The Trend of Aggressive Treatments in End-of-Life Care for Older People With Dementia After a Policy Change in Taiwan

Survival and critical care use among people with dementia in a large English cohort

BACKGROUND

Admitting people with dementia to critical care units may not always lead to a clear survival benefit. Critical care admissions of people with dementia vary across countries. Little is known about the use and trends of critical care admissions of people with dementia in England.

OBJECTIVE

To investigate critical care use and survival among people with dementia in a large London catchment area.

METHODS

A retrospective cohort study using data from dementia assessment services in south London, UK (2007-20) linked with national hospitalisation data to ascertain critical care admissions. Outcomes included age-sex-standardised critical care use and 1-year post-critical care admission survival by dementia severity (binary: mild versus moderate/severe). We used logistic regression and Kaplan-Meier survival plots for investigating 1-year survival following a critical care admission and linear regressions for time trends.

RESULTS

Of 19,787 people diagnosed with dementia, 726 (3.7%) had ≥1 critical care admission at any time after receiving their dementia diagnosis. The overall 1-year survival of people with dementia, who had a CCA, was 47.5% (n = 345). Dementia severity was not associated with 1-year survival following a critical care admission (mild dementia versus moderate-severe dementia odds of 1-year mortality OR: 0.90, 95% CI [0.66-1.22]). Over the 12-year period from 2008 to 2019, overall critical care use decreased (β = -0.05; 95% CI = -0.01, -0.0003; P = 0.03), while critical care admissions occurring during the last year of life increased (β = 0.11, 95% CI = 0.01, 0.20, P = 0.03).

CONCLUSIONS

In this cohort, while critical care use among people with dementia declined overall, its use increased among those in their last year of life. Survival remains comparable to that observed in general older populations.

Taiwanese Older Adults Prefer to Use Antibiotics and Intravenous Infusion at the End of Life based on a Cartoon Version of the Life Support Preferences Questionnaire

Asians believe discussing death-related topics is inauspicious and may bring bad luck. It is critical to explore the end-of-life care preferences of the Asian elderly with less-threatening tools. The study examined older adults' preferences regarding end-of-life treatments by applying a cartoon version of the Life Support Preferences Questionnaire (LSPQ). A cross-sectional survey was conducted to understand older adults' preferences for end-of-life treatments. A total of 342 older adults participated in the study, comprising 268 elderly patients from a veterans hospital located in northern Taiwan and 74 elderly family members of the patients. Regardless of scenario, cardiopulmonary resuscitation (CPR) had the lowest score, indicating that older adults considered it a less desirable medical treatment. By contrast, antibiotics and intravenous infusions had the highest scores, indicating that older adults tended to prefer them. End-of-life care preferences were significantly different in genders. CPR and surgical preferences of older adults differed significantly with education level. Different demographic characteristics had different end-of-life treatment preferences, and future research may develop advance care planning programs for different attributes. This cartoon version of the LSPQ can help healthcare professionals to understand older adults' preferences for end-of-life care and warrants further empirical research.

Nursing Home Residents Hospitalization at the End of Life: Experience and Predictors in Portuguese Nursing Homes

(1) Background: Nursing Home (NH) residents are a population with health and social vulnerabilities, for whom emergency department visits or hospitalization near the end of life can be considered a marker of healthcare aggressiveness. With the present study, we intend to identify and characterize acute care transitions in the last year of life in Portuguese NH residents, to characterize care integration between the different care levels, and identify predictors of death at hospital and potentially burdensome transitions; (2) Methods: a retrospective after-death study was performed, covering 18 months prior to the emergence of the COVID-19 pandemic, in a nationwide sample of Portuguese NH with 614 residents; (3) Results: 176 deceased patients were included. More than half of NH residents died at hospital. One-third experienced a potentially burdensome care transition in the last 3 days of life, and 48.3% in the last 90 days. Younger age and higher technical staff support were associated with death at hospital and a higher likelihood of burdensome transitions in the last year of life, and Palliative Care team support with less. Advanced Care planning was almost absent; (4) Conclusions: The studied population was frail and old without advance directives in place, and subject to frequent hospitalization and potentially burdensome transitions near the end of life. Unlike other studies, staff provisioning did not improve the outcomes. The results may be related to a low social and professional awareness of Palliative Care and warrant further study.

Gender differences in the intention to withhold life-sustaining treatments involving severe dementia for self and on behalf of parent or spouse

Background

Few studies have explored gender differences in the attitudes toward advanced care planning and the intention to withhold life-sustaining treatments (LSTs) involving severe dementia in Asian countries. We examined gender differences in the attitude toward the Patient Autonomy Act (PAA) in Taiwan and how the gender differences in these attitudes affect the intention to withhold LSTs for severe dementia. We also investigated self–other differences in the intention to withhold LSTs between genders.

Methods

Between March and October 2019, a structured questionnaire was distributed to hospitalized patients’ family members through face-to-face contact in an academic medical center. Exploratory factor analysis and independent and paired-sample t-tests were used to describe gender differences. Mediation analyses controlled for age, marital status, and education level were conducted to examine whether the attitude toward the PAA mediates the gender effect on the intention to withhold LSTs for severe dementia.

Results

Eighty respondents filled out the questionnaire. Exploratory factor analysis of the attitude toward the PAA revealed three key domains: regarding the PAA as (1) promoting a sense of abandonment, (2) supporting patient autonomy, and (3) contributing to the collective good. Relative to the men, the women had lower average scores for promoting a sense of abandonment (7.48 vs. 8.94, p = 0.030), higher scores for supporting patient autonomy (8.74 vs. 7.94, p = 0.006), and higher scores for contributing to the collective good (8.64 vs. 7.47, p = 0.001). Compared with the women, the men were less likely to withhold LSTs for severe dementia (15.84 vs. 18.88, p = 0.01). Mediation analysis revealed that the attitude toward the PAA fully mediated the gender differences in the intention to withhold LSTs for severe dementia. Both men and women were more likely to withhold LSTs for themselves than for their parents. Compared with the women, the men were more likely to withhold resuscitation for themselves than for their parents (p = 0.05). Women were more likely to agree to enteral tube feeding and a tracheotomy for their husbands than for themselves; men made consistent decisions for themselves and their wives in those LST scenarios.

Conclusion

Gender influences the attitude toward advanced care planning and consequently affects the intention to withhold LSTs, indicating that there may be a difference in how men and women perceive EOL decision-making for severe dementia in Taiwan. Further studies are warranted.

Predictors and Assessment of Hospice Use for End-Stage Renal Disease Patients in Taiwan

OBJECTIVES

Hospice and early palliative care are generally considered as an alternative and supportive care to offer symptoms relief and optimize the quality of life among end-stage renal disease (ESRD) patients, but hospice care remains underutilized. This study aimed to examine patient and health system characteristics and develop a patient assessment scale to evaluate ESRD patients for hospice care after the implementation of non-cancer hospice care reimbursement policy in 2009 in Taiwan.

METHOD

We conducted a retrospective cohort study using nationwide population-based datasets. Adult long-term dialysis patients between 2009 and 2012 were included. Multivariable logistic regression and the Firth penalized likelihood estimation were used to estimate the likelihood of receiving hospice care. A receiver operating characteristic curve (ROC) analysis and C-statistic were calculated to determine the optimal models for a patient assessment of hospice use.

RESULTS

Patients who were older, comorbid with anemia (odds ratio [OR] 3.53, 95% CI 1.43-8.70) or sepsis (OR 1.62, 95% CI 1.08-2.44), with longer dialysis durations, more hospitalizations (OR 4.68, 95% CI 2.56-8.55), or primary provider care with hospice (OR 5.15, 95% CI 2.80-9.45) were more likely to receive hospice care. The total score of the patient assessment scale of hospice care was 0-28 with a cut-off value of 19 based on the results of the receiver operating characteristic curve.

CONCLUSION

Given the "Patient Right to Autonomy Act" implemented in Taiwan in 2019 to promote the concept of a "good quality of death", this patient assessment scale may help health professionals target ESRD patients for hospice care and engage in shared decision making and the advance care planning process.

Analysis of high-intensity care in intensive care units and its cost at the end of life among older people in South Korea between 2016 and 2019: a cross-sectional study of the health insurance review and assessment service national patient sample database

OBJECTIVES

To provide useful information for clinicians and policy makers to prepare guidelines for adequate use of medical resources during end-of-life period by analysing the intensive care use and related costs at the end of life in South Korea.

DESIGN

Cross-sectional, retrospective, observational study.

SETTING

Tertiary hospitals in South Korea.

PARTICIPANTS

We analysed claim data and patient information from the Health Insurance Review and Assessment Service national dataset. This dataset included 19 119 older adults aged 65 years or above who received high-intensity care at least once and died in the intensive care unit in South Korea between 2016 and 2019. High-intensity care was defined as one of the following treatments or procedures: cardiopulmonary resuscitation, mechanical ventilation, extra-corporeal membrane oxygenation, haemodialysis, transfusion, chemotherapy and vasopressors.

PRIMARY AND SECONDARY OUTCOME MEASURES

Usage and cost of high-intensity care.

RESULTS

The most commonly used high-intensity care was transfusion (68.9%), mechanical ventilation (50.6%) and haemodialysis (35.7%) during the study period. The annual cost of high-intensity care at the end of life increased steadily from 2016 to 2019. There existed differences by age, gender, length of hospital stays and primary cause of death in use of high-intensity care and associated costs.

CONCLUSION

Findings indicate that invasive and device-dependent high-intensity care is frequently provided at the end of life among older adults, which could potentially place an economic burden on patients and their families. In Korea's ageing society, increased rates of chronic illness are expected to significantly burden those who lack the financial resources to provide end-of-life care. Therefore, guidelines for the use of high-intensity care are required to ensure affordable end-of-life care.