UK
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85
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Abstract
Ensuring high quality of care for dying patients and their families is a challenge for both primary and specialist palliative care services throughout the UK. A model of a consultant-led palliative care community team was set up following the closure of a specialist palliative care inpatient unit in Midhurst, with the aim of providing that same level of care to patients in their own homes, care homes and community hospitals. It works closely with primary care to enhance community services and with secondary care to enable rapid discharge from hospital to the community. Anticipatory prescribing, advanced care planning and education of social care and nursing home staff are also key aspects of the service. The Macmillan Midhurst Service costs an average of less than £3,000 per patient and enables 85% of referred patients to die in their preferred place. Evaluations of the service have highlighted benefits to patients and families as well as cost reductions to the NHS of around 20% when patients are referred early.
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Affiliation(s)
| | - Bill Noble
- Public Health Palliative Care International
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86
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Aoun SM, Ewing G, Grande G, Toye C, Bear N. The Impact of Supporting Family Caregivers Before Bereavement on Outcomes After Bereavement: Adequacy of End-of-Life Support and Achievement of Preferred Place of Death. J Pain Symptom Manage 2018; 55:368-378. [PMID: 29030206 DOI: 10.1016/j.jpainsymman.2017.09.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 09/21/2017] [Accepted: 09/21/2017] [Indexed: 11/17/2022]
Abstract
CONTEXT The investigation of the situation of bereaved family caregivers following caregiving during the end-of-life phase of illness has not received enough attention. OBJECTIVES This study investigated the extent to which using the Carer Support Needs Assessment Tool (CSNAT) intervention during the caregiving period has affected bereaved family caregivers' perceptions of adequacy of support, their grief and well-being, and achievement of their preferred place of death. METHOD All family caregivers who participated in a stepped-wedge cluster trial of the CSNAT intervention in Western Australia (2012-2014) and completed the pre-bereavement study (n = 322) were invited to take part in a caregiver survey by telephone four to six months after bereavement (2015). The survey measured the adequacy of end-of-life support, the level of grief, the current physical and mental health, and the achievement of the preferred place of death. RESULTS The response rate was 66% (152, intervention; 60, control). The intervention group perceived that their pre-bereavement support needs had been adequately met to a significantly greater extent than the control group (d = 0.43, P < 0.001) and that patients have achieved their preferred place of death more often according to their caregivers (79.6% vs. 63.6%, P = 0.034). There was also a greater agreement on the preferred place of death between patients and their caregivers in the intervention group (P = 0.02). CONCLUSIONS The results from this study provide evidence that the CSNAT intervention has a positive impact on perceived adequacy of support of bereaved family caregivers and achievement of preferred place of death according to caregivers. The benefits gained by caregivers in being engaged in early and direct assessment of their support needs before bereavement reinforce the need for palliative care services to effectively support caregivers well before the patient's death.
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Affiliation(s)
- Samar M Aoun
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia; Adjunct Professor, LaTrobe University, Melbourne, Victoria, Australia.
| | - Gail Ewing
- Centre for Family Research, University of Cambridge, Cambridge, United Kingdom
| | - Gunn Grande
- Division of Nursing, Midwifery & Social Work, The University of Manchester, Manchester, United Kingdom
| | - Chris Toye
- School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia; Centre for Nursing Research, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Natasha Bear
- Department of Clinical Research and Education, Child and Adolescent Health Services, Perth, Western Australia, Australia
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87
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Cirrhosis with ascites in the last year of life: a nationwide analysis of factors shaping costs, health-care use, and place of death in England. Lancet Gastroenterol Hepatol 2018; 3:95-103. [DOI: 10.1016/s2468-1253(17)30362-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/14/2017] [Accepted: 09/15/2017] [Indexed: 01/02/2023]
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88
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Lowrie D, Ray R, Plummer D, Yau M. Exploring the Contemporary Stage and Scripts for the Enactment of Dying Roles: A Narrative Review of the Literature. OMEGA-JOURNAL OF DEATH AND DYING 2017; 76:328-350. [PMID: 29284312 DOI: 10.1177/0030222817696541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This narrative review explores the literature regarding the drama of dying from several academic perspectives. Three key themes were identified including "The impact of blurred boundaries on roles and transitions," "The orchestration of death and dying through time," and "Contemporary dying and new machinery of control." This review reveals the manner in which tightly scripted dying roles serve the needs of the living to a greater extent than those of the dying, by ensuring the depiction of both dying and death as phenomena which have been brought under the control of the living, thereby countering death anxiety. An incongruence between the actual experience of dying and contemporary dying scripts is also highlighted. The authors argue that this incongruence is hidden from the broader societal audience through the maintenance of a dying role that demands serenity and acceptance, thus downplaying or even hiding the actual end-of-life experiences of the dying themselves.
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Affiliation(s)
- Daniel Lowrie
- 1 College of Healthcare Sciences, James Cook University, Douglas, Australia
| | - Robin Ray
- 2 College of Medicine and Dentistry, James Cook University, Douglas, Australia
| | - David Plummer
- 3 College of Public Health, Medical and Veterinary Sciences, James Cook University, Douglas, Australia
| | - Matthew Yau
- 4 School of Medical & Health Sciences, Tung Wah College, Kowloon, Hong Kong
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89
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Gott M, Frey R, Wiles J, Rolleston A, Teh R, Moeke-Maxwell T, Kerse N. End of life care preferences among people of advanced age: LiLACS NZ. BMC Palliat Care 2017; 16:76. [PMID: 29258480 PMCID: PMC5738169 DOI: 10.1186/s12904-017-0258-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 12/01/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Understanding end of life preferences amongst the oldest old is crucial to informing appropriate palliative and end of life care internationally. However, little has been reported in the academic literature about the end of life preferences of people in advanced age, particularly the preferences of indigenous older people, including New Zealand Māori. METHODS Data on end of life preferences were gathered from 147 Māori (aged >80 years) and 291 non- Māori aged (>85 years), during three waves of Te Puawaitangi O Nga Tapuwae Kia Ora Tonu, Life and Living in Advanced Age (LiLACs NZ). An interviewer-led questionnaire using standardised tools and including Māori specific subsections was used. RESULTS The top priority for both Māori and non-Māori participants at end of life was 'not being a burden to my family'. Interestingly, a home death was not a high priority for either group. End of life preferences differed by gender, however these differences were culturally contingent. More female Māori participants wanted spiritual practices at end of life than male Māori participants. More male non-Māori participants wanted to be resuscitated than female non- Māori participants. CONCLUSIONS That a home death was not in the top three end of life priorities for our participants is not consistent with palliative care policy in most developed countries where place of death, and particularly home death, is a central concern. Conversely our participants' top concern - namely not being a burden - has received little research or policy attention. Our results also indicate a need to pay attention to diversity in end of life preferences amongst people of advanced age, as well as the socio-cultural context within which preferences are formulated.
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Affiliation(s)
- Merryn Gott
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Rosemary Frey
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Janine Wiles
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Anna Rolleston
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ruth Teh
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Tess Moeke-Maxwell
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ngaire Kerse
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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90
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Higginson IJ, Daveson BA, Morrison RS, Yi D, Meier D, Smith M, Ryan K, McQuillan R, Johnston BM, Normand C. Social and clinical determinants of preferences and their achievement at the end of life: prospective cohort study of older adults receiving palliative care in three countries. BMC Geriatr 2017; 17:271. [PMID: 29169346 PMCID: PMC5701500 DOI: 10.1186/s12877-017-0648-4] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 10/19/2017] [Indexed: 11/10/2022] Open
Abstract
Background Achieving choice is proposed as a quality marker. But little is known about what influences preferences especially among older adults. We aimed to determine and compare, across three countries, factors associated with preferences for place of death and treatment, and actual site of death. Methods We recruited adults aged ≥65-years from hospital-based multiprofessional palliative care services in London, Dublin, New York, and followed them for >17 months. All services offered consultation on hospital wards, support for existing clinical teams, outpatient services and received funding from their National Health Service and/or relevant Insurance reimbursements. The New York service additionally had 10 inpatient beds. All worked with and referred patients to local hospices. Face-to-face interviews recorded most and least preferred place of death, treatment goal priorities, demographic and clinical information using validated questionnaires. Multivariable and multilevel analyses assessed associated factors. Results One hundred and thirty eight older adults (64 London, 59 Dublin, 15 New York) were recruited, 110 died during follow-up. Home was the most preferred place of death (77/138, 56%) followed by inpatient palliative care/hospice units (22%). Hospital was least preferred (35/138, 25%), followed by nursing home (20%) and home (16%); hospice/palliative care unit was rarely least preferred (4%). Most respondents prioritised improving quality of life, either alone (54%), or equal with life extension (39%); few (3%) chose only life extension. There were no significant differences between countries. Main associates with home preference were: cancer diagnosis (OR 3.72, 95% CI 1.40–9.90) and living with someone (OR 2.19, 1.33–3.62). Adults with non-cancer diagnoses were more likely to prefer palliative care units (OR 2.39, 1.14–5.03). Conversely, functional independence (OR 1.05, 1.04–1.06) and valuing quality of life (OR 3.11, 2.89–3.36) were associated with dying at home. There was a mismatch between preferences and achievements – of 85 people who preferred home or a palliative care unit, 19 (25%) achieved their first preference. Conclusion Although home is the most common first preference, it is polarising and for 16% it is the least preferred. Inpatient palliative care unit emerges as the second most preferred place, is rarely least preferred, and yet was often not achieved for those who wanted to die there. Factors affecting stated preferences and met preferences differ. Available services, notably community support and palliative care units, require expansion. Contrasting actual place of death with capacity for meeting patient and family needs may be a better quality indicator than simply ‘achieved preferences’. Electronic supplementary material The online version of this article (10.1186/s12877-017-0648-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Irene J Higginson
- Cicely Saunders Institute Of Palliative Care, Policy & Rehabilitation, King's College London, and King's College Hospital, Bessemer Road, London, SE5 9PJ, UK.
| | - Barbara A Daveson
- Cicely Saunders Institute Of Palliative Care, Policy & Rehabilitation, King's College London, and King's College Hospital, Bessemer Road, London, SE5 9PJ, UK
| | - R Sean Morrison
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029-6574, USA
| | - Deokhee Yi
- Cicely Saunders Institute Of Palliative Care, Policy & Rehabilitation, King's College London, and King's College Hospital, Bessemer Road, London, SE5 9PJ, UK.
| | - Diane Meier
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029-6574, USA
| | - Melinda Smith
- Cicely Saunders Institute Of Palliative Care, Policy & Rehabilitation, King's College London, and King's College Hospital, Bessemer Road, London, SE5 9PJ, UK
| | - Karen Ryan
- Mater Misericordiae Hospital, Eccles Street, Dublin 7, Ireland
| | | | - Bridget M Johnston
- The Centre of Health Policy and Management, Trinity College Dublin, Room 0.21, 3-4 Foster Place, College Green, Dublin 2, Ireland
| | - Charles Normand
- The Centre of Health Policy and Management, Trinity College Dublin, Room 0.21, 3-4 Foster Place, College Green, Dublin 2, Ireland
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91
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Fleming J, Calloway R, Perrels A, Farquhar M, Barclay S, Brayne C. Dying comfortably in very old age with or without dementia in different care settings - a representative "older old" population study. BMC Geriatr 2017; 17:222. [PMID: 28978301 PMCID: PMC5628473 DOI: 10.1186/s12877-017-0605-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 09/01/2017] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Comfort is frequently ranked important for a good death. Although rising numbers of people are dying in very old age, many with dementia, little is known about symptom control for "older old" people or whether care in different settings enables them to die comfortably. This study aims to examine, in a population-representative sample, associations between factors potentially related to reported comfort during very old people's final illness: physical and cognitive disability, place of care and transitions in their final illness, and place of death. METHODS Retrospective analyses linked three data sources for n = 180 deceased study participants (68% women) aged 79-107 in a representative population-based UK study, the Cambridge City over-75s Cohort (CC75C): i) prospective in-vivo dementia diagnoses and cognitive assessments, ii) certified place of death records, iii) data from interviews with relatives/close carers including symptoms and "How comfortable was he/she in his/her final illness?" RESULTS In the last year of life 83% were disabled in basic activities, 37% had moderate/severe dementia and 45% minimal/mild dementia or cognitive impairment. Regardless of dementia/cognitive status, three-quarters died following a final illness lasting a week or longer. 37%, 44%, 13% and 7% of the deceased were described as having been "very comfortable", "comfortable", "fairly comfortable" or "uncomfortable" respectively during their final illness, but reported symptoms were common: distress, pain, depression and delirium or confusion each affected 40-50%. For only 10% were no symptoms reported. There were ≥4-fold increased odds of dying comfortably associated with being in a care home during the final illness, dying in a care home, and with staying in place (dying at what death certificates record as "usual address"), whether home or care home, compared with hospital, but no significant association with disability or dementia/cognitive status, regardless of adjustment. CONCLUSIONS These findings are consistent with reports that care homes can provide care akin to hospice for the very old and support an approach of supporting residents to stay in their care home or own home if possible. Findings on reported high prevalence of multiple symptoms can inform policy and training to improve older old people's end-of-life care in all settings.
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Affiliation(s)
- Jane Fleming
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
| | - Rowan Calloway
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- North East Thames Foundation School, London, UK
| | - Anouk Perrels
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Faculty of Medicine, Vrije Universiteit, Amsterdam, Netherlands
| | - Morag Farquhar
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Stephen Barclay
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
- Primary Care Unit, Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
| | - Carol Brayne
- Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR UK
- Department of Public Health & Primary Cambridge, University of Cambridge, Cambridge, UK
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Hicks K, Downey L, Engelberg RA, Fausto JA, Starks H, Dunlap B, Sibley J, Lober W, Khandelwal N, Loggers ET, Curtis JR. Predictors of Death in the Hospital for Patients with Chronic Serious Illness. J Palliat Med 2017; 21:307-314. [PMID: 28926294 DOI: 10.1089/jpm.2017.0127] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Most people prefer to die at home, yet most do not. Understanding factors associated with terminal hospitalization may inform interventions to improve care. OBJECTIVE Among patients with chronic illness receiving care in a multihospital healthcare system, we identified the following: (1) predictors of death in any hospital; (2) predictors of death in a hospital outside the system; and (3) trends from 2010 to 2015. DESIGN Retrospective cohort using death certificates and electronic health records. Settings/Subjects: Decedents with one of nine chronic illnesses. RESULTS Among 20,486 decedents, those most likely to die in a hospital were younger (odds ratio [OR] 0.977, confidence interval [CI] 0.974-0.980), with more comorbidities (OR 1.188, CI 1.079-1.308), or more outpatient providers (OR 1.031, CI 1.015-1.047); those with cancer or dementia, or more outpatient visits were less likely to die in hospital. Among hospital deaths, patients more likely to die in an outside hospital had lower education (OR 0.952, CI 0.923-0.981), cancer (OR 1.388, CI 1.198-1.608), diabetes (OR 1.507, CI 1.262-1.799), fewer comorbidities (OR 0.745, CI 0.644-0.862), or fewer hospitalizations within the system during the prior year (OR 0.900, CI 0.864-0.938). Deaths in hospital did not change from 2010 to 2015, but the proportion of hospital deaths outside the system increased (p < 0.022). CONCLUSIONS Patients dying in the hospital who are more likely to die in an outside hospital, and therefore at greater risk for inaccessibility of advance care planning, were more likely to be less well-educated and have cancer or diabetes, fewer comorbidities, and fewer hospitalizations. These findings may help target interventions to improve end-of-life care.
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Affiliation(s)
- Katy Hicks
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Department of Medicine, University of Washington , Seattle, Washington
| | - Lois Downey
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,3 Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington , Seattle, Washington
| | - Ruth A Engelberg
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Department of Medicine, University of Washington , Seattle, Washington.,3 Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington , Seattle, Washington
| | - James A Fausto
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,4 Department of Family Medicine, University of Washington , Seattle, Washington
| | - Helene Starks
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,4 Department of Family Medicine, University of Washington , Seattle, Washington.,5 Department of Bioethics and Humanities, University of Washington , Seattle, Washington
| | - Ben Dunlap
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,3 Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington , Seattle, Washington
| | - James Sibley
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,6 Department of Bioinformatics and Medical Education, University of Washington , Seattle, Washington
| | - William Lober
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,6 Department of Bioinformatics and Medical Education, University of Washington , Seattle, Washington
| | - Nita Khandelwal
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,7 Department of Anesthesiology and Pain Medicine, University of Washington , Seattle, Washington
| | - Elizabeth T Loggers
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Department of Medicine, University of Washington , Seattle, Washington.,8 Seattle Cancer Care Alliance , Seattle, Washington.,9 Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle, Washington
| | - J Randall Curtis
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Department of Medicine, University of Washington , Seattle, Washington.,3 Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington , Seattle, Washington.,5 Department of Bioethics and Humanities, University of Washington , Seattle, Washington
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93
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Aparicio M, Centeno C, Carrasco JM, Barbosa A, Arantzamendi M. What are families most grateful for after receiving palliative care? Content analysis of written documents received: a chance to improve the quality of care. BMC Palliat Care 2017; 16:47. [PMID: 28874150 PMCID: PMC5586049 DOI: 10.1186/s12904-017-0229-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 08/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Family members are involved in the care of palliative patients at home and therefore, should be viewed as important sources of information to help clinicians better understand the quality palliative care service patients receive. The objective of the study was to analyse what is valued most by family carers undergoing bereavement of a palliative care home service in order to identify factors of quality of care. METHODS Qualitative exploratory study based on documentary analysis. Content analysis of 77 gratitude documents received over 8 years by a palliative home service in Odivelas, near Lisbon (Portugal) was undertaken, through an inductive approach and using investigator triangulation. Frequency of distinct categories was quantitatively defined. RESULTS Three different content categories emerged from the analysis: a) Recognition of the care received and the value of particular aspects of care within recognised difficult situations included aspects such as kindness, listening, attention to the family, empathy, closeness, affection and the therapeutic relationships established (63/77 documents); b) Family recognition of the achievements of the palliative care team (29/77) indicated as relief from suffering for the patient and family, opportunity of dying at home, help in facing difficult situations, improvement in quality of life and wellbeing, and feeling of serenity during bereavement; c) Messages of support (45/77) related to the need of resources provided. The relational component emerges as an underlying key aspect of family carers' experience with palliative care home service. CONCLUSION Family carers show spontaneous gratitude for the professionalism and humanity found in palliative care. The relational component of care emerges as key to achieve a high quality care experience of palliative care homes service, and could be one indicator of quality of palliative care.
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Affiliation(s)
- María Aparicio
- St John’s Hospice, London, UK
- Universidad de Navarra, ICS, ATLANTES, Campus Universitario, 31080 Pamplona, España
| | - Carlos Centeno
- Universidad de Navarra, ICS, ATLANTES, Campus Universitario, 31080 Pamplona, España
- Clínica Universidad de Navarra, Departamento de Medicina Paliativa, Avenidad Pío XII, 31080 Pamplona, España
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, Grupo: Medicina paliativa, Pamplona, España
| | - José Miguel Carrasco
- Universidad de Navarra, ICS, ATLANTES, Campus Universitario, 31080 Pamplona, España
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, Grupo: Medicina paliativa, Pamplona, España
| | - Antonio Barbosa
- Centre for Bioethics, Faculty of Medicine, University of Lisboa, Lisbon, Portugal
| | - María Arantzamendi
- Universidad de Navarra, ICS, ATLANTES, Campus Universitario, 31080 Pamplona, España
- IdiSNA, Instituto de Investigación Sanitaria de Navarra, Grupo: Medicina paliativa, Pamplona, España
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94
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McCaughan D, Roman E, Smith AG, Garry A, Johnson M, Patmore R, Howard M, Howell DA. Determinants of hospital death in haematological cancers: findings from a qualitative study. BMJ Support Palliat Care 2017; 8:78-86. [PMID: 28663341 PMCID: PMC5867428 DOI: 10.1136/bmjspcare-2016-001289] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 04/07/2017] [Accepted: 05/20/2017] [Indexed: 11/10/2022]
Abstract
Objectives Current UK health policy promotes enabling people to die in a place they choose, which for most is home. Despite this, patients with haematological malignancies (leukaemias, lymphomas and myeloma) are more likely to die in hospital than those with other cancers, and this is often considered a reflection of poor quality end-of-life care. This study aimed to explore the experiences of clinicians and relatives to determine why hospital deaths predominate in these diseases. Methods The study was set within the Haematological Malignancy Research Network (HMRN—www.hmrn.org), an ongoing population-based cohort that provides infrastructure for evidence-based research. Qualitative interviews were conducted with clinical staff in haematology, palliative care and general practice (n=45) and relatives of deceased HMRN patients (n=10). Data were analysed for thematic content and coding and classification was inductive. Interpretation involved seeking meaning, salience and connections within the data. Results Five themes were identified relating to: the characteristics and trajectory of haematological cancers, a mismatch between the expectations and reality of home death, preference for hospital death, barriers to home/hospice death and suggested changes to practice to support non-hospital death, when preferred. Conclusions Hospital deaths were largely determined by the characteristics of haematological malignancies, which included uncertain trajectories, indistinct transitions and difficulties predicting prognosis and identifying if or when to withdraw treatment. Advance planning (where possible) and better communication between primary and secondary care may facilitate non-hospital death.
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Affiliation(s)
- Dorothy McCaughan
- Epidemiology & Cancer Statistics Group, Seebohm Rowntree Building, University of York, York, UK
| | - Eve Roman
- Epidemiology & Cancer Statistics Group, Seebohm Rowntree Building, University of York, York, UK
| | - Alexandra G Smith
- Epidemiology & Cancer Statistics Group, Seebohm Rowntree Building, University of York, York, UK
| | - Anne Garry
- Department of Palliative Care, York Hospital, York, UK
| | - Miriam Johnson
- Centre for Health and Population Sciences, University of Hull, Hull, UK
| | - Russell Patmore
- Queens Centre for Oncology and Haematology, Castle Hill Hospital, Cottingham, UK
| | | | - Debra A Howell
- Epidemiology & Cancer Statistics Group, Seebohm Rowntree Building, University of York, York, UK
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95
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Home as a place of caring and wellbeing? A qualitative study of informal carers and caring networks lived experiences of providing in-home end-of-life care. Health Place 2017; 46:58-64. [PMID: 28499149 DOI: 10.1016/j.healthplace.2017.04.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 04/10/2017] [Accepted: 04/13/2017] [Indexed: 11/20/2022]
Abstract
Although the burden of caring is well described, the value of home as a potential place of wellbeing and support for informal caring networks when providing end-of-life care is not well recognised. Interviews and focus groups with 127 primary carers and members of informal care networks revealed their collaborative stories about caring for a dying person at home. Four themes emerged from the data: home as a place of comfort and belonging; places of social connection and collaborative caring; places of connection to nature and the non-human; places of achievement and triumph. When support is available, nurturing carer wellbeing may be best achieved at home.
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96
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Chisumpa VH, Odimegwu CO, De Wet N. Adult mortality in sub-saharan Africa, Zambia: Where do adults die? SSM Popul Health 2017; 3:227-235. [PMID: 29349220 PMCID: PMC5769069 DOI: 10.1016/j.ssmph.2017.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 01/30/2017] [Accepted: 02/01/2017] [Indexed: 11/23/2022] Open
Abstract
Place of death remains an issue of growing interest and debate among scholars as an indicator of quality of end-of-life care in developed countries. In sub-Saharan Africa, however, variations in place of death may suggest inequalities in access to and the utilization of health care services that should be addressed by public health interventions. Limited research exists on factors associated with place of death in sub-Saharan Africa. The study examines factors associated with the place of death among Zambian adults aged 15–59 years using the 2010–2012 sample vital registration with verbal autopsy survey (SAVVY) data, descriptive statistics and multivariate logistic regression analysis. Results show that more than half of the adult deaths occurred in a health facility and two-fifths died at home. Higher educational attainment, urban versus rural residence, and being of female gender were significant predictors of the place of death. Improvement in educational attainment and investment in rural health facilities and the health care system as a whole may improve access and utilization of health services among adults. We examined factors associated with place of death among adults aged 15–59 in Zambia. Health facility remains the common place of death in Zambia followed by the deceased's home. High proportion of adults still dying at home indicates a lack of access to and the utilization of health care services. Educational attainment, sex, and urban-rural residence were strong predictors of the place of death. Variations in place of death by population background characteristics among adult decedents may suggest inequalities in access and utilization of health services.
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Affiliation(s)
- Vesper H Chisumpa
- Department of Population Studies, School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia.,Demography and Population Studies Programme, School of Social Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Clifford O Odimegwu
- Demography and Population Studies Programme, Schools of Public Health and Social Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicole De Wet
- Demography and Population Studies Programme, School of Social Sciences, University of the Witwatersrand, Johannesburg, South Africa
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97
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Barratt H, Asaria M, Sheringham J, Stone P, Raine R, Cookson R. Dying in hospital: socioeconomic inequality trends in England. J Health Serv Res Policy 2017; 22:149-154. [PMID: 28429981 PMCID: PMC5548360 DOI: 10.1177/1355819616686807] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To describe trends in socioeconomic inequality in the proportion of deaths occurring in hospital, during a period of sustained effort by the NHS in England to improve end of life care. Methods Whole-population, small area longitudinal study involving 5,260,871 patients of all ages who died in England from 2001/2002 to 2011/2012. Our primary measure of inequality was the slope index of inequality. This represents the estimated gap between the most and least deprived neighbourhood in England, allowing for the gradient in between. Neighbourhoods were geographic Lower Layer Super Output Areas containing about 1500 people each. Results The overall proportion of patients dying in hospital decreased from 49.5% to 43.6% during the study period, after initially increasing to 52.0% in 2004/2005. There was substantial ‘pro-rich’ inequality, with an estimated difference of 5.95 percentage points in the proportion of people dying in hospital (confidence interval 5.26 to 6.63), comparing the most and least deprived neighbourhoods in 2011/2012. There was no significant reduction in this gap over time, either in absolute terms or relative to the mean, despite the overall reduction in the proportion of patients dying in hospital. Conclusions Efforts to reduce the proportion of patients dying in hospital in England have been successful overall but did not reduce inequality. Greater understanding of the reasons for such inequality is required before policy changes can be determined.
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Affiliation(s)
- Helen Barratt
- Senior Clinical Research Associate, Department of Applied Health Research, University College London, UK
| | - Miqdad Asaria
- Research Fellow, Centre for Health Economics, University of York, UK
| | - Jessica Sheringham
- Senior Research Associate, Department of Applied Health Research, University College London, UK
| | - Patrick Stone
- Professor of Palliative and End of Life Care, Marie Curie Palliative Care Research Department, University College London, UK
| | - Rosalind Raine
- Professor of Health Care Evaluation and Head of Department of Applied Health Research, University College London, UK
| | - Richard Cookson
- Professor and NIHR Senior Research Fellow, Centre for Health Economics, University of York, UK
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98
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Clark K, Connolly A, Clapham S, Quinsey K, Eagar K, Currow DC. Physical Symptoms at the Time of Dying Was Diagnosed: A Consecutive Cohort Study To Describe the Prevalence and Intensity of Problems Experienced by Imminently Dying Palliative Care Patients by Diagnosis and Place of Care. J Palliat Med 2016; 19:1288-1295. [DOI: 10.1089/jpm.2016.0219] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Katherine Clark
- Department of Palliative Care, Calvary Mater Newcastle, Newcastle, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Alanna Connolly
- Palliative Care Outcomes Collaboration, Australian Health Services Research Institute (AHSRI), University of Wollongong, Wollongong, Australia
| | - Sabina Clapham
- Palliative Care Outcomes Collaboration, Australian Health Services Research Institute (AHSRI), University of Wollongong, Wollongong, Australia
| | - Karen Quinsey
- Palliative Care Outcomes Collaboration, Australian Health Services Research Institute (AHSRI), University of Wollongong, Wollongong, Australia
| | - Kathy Eagar
- Palliative Care Outcomes Collaboration, Australian Health Services Research Institute (AHSRI), University of Wollongong, Wollongong, Australia
- Centre for Health Service Development, Australian Health Services Research Institute (AHSRI), University of Wollongong, Wollongong, Australia
| | - David C. Currow
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
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99
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Bähler C, Signorell A, Reich O. Health Care Utilisation and Transitions between Health Care Settings in the Last 6 Months of Life in Switzerland. PLoS One 2016; 11:e0160932. [PMID: 27598939 PMCID: PMC5012658 DOI: 10.1371/journal.pone.0160932] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 07/27/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Many efforts are undertaken in Switzerland to enable older and/or chronically ill patients to stay home longer at the end-of-life. One of the consequences might be an increased need for hospitalisations at the end-of-life, which goes along with burdensome transitions for patients and higher health care costs for the society. AIM We aimed to examine the health care utilisation in the last six months of life, including transitions between health care settings, in a Swiss adult population. METHODS The study population consisted of 11'310 decedents of 2014 who were insured at the Helsana Group, the leading health insurance in Switzerland. Descriptive statistics were used to analyse the health care utilisation by age group, taking into account individual and regional factors. Zero-inflated Poisson regression model was used to predict the number of transitions. RESULTS Mean age was 78.1 in men and 83.8 in women. In the last six months of life, 94.7% of the decedents had at least one consultation; 61.6% were hospitalised at least once, with a mean length of stay of 28.3 days; and nursing home stays were seen in 47.4% of the decedents. Over the same time period, 64.5% were transferred at least once, and 12.9% experienced at least one burdensome transition. Main predictors for transitions were age, sex and chronic conditions. A high density of home care nurses was associated with a decrease, whereas a high density of ambulatory care physicians was associated with an increase in the number of transitions. CONCLUSIONS Health care utilisation was high in the last six months of life and a considerable number of decedents were being transferred. Advance care planning might prevent patients from numerous and particularly from burdensome transitions.
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Affiliation(s)
- Caroline Bähler
- Department of Health Sciences, Helsana Insurance Group, P.O. Box, 8081 Zürich, Switzerland
| | - Andri Signorell
- Department of Health Sciences, Helsana Insurance Group, P.O. Box, 8081 Zürich, Switzerland
| | - Oliver Reich
- Department of Health Sciences, Helsana Insurance Group, P.O. Box, 8081 Zürich, Switzerland
- * E-mail:
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100
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Shimada N, Ishiki H, Iwase S, Chiba T, Fujiwara N, Watanabe A, Kinkawa J, Nojima M, Tojo A, Imai K. Cancer Transitional Care for Terminally Ill Cancer Patients Can Reduce the Number of Emergency Admissions and Emergency Department Visits. Am J Hosp Palliat Care 2016; 34:831-837. [PMID: 27413014 DOI: 10.1177/1049909116658641] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Emergency admissions and emergency department visits (EAs/EDVs) have been used as quality indicators of home care in terminally ill cancer patients. We established a cancer transitional care (CTC) program to monitor and manage terminally ill cancer patients receiving care at home. The purpose of this study was to evaluate the effectiveness of CTC by the frequency of EAs/EDVs. METHODS In a retrospective chart review, we identified 133 patients with cancer admitted to our department, of whom 56 met study eligibility criteria. The CTC consisted of at least 1 or more following components: (1) a 24-hour hotline for general physicians or home care nurses to reach hospital-based physicians, (2) periodic phone calls from an expert hospital-based oncology nurse to home care medical staff, and (3) reports sent to our department from home care medical staff. The primary outcome variable was the frequency of EAs/EDVs. RESULTS There were 32 EAs/EDVs and 69 planned admissions during the observation period. In the last 30 days of life, 16 patients (28.6%) had 1 EA/EDV and none had multiple EAs/EDVs. Compared with previous studies, our study found a similar or lower frequency of EAs/EDVs. CONCLUSION Our findings suggest that the implementation of CTC reduces the number of EAs/EDVs by replacing them with planned admissions. Further prospective studies to evaluate CTC are warranted.
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Affiliation(s)
- Naoki Shimada
- 1 Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Hiroto Ishiki
- 1 Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Satoru Iwase
- 1 Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Tsukuru Chiba
- 1 Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Noriko Fujiwara
- 1 Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Aya Watanabe
- 1 Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Junya Kinkawa
- 1 Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Masanori Nojima
- 2 Center for Translational Research, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Arinobu Tojo
- 1 Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan.,3 Department of Hematology/Oncology, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Kohzoh Imai
- 4 Center for Antibody and Vaccine Therapy, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
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