Association between referral-to-death interval and location of death of patients referred to a hospital-based specialist palliative care service

Quality of End-of-Life Care during the COVID-19 Pandemic at a Comprehensive Cancer Center

To evaluate how the COVID-19 pandemic impacted the quality of end-of-life care for patients with advanced cancer, we compared a random sample of 250 inpatient deaths from 1 April 2019, to 31 July 2019, with 250 consecutive inpatient deaths from 1 April 2020, to 31 July 2020, at a comprehensive cancer center. Sociodemographic and clinical characteristics, the timing of palliative care referral, timing of do-not-resuscitate (DNR) orders, location of death, and pre-admission out-of-hospital DNR documentation were included. During the COVID-19 pandemic, DNR orders occurred earlier (2.9 vs. 1.7 days before death, p = 0.028), and palliative care referrals also occurred earlier (3.5 vs. 2.5 days before death, p = 0.041). During the pandemic, 36% of inpatient deaths occurred in the Intensive Care Unit (ICU) and 36% in the Palliative Care Unit, compared to 48 and 29%, respectively, before the pandemic (p = 0.001). Earlier DNR orders, earlier palliative care referrals, and fewer ICU deaths suggest an improvement in the quality of end-of-life care in response to the COVID-19 pandemic. These encouraging findings may have future implications for maintaining quality end-of-life care post-pandemic.

Death at home versus other locations in older people receiving physician‐led home visits: A multicenter prospective study in Japan

BACKGROUND

The Japanese government is promoting physician-led home visits as well as end-of-life care at home. However, the proportion of deaths occurring at home has remained unchanged for the past 20 years.

OBJECTIVES

To report the cumulative incidence of deaths at home and to explore the factors associated with deaths at home versus other places, mainly hospitals.

METHODS

This was a multicenter prospective cohort study in a primary care setting. We enrolled patients aged ≥65 years who had started to receive regular visits by family physicians from 13 facilities in and around Tokyo between February 1, 2013 and January 31, 2016. Patients were followed-up until January 31, 2017. The primary outcome measures were mortality rate and cumulative incidence of deaths at home.

RESULTS

We enrolled 762 patients. Of 368 deaths, 133 occurred in the patient's home. The mortality rates at home were 137.6/1000 person-years (95% confidence interval 116.1-163.1). In cumulative incidence function, the longer duration of care at home lowers the likelihood of death at home. Multivariable multinomial logistic models showed that younger age and higher Barthel Index score reduced the likelihood of deaths at home, while receiving oxygen therapy and the presence of a full-time caregiver increased the likelihood of deaths at home relative to deaths at other locations.

CONCLUSIONS

Of deceased patients, only one-third died in patients' homes. We found several factors associated with deaths at home, which appeared to reflect the readiness of patients and their families for death. Geriatr Gerontol Int 2022; 22: 1005-1012.

End-of-life care of patients with esophageal or gastric cancer: decision making and the goal of care

BACKGROUND

Overall survival (OS) with advanced esophageal or gastric cancer is poor. To avoid overly aggressive treatments at the end-of-life and assure adequate end-of-life quality, the decision to focus on symptom-centered palliative care (PC) and terminate anticancer treatments, i.e., the PC decision, should be made in time.

MATERIAL AND METHODS

We reviewed the charts of patients (N = 160) with esophageal or gastric cancer treated at the Department of Oncology at Helsinki University Central Hospital in 2013 and deceased by December 2014. The use of acute services (Emergency department (ED) visits and hospitalizations) and places of death were compared according to the timing of the PC decision. Reasons for ED visits and hospitalizations were collected.

RESULTS

The median OS from diagnosis of advanced cancer was 6 months. Anti-cancer treatments were never started for 34% of the patients. The PC decision was made early (>30 days before death) for 54% of the patients and late (≤30 days before death) or not at all for 46%. Patients with late or no PC decision died more often in tertiary/secondary hospital (29 versus 7%, p = 0.001) and had more ED visits (49 versus 29%, p < 0.001) and hospitalizations (53 versus 28%, p = 0.001) in their last month, and visited the PC unit less often (18 versus 69%, p < 0.001), than the patients with early PC decision. The ED visits were most commonly related to cancer progression, and clinical deterioration (17%), fever (16%), and dysphagia (15%) were the most common symptoms.

CONCLUSION

The decision to focus on PC and terminate anticancer treatments, i.e., the PC decision, was made late or not at all in every other patient, leading to increased tertiary/secondary hospital service use and deaths at tertiary/secondary hospital. Early decision-making increased end-of-life care at specialized PC services or at home, implying better end-of-life care.

Association between immigrant status and advanced cancer patients' location and quality of death

Background

Cancer patients often prefer to die at home, a location associated with better quality of death (QoD). Several studies demonstrate disparities in end‐of‐life care among immigrant populations in the United States. This study aimed to evaluate how immigrant status affects location and quality of death among patients with advanced cancer in the United States.

Methods

Data were derived from Coping with Cancer, a federally funded multi‐site prospective study of advanced cancer patients and caregivers. The sample of patients who died during the study period was weighted (N_w = 308) to reduce statistically significant differences between immigrant (N_w = 49) and nonimmigrant (N_w = 259) study participants. Primary outcomes were location of death, death at preferred location, and poor QoD.

Results

Analyses adjusted for covariates indicated that patients who were immigrants were more likely to die in a hospital than home (adjusted odds ratio [AOR], 3.33; 95% confidence interval [CI], 1.65–6.71) and less likely to die where they preferred (AOR, 0.42; 95% CI, 0.20–0.90). Furthermore, immigrants were more likely to have poor QoD (AOR, 5.47; 95% CI, 2.70–11.08).

Conclusions

Immigrants, as compared to nonimmigrants, are more likely to die in hospital settings, less likely to die at their preferred location, and more likely to have poor QoD.

Lay summary

Cancer patients typically prefer to die in their own homes, which is associated with improved quality of death.

However, disparities in end‐of‐life care among immigrant populations in the United States remain significant.

Our study found that immigrants are less likely to die in their preferred locations and more likely to die in hospital settings, resulting in poorer quality of death.

Disparities in end‐of‐life care and quality of death are prevalent among immigrants. The findings of this study illustrate that immigrants in the United States are more likely to die in hospital settings and less likely to die at their preferred location.

Prevalence and timing of specialist palliative care access among advanced cancer patients and association with hospital death

Background

Patients with advanced cancer have poor quality of life and high utilisation of acute healthcare services. Early access to palliative care has been shown to improve quality of life as well as reduce acute healthcare utilisation and costs.

Objectives

To determine the prevalence and timing of hospital-based specialist palliative care reviews for patients with advanced cancer known to National Cancer Centre Singapore. We also explored the association between specialist palliative care review and place of death.

Methods

A retrospective study of patients with Stage 4 cancer who died in a 2-year period from 1 January 2016 to 31 December 2017 (regardless of their date of diagnosis) and who received treatment in National Cancer Centre Singapore (NCCS).

Results

A total of 2572 patients were included, of which 1226 (47.7%) had at least one inpatient or outpatient specialist palliative care consultation. Those who had their first specialist palliative care review 30 days or less before death had a 2.01 (95% CI 1.62 to 2.49, p < 0.001) increased odds of hospital death while those who had the first hospital-based palliative care review more than 30 days before death a 0.76 (95% CI 0.62 to 0.93, p = 0.009) reduced odds of hospital death.

Conclusions

Our study found inadequate and late access to specialist palliative care among advanced cancer patients. Furthermore, late access to specialist palliative care was associated with hospital death. There is an urgent need to improve access to specialist palliative care in order to improve patient outcomes.

Trajectories of Suffering in the Last Year of Life Among Patients With a Solid Metastatic Cancer

BACKGROUND

Reducing suffering at the end of life is important. Doing so requires a comprehensive understanding of the course of suffering for patients with cancer during their last year of life. This study describes trajectories of psychological, spiritual, physical, and functional suffering in the last year of life among patients with a solid metastatic cancer.

PATIENTS AND METHODS

We conducted a prospective cohort study of 600 patients with a solid metastatic cancer between July 2016 and December 2019 in Singapore. We assessed patients' psychological, spiritual, physical, and functional suffering every 3 months until death. Data from the last year of life of 345 decedents were analyzed. We used group-based multitrajectory modeling to delineate trajectories of suffering during the last year of a patient's life.

RESULTS

We identified 5 trajectories representing suffering: (1) persistently low (47% of the sample); (2) slowly increasing (14%); (3) predominantly spiritual (21%); (4) rapidly increasing (12%); and (5) persistently high (6%). Compared with patients with primary or less education, those with secondary (high school) (odds ratio [OR], 3.49; 95% CI, 1.05-11.59) education were more likely to have rapidly increasing versus persistently low suffering. In multivariable models adjusting for potential confounders, compared with patients with persistently low suffering, those with rapidly increasing suffering had more hospital admissions (β=0.24; 95% CI, 0.00-0.47) and hospital days (β=0.40; 95% CI, 0.04-0.75) during the last year of life. Those with persistently high suffering had more hospital days (β=0.70; 95% CI, 0.23-1.17).

CONCLUSIONS

The course of suffering during the last year of life among patients with cancer is variable and related to patients' hospitalizations. Understanding this variation can facilitate clinical decisions to minimize suffering and reduce healthcare costs at the end of life.

Frequency and Characteristics of First-Time Palliative Care Referrals During the Last Day of Life

CONTEXT

Palliative care referrals (PCRs) improve symptom management, provide psychosocial and spiritual support, clarify goals of care, and facilitate discharge planning. However, very late PCR can result in increased clinician distress and prevent patients and families from benefiting from the full spectrum of interdisciplinary care.

OBJECTIVES

To determine the frequency and predictors of PCR within 24 hours of death.

METHODS

Consecutive first-time inpatient PCR from September 1, 2013 to August 31, 2017 was identified to determine the frequency and predictors of referrals within 24 hours of death. We compared the clinical characteristics with a random sample of patients discharged alive or died more than 24 hours after first-time PCR as a control, stratified by year of consult in a 1:1 ratio.

RESULTS

Of 7322 first-time PCRs, 154 (2%) died within 24 hours of referral. These patients were older (P = 0.003) and had higher scores for depression (P = 0.0009), drowsiness (P = 0.02), and shortness of breath (P = 0.008) compared with a random sample of 153 patients discharged alive or died more than 24 hours after first-time PCR. Patients who received a PCR within 24 hours of death were more likely than the control group to have Eastern Cooperative Oncology Group 4 (95% vs. 25%, P < 0.0001), delirium (89% vs. 17%, P < 0.0001), do-not-resuscitate code status (81% vs. 18%, P < 0.0001), and hematologic malignancies (39% vs. 16%, P < 0.0001). In the multivariate analysis, depression (odds ratio [OR] 1.4; P = 0.005), do-not-resuscitate code status (OR 9.1; P = 0.003), and Eastern Cooperative Oncology Group 4 (OR 9.8; P = 0.003) were independently associated with first-time PCR within 24 hours of death.

CONCLUSION

Although only a small proportion of first-time PCR occurred in the last 24 hours of life, the patients had a significant amount of distress, indicating a missed opportunity for timely palliative care intervention. These sentinel events call for specific guidelines to better support patients, families, and clinicians during this difficult time. Further research is needed to understand how to minimize very late PCR.

Impacts of multidisciplinary meeting case discussion on palliative care referral and end-of-life care in lung cancer: a retrospective observational study

BACKGROUND

Multidisciplinary meeting (MDM) discussion and early palliative care are recommended in lung cancer management. The literature is unclear whether MDM discussion leads to early palliative care and improved end-of-life care.

AIMS

To evaluate impacts of discussion at an Australian lung MDM on palliative care referral, and MDM and early palliative care on aggressive end-of-life care.

METHODS

A retrospective, cross-sectional study was conducted of 352 patients diagnosed with primary lung cancer from 2017 to 2019 at the Alfred Hospital, Melbourne. The primary question was whether MDM discussion influenced palliative care referrals. Secondary questions were whether MDM discussion and early palliative care reduced aggressive treatment (chemotherapy, hospitalisation, emergency department visits, intensive care admission and in-hospital death) during the last 30 days of life. Multivariable logistic regression was used to determine independent association between MDM discussion and palliative care referral.

RESULTS

MDM discussion did not independently impact palliative care referral. There was reduced likelihood of MDM presentation in patients with metastatic disease (P < 0.0001) and poorer performance status (P = 0.025), and higher likelihood of palliative care referral in these patients (both P < 0.001). MDM discussion reduced end-of-life intensive care unit (ICU) admission in patients with metastatic disease (P = 0.04). A palliative care referral-to-death interval of ≥30 days was associated with reduced hospitalisation at the end of life (P < 0.0001) and hospital deaths (P = 0.001).

CONCLUSION

Discussion at lung MDM did not increase palliative care referral, but did reduce ICU admission among metastatic patients at the end of life. Longer palliative care referral-to-death interval was associated with reduced aggressive end-of-life care. Further research is needed in these areas.

End-of-life care and intensive care unit clinician involvement in a private acute care hospital: A retrospective descriptive medical record audit

INTRODUCTION

More Australians die in the hospital than in any other setting. This study aimed to (i) evaluate the quality of end-of-life (EOL) care in the hospital against an Australian National Standard, (ii) describe the characteristics of intensive care unit (ICU) clinician involvement in EOL care, and (iii) explore the demographic and clinical factors associated with quality of EOL care.

METHOD

A retrospective descriptive medical record audit was conducted on 297 adult inpatients who died in 2017 in a private acute care hospital in Melbourne, Australia. Data collected related to 20 'Processes of Care', considered to contribute to the quality of EOL care. The decedent sample was separated into three cohorts as per ICU clinician involvement.

RESULTS

The median age of the sample was 81 (25th-75th percentile = 72-88) years. The median tally for EOL care quality was 16 (25th-75th percentile = 13-17) of 20 care processes. ICU clinicians were involved in 65.7% (n = 195) of cases; however, contact with the ICU outreach team or an ICU admission during the final inpatient stay was negatively associated with quality of EOL care (coefficient = -1.51 and -2.07, respectively). Longer length of stay was positively associated with EOL care (coefficient = .05). Specialist palliative care was involved in 53% of cases, but this was less likely for those admitted to the ICU (p < .001). Evidence of social support, bereavement follow-up, and religious support were low across all cohorts.

CONCLUSION

Statistically significant differences in the quality of EOL care and a negative association between ICU involvement and EOL care quality suggest opportunities for ICU outreach clinicians to facilitate discussion of care goals and the appropriateness of ICU admission. Advocating for inclusion of specialist palliative care and nonclinical support personnel in EOL care has merit. Future research is necessary to investigate the relationship between ICU intervention and EOL care quality.

Duration of palliative care before death in international routine practice: a systematic review and meta-analysis

BACKGROUND

Early provision of palliative care, at least 3-4 months before death, can improve patient quality of life and reduce burdensome treatments and financial costs. However, there is wide variation in the duration of palliative care received before death reported across the research literature. This study aims to determine the duration of time from initiation of palliative care to death for adults receiving palliative care across the international literature.

METHODS

We conducted a systematic review and meta-analysis that was registered with PROSPERO (CRD42018094718). Six databases were searched for articles published between Jan 1, 2013, and Dec 31, 2018: MEDLINE, Embase, CINAHL, Global Health, Web of Science and The Cochrane Library, as well undertaking citation list searches. Following PRISMA guidelines, articles were screened using inclusion (any study design reporting duration from initiation to death in adults palliative care services) and exclusion (paediatric/non-English language studies, trials influencing the timing of palliative care) criteria. Quality appraisal was completed using Hawker's criteria and the main outcome was the duration of palliative care (median/mean days from initiation to death).

RESULTS

One hundred sixty-nine studies from 23 countries were included, involving 11,996,479 patients. Prior to death, the median duration from initiation of palliative care to death was 18.9 days (IQR 0.1), weighted by the number of participants. Significant differences between duration were found by disease type (15 days for cancer vs 6 days for non-cancer conditions), service type (19 days for specialist palliative care unit, 20 days for community/home care, and 6 days for general hospital ward) and development index of countries (18.91 days for very high development vs 34 days for all other levels of development). Forty-three per cent of studies were rated as 'good' quality. Limitations include a preponderance of data from high-income countries, with unclear implications for low- and middle-income countries.

CONCLUSIONS

Duration of palliative care is much shorter than the 3-4 months of input by a multidisciplinary team necessary in order for the full benefits of palliative care to be realised. Furthermore, the findings highlight inequity in access across patient, service and country characteristics. We welcome more consistent terminology and methodology in the assessment of duration of palliative care from all countries, alongside increased reporting from less-developed settings, to inform benchmarking, service evaluation and quality improvement.

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

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

Inequity in palliative care service full utilisation among patients with advanced cancer: a retrospective Cohort study

Background: Advanced cancer patients often die in hospital after receiving needless, aggressive treatment. Although palliative care improves symptom management, barriers to accessing palliative care services affect its utilisation, and such disparities challenge the equitable provision of palliative care. This study aimed to identify which factors are associated with inequitable palliative care service utilisation among advanced cancer patients by applying the Andersen Behavioural Model of Health Services Use.Material and methods: This was a retrospective cohort study using administrative healthcare data. A total of 13,656 patients residing in the Lazio region of Italy, who died of an advanced cancer-related cause-either in hospital or in a specialised palliative care facility-during the period of 2012-2016 were included in the study. Potential predictors of specialised palliative service utilisation were explored by grouping the following factors: predisposing factors (i.e., individuals' characteristics), enabling factors (i.e., systemic/structural factors) and need factors (i.e., type/severity of illness).Results: The logistic hierarchical regression showed that older patients (odds ratio [OR] = 1.45; <0.0001) of Caucasian ethnicity (OR = 4.17; 0.02), with a solid tumour (OR = 1.87; <0.0001) and with a longer survival time (OR = 2.09; <0.0001) were more likely to be enrolled in a palliative care service. Patients who lived farther from a specialised palliative care facility (OR = 0.13; <0.0001) and in an urban area (OR = 0.58; <0.0001) were less likely to be enrolled.Conclusion: This study found that socio-demographic (age, ethnicity), clinical (type of tumour, survival time) and organisational (area of residence, distance from service) factors affect the utilisation of specialised palliative care services. The fact that service utilisation is not only a function of patients' needs but also of other aspects demonstrates the presence of inequity in access to palliative care among advanced cancer patients.

The impact of the duration of the palliative care period on cancer patients with regard to the use of hospital services and the place of death: a retrospective cohort study

Background

In order to avoid unnecessary use of hospital services at the end-of-life, palliative care should be initiated early enough in order to have sufficient time to initiate and carry out good quality advance care planning (ACP). This single center study assesses the impact of the PC decision and its timing on the use of hospital services at EOL and the place of death.

Methods

A randomly chosen cohort of 992 cancer patients treated in a tertiary hospital between Jan 2013 –Dec 2014, who were deceased by the end of 2014, were selected from the total number of 2737 identified from the hospital database. The PC decision (the decision to terminate life-prolonging anticancer treatments and focus on symptom centered palliative care) and use of PC unit services were studied in relation to emergency department (ED) visits, hospital inpatient days and place of death.

Results

A PC decision was defined for 82% of the patients and 37% visited a PC unit. The earlier the PC decision was made, the more often patients had an appointment at the PC unit (> 180 days prior to death 72% and < 14 days 10%). The number of ED visits and inpatient days were highest for patients with no PC decision and lowest for patients with both a PC decision and an PC unit appointment (60 days before death ED visits 1.3 vs 0.8 and inpatient days 9.9 vs 2.9 respectively, p < 0.01). Patients with no PC decision died more often in secondary/tertiary hospitals (28% vs. 19% with a PC decision, and 6% with a decision and an appointment to a PC unit).

Conclusions

The PC decision to initiate a palliative goal for the treatment had a distinct impact on the use of hospital services at the EOL. Contact with a PC unit further increased the likelihood of EOL care at primary care.

Hospital and Patient Characteristics Regarding the Place of Death of Hospitalized Impending Death Patients: A Multilevel Analysis

Objectives: To explore the influence of hospital and patient characteristics on deaths at home among inpatients facing impending death. Method: In this historical cohort study, 95,626 inpatients facing impending death from 362 hospitals in 2011 were recruited. The dependent variable was the place of death. The independent variables were the characteristics of the hospitals and the patients. A two-level hierarchical generalized linear model was used. Results: In total, 41.06% of subjects died at home. The hospital characteristics contributed to 29.25% of the total variation of the place of death. Private hospitals (odds ratio [OR] = 1.32, 95% confidence interval [CI] = 1.00–1.75), patients >65 years old (OR = 1.48, 95% CI. = 1.42–1.54), married (OR = 3.15, 95% CI. = 2.93–3.40) or widowed (OR = 3.39, 95% CI. = 3.12–3.67), from near-poor households (OR = 5.16, 95% CI. = 4.57–5.84), having diabetes mellitus (OR = 1.79, 95% CI. = 1.65–1.94), and living in a subcounty (OR = 2.27, 95% CI. = 2.16–2.38) were all risk factors for a death at home. Conclusion: Both hospital and patient characteristics have an effect of deaths at home among inpatients facing impending death. The value of the inpatient mortality rate as a major index of hospital accreditation should be interpreted intrinsically with the rate of deaths at home.

Dying of amyotrophic lateral sclerosis

Objective

To describe health care service utilization and cost for decedents with and without amyotrophic lateral sclerosis (ALS) in the last year of life.

Methods

Using linked health administrative data, we conducted a retrospective, population-based cohort study of Ontario, Canada, decedents from 2013 to 2015. We examined demographic data, rate of utilization, and cost of health care services in the last year of life.

Results

We identified 283,096 decedents in Ontario, of whom 1,212 (0.42%) had ALS. Decedents with ALS spent 3 times as many days in an intensive care unit (ICU) (mean 6.3 vs 2.1, p < 0.001), and twice as many days using complex continuing care (mean 12.7 vs 6.0, p < 0.001) and home care (mean 99.1 vs 41.3, p < 0.001). A greater percentage of decedents with ALS received palliative home care (44% vs 20%, p < 0.001) and palliative physician home visits (40% vs 18%, p < 0.001) than decedents without ALS. Among decedents with ALS, a palliative physician home visit in the last year of life was associated with reduced adjusted odds of dying in hospital (odds ratio 0.65, 95% confidence interval 0.48–0.89) and fewer days spent in the ICU. Mean cost of care in the last year of life was greater for those with ALS ($68,311.98 vs $55,773.48, p < 0.001).

Conclusions

In this large population-based cohort of decedents, individuals with ALS spent more days in the ICU, received more community-based services, and incurred higher costs of care in the last year of life. A palliative care physician home visit was associated with improved end of life outcomes; however, the majority of patients with ALS did not access such services.

Retrospective Prognostic Study of Death at Home or Hospice Versus at a Hospital Among Patients With Advanced Non-Small Cell Lung Cancer

BACKGROUND

Patients with advanced non-small cell lung cancer greatly care about where they will die. Most people in Japan preferred their location of death as their homes. But only 8.2% of patients with cancer spend their last days at home with palliative care in Japan. Many patients with cancer are still going to spend their last days at a hospital (81.7%).

OBJECTIVE

We examined the survival times of such patients according to their place of death; that is, whether they died at home, at a hospice, or at a hospital, and investigated patient characteristics.

RESULTS

Among the 313 patients recruited, 214 were analyzed in this study: 90, 49, and 75 received hospital-based, home-based, and hospice-based palliative care, respectively. The patients who died at a hospice exhibited significantly longer survival than those who died at hospital (estimated median survival time, 420 days [95% confidence interval [CI]: 325-612 days] versus 252 days [95% CI: 201-316 days]; P < .0001). The characteristics of patients did not differ significantly according to place of death.

CONCLUSIONS

Patients who died at a hospice or at home exhibited significantly longer survival than those who died at a hospital for advanced non-small cell lung cancer.

Individual, clinical and system factors associated with the place of death: A linked national database study

BACKGROUND

Many middle- and high-income countries face the challenge of meeting preferences for home deaths. A better understanding of associated factors could support the design and implementation of policies and practices to enable dying at home. This study aims to identify factors associated with the place of death in Singapore, a country with a strong sense of filial piety.

SETTINGS/PARTICIPANTS

A retrospective cohort of 62,951 individuals (≥21 years old) who had died from chronic diseases in Singapore between 2012-2015 was obtained. Home death was defined as a death that occurred in a private residence whereas non-home deaths occurred in hospitals, nursing homes, hospices and other locations. Data were obtained by extracting and linking data from five different databases. Hierarchical multivariable logistic regression models were used to examine the effects of individual, clinical and system factors sequentially.

RESULTS

Twenty-eight percent of deaths occurred at home. Factors associated with home death included being 85 years old or older (OR 4.45, 95% CI 3.55-5.59), being female (OR 1.21, 95% CI 1.16-1.25), and belonging to Malay ethnicity (OR 1.91, 95% CI 1.82-2.01). Compared to malignant neoplasm, deaths as a result of diabetes mellitus (OR 1.93, 95% CI 1.69-2.20), and cerebrovascular diseases (OR 1.28, 95% CI 1.19-1.36) were also associated with a higher likelihood of home death. Independently, receiving home palliative care (OR 3.45, 95% CI 3.26-3.66) and having a documented home death preference (OR 5.08, 95% CI 3.96-6.51) raised the odds of home deaths but being admitted to acute hospitals near the end-of-life was associated with lower odds (OR 0.92, 95% CI 0.90-0.94).

CONCLUSION

Aside from cultural and clinical factors, system-based factors including access to home palliative care and discussion and documentation of preferences were found to influence the likelihood of home deaths. Increasing home palliative care capacity and promoting advance care planning could facilitate home deaths if this is the desired option of patients.

Patterns of end-of-life hospital care for patients with non-Hodgkin lymphoma: exploring the landscape

Rapid change, treatment responsiveness, and prognostication difficulties present challenges for palliative care integration for hematology patients. This Australian study aimed to document end-of-life hospital care for patients with non-Hodgkin lymphoma (NHL) to consider opportunities for palliative care integration. A retrospective population cohort design examining existing linked datasets of health service utilization and death registration. The results revealed 4380 NHL patients, majority male (58%) and aged 70+ years (70%), spent 32 days (median) in hospital in final 6 months of life, and in the last month, 56% had more than 1 hospital admission, and 57% stayed more than 14 days. Forty-one percent accessed palliative care, with first contact 23 days (median) before death, and for 77% in final admission. Early palliative care was more likely for patients with greater symptom burden. This study mapping patterns of care for patients who die from NHL establishes a baseline enabling comparisons for future care innovations.

[A retrospective study about the influence of an emergency information form on the place of death of palliative care patients]

In palliative medicine planning in advance is important for critical care situations. It is highly significant to make useful and by the patient and his relatives desired decisions. These concern transport in a situation of crisis and the venue of death (either death at home or transfer to a hospital).In this study the effect of a new Emergency Information Form about the place of death was examined. The used Emergency Information Form enabled the patient to express a wish on transfer in the case of crisis in advance and communicate this wish to the Emergency system.A total of 858 patients, taken care of by the mobile palliative-team Hartberg/Weiz/Vorau in the period from 2010 to 2015, were included in the study. The Intervention group-the patients for whom an Emergency Information Form was established-counted 38 patients. Data analysis was retrospective, pseudo anonymized and external.The 4 most important results were:1) The Emergency Information Form increased the probability for the intervention group to die at home (intervention group: 72.2%, controll group 1: 53.0%, controll group 2: 56.6%).2) Important in this change was, that the opinion of the patients was considered. The decision made in the Emergency Information Form correlated with a high significance (p = 0.01) with the actual place of death.3) Furthermore, it came clear that the Emergency Information Form was a useful tool to handle the utilization of special facilities. Within the intervention group young patients (with a lot of symptoms) died in a special facility more often than old patients. These, rather geriatric people, were mostly brought to a general hospital.4) There was no significant relation between the duration of care and the probability that an Emergency Information Form was established (p = 0.63). However, there was a high significance between the number of home visits and the probability that an Emergency Information Form was written (p = 0.02).Due to the fact that there was a small intervention group restricted to only one palliative team further studies could help to make clear advises for palliative teams regarding scope, duration and frequency of home-visits. Thus the term "care continuity" could be concretized in the guidelines.The study brought forward that numerous (and short) contacts with the patient were more convenient than less but long home-visits in order to fulfil the patients wish concerning his place of death.

Early initiation of palliative care is associated with reduced late-life acute-hospital use: A population-based retrospective cohort study

BACKGROUND:

Early palliative care can reduce end-of-life acute-care use, but findings are mainly limited to cancer populations receiving hospital interventions. Few studies describe how early versus late palliative care affects end-of-life service utilization.

AIM:

To investigate the association between early versus late palliative care (hospital/community-based) and acute-care use and other publicly funded services in the 2 weeks before death.

DESIGN:

Retrospective population-based cohort study using linked administrative healthcare data.

SETTING/PARTICIPANTS:

Decedents (cancer, frailty, and organ failure) between 1 April 2010 and 31 December 2012 in Ontario, Canada. Initiation time before death (days): early (⩾60) and late (⩾15 and <60). ‘Acute-care settings’ included acute-hospital admissions with (‘palliative-acute-care’) and without palliative involvement (‘non-palliative-acute-care’).

RESULTS:

We identified 230,921 decedents. Of them, 27% were early palliative care recipients and 13% were late; 45% of early recipients had a community-based initiation and 74% of late recipients had a hospital-based initiation. Compared to late recipients, fewer early recipients used palliative-acute care (42% vs 65%) with less days (mean days: 9.6 vs 12.0). Late recipients were more likely to use acute-care settings; this was further modified by disease: comparing late to early recipients, cancer decedents were nearly two times more likely to spend >1 week in acute-care settings (odds ratio = 1.84, 95% confidence interval: 1.83–1.85), frailty decedents were three times more likely (odds ratio = 3.04, 95% confidence interval: 3.01–3.07), and organ failure decedents were four times more likely (odds ratio = 4.04, 95% confidence interval: 4.02–4.06).

CONCLUSION:

Early palliative care was associated with improved end-of-life outcomes. Late initiations were associated with greater acute-care use, with the largest influence on organ failure and frailty decedents, suggesting potential opportunities for improvement.

Timing of palliative care referral and aggressive cancer care toward the end-of-life in pancreatic cancer: a retrospective, single-center observational study

Background

Pancreatic cancer is noted for its late presentation at diagnosis, limited prognosis and physical and psychosocial symptom burden. This study examined associations between timing of palliative care referral (PCR) and aggressive cancer care received by pancreatic cancer patients in the last 30 days of life through a single health service.

Method

A retrospective cohort analysis of end-of-life (EOL) care outcomes of patients with pancreatic cancer who died between 2012 and 2016. Key indicators of aggressive cancer care in the last 30 days of life used were: ≥1 emergency department (ED) presentations, acute inpatient/intensive care unit (ICU) admission, and chemotherapy use. We examined time from PCR to death and place of death. Early and late PCR were defined as > 90 and ≤ 90 days before death respectively.

Results

Out of the 278 eligible deaths, 187 (67.3%) were categorized as receiving a late PCR and 91 (32.7%) an early PCR. The median time between referral and death was 48 days. Compared to those receiving early PCR, those with late PCR had: 18.1% (95% CI 6.8–29.4%) more ED presentations; 12.5% (95% CI 1.7–24.8%) more acute hospital admissions; with no differences in ICU admissions. Pain and complications of cancer accounted for the majority of overall ED presentations. Of the 166 patients who received chemotherapy within 30 days of death, 23 (24.5%) had a late PCR and 12 (16.7%) an early PCR, with no association of PCR status either unadjusted or adjusted for age or gender. The majority of patients (55.8%) died at the inpatient palliative care unit.

Conclusion

Our findings reaffirm the benefits of early PCR for pancreatic cancer patients to avoid inappropriate care toward the EOL. We suggest that in modern cancer care, there can sometimes be a need to reconsider the use of the term ‘aggressive cancer care’ at the EOL when the care is appropriately based on an individual patient’s presenting physical and psychosocial needs. Pancreatic cancer patients warrant early PCR but the debate must thus continue as to how we best achieve and benchmark outcomes that are compatible with patient and family needs and healthcare priorities.

Factors Associated with Fulfilling the Preference for Dying at Home among Cancer Patients: The role of General Practitioners

Aim: This study aimed to explore clinical and care-related factors associated with fulfilling cancer patients’ preference for home death across four countries: Belgium (BE), the Netherlands (NL), Italy (IT), and Spain (ES). Methods: A mortality follow-back study was undertaken from 2009 to 2011 via representative networks of general practitioners (GPs). The study included all patients aged 18 and over who had died of cancer and whose home death preference and place of death were known by the GP. Factors associated with meeting home death preference were tested using multivariable logistic regressions. Results: Among 2,048 deceased patients, preferred and actual place of death was known in 42.6 percent of cases. Home death preference met ranged from 65.5 to 90.9 percent. Country-specific factors included older age in BE, and decisionmaking capacity and being female in the NL GPs’ provision of palliative care was positively associated with meeting home death preference. Odds ratios (ORs) were: BE: 9.9 (95 percent confidence interval [CI] 3.7–26.6); NL: 9.7 (2.4–39.9); and IT: 2.6 (1.2–5.5). ORs for Spain are not shown because a multivariate model was not performed. Conclusion: Those who develop policy to facilitate home death need to examine available resources for primary end-of-life care.

But: Cette étude avait pour objectif d'examiner les facteurs cliniques associés aux demandes des patients désirant mourir à la maison. Cette re-cherche s'étendait sur quatre pays soit la Belgique, les Pays-Bas, l'Italie, et l'Espagne. Méthode: Par l'inter-médaire des réseaux représentatifs d'omnipraticiens, nous avons pu faire un suivi rétrospectif des mortalités survenues durant les années 2009, 2010, et 2011. Cette étude comprenait les patients agés de 18 ans et plus morts du cancer et dont les médecins connaissaient tout autant les volontés de pouvoir mourir à la maison que l'endroit où les patients étaient morts. Les facteurs correspondants aux préférences des patients ont été validés à l'aide de la méthode statistique de regression logistique à variables multiples. Résultats: Parmi les 2 048 personnes décédées on connaissait, chez 42,6 pourcent d'entre elles, la préférence et l'endroit de la mort. Le choix de mourir à domicile variait de 65,5 pourcent à 90,9 pourcent. Les facteurs spécifiques à certains pays étaient l'âge avancé pour la Belgique et, pour les Pays-Bas, la capacité décisionnelle et le fait d'être de sexe feminin. La prestation des soins palliatifs par les omnipraticiens est associée de façon positive au choix de mourir à la maison. Les rapports de probabilités étaient les suivants: Belgique: 9,9 [95 pourcent d'intervalle de fiabilité (3,7–26,6)], Pays-Bas: 9,7 (2,4–39,9) et l'Italie: 2,6 (1,2–5,5). Les facteurs de probabilité pour l'Espagne ne sont pas indiqués car on n'a pas fait d'analyse selon le modèle multivariable. Conclusion: Les professionnels de la santé ayant pour tâche d'établir les politiques pour faciliter la mort à la maison doivent connnaître toutes les resources dont ils disposent dans leur communauté afin de pouvoir offrir les soins de première ligne à domicile.

Factors Related with Utilizing Hospice Palliative Care Unit among Terminal Cancer Patients in Korea between 2010 and 2014: a Single Institution Study

BACKGROUND

Establishing and designating specialized hospice palliative care units (HPCUs) has been an important part of national policy to promote hospice palliative care in Korea in the recent decade. However, few studies have sought to identify patterns and barriers for utilizing HPCU over the period of national policy implementation. We aimed to investigate factors related with utilizing HPCU for terminal cancer patients after consultation with a palliative care team (PCT).

METHODS

We reviewed medical records for 1,028 terminal cancer patients who were referred to the PCT of the National Cancer Center in 2010 and 2014. We compared the characteristics of the patients who decided to utilize HPCU and those who did not. We also analyzed factors influencing choices for a medical institution and reasons for not selecting an HPCU.

RESULTS

The patients' mean age was 61.0 ± 12.2, with lung cancer patients (24.3%) comprising the largest percentage of these patients. The percentage of referred patients who utilized an HPCU was 53.9% in 2014, increasing from 44.6% in 2010. Older age and awareness of terminal illness were found to be positively associated with utilization of an HPCU. The most common reason for not selecting an HPCU was "refusing hospice facility" (34.9%), followed by "near death," "poor accessibility to an HPCU," and "caregiving problems."

CONCLUSION

Compared to 2010, HPCU utilization by terminal cancer patients increased in 2014. Improving awareness of terminal condition among patients and family members and earlier discussion of end-of-life care would be important to promote utilization of HPCU.

Trends of Earlier Palliative Care Consultation in Advanced Cancer Patients Receiving Palliative Radiation Therapy

CONTEXT

The American Society of Clinical Oncology recommends that all patients with metastatic disease receive dedicated palliative care (PC) services early in their illness, ideally via interdisciplinary care teams.

OBJECTIVES

We investigated the time trends of specialty palliative care consultations from the date of metastatic cancer diagnosis among patients receiving palliative radiation therapy (PRT). A shorter time interval between metastatic diagnosis and first PC consultation suggests earlier involvement of palliative care in a patient's life with metastatic cancer.

METHODS

In this IRB-approved retrospective analysis, patients treated with PRT for solid tumors (bone and brain) at a single tertiary care hospital between 2010 and 2016 were included. Cohorts were arbitrarily established by metastatic diagnosis within approximately two-year intervals: 1) 1/1/2010-3/27/2012, 2) 3/28/2012-5/21/2014, and 3) 5/22/2014-12/31/2016. Cox proportional hazards regression modeling was used to compare trends of PC consultation among cohorts.

RESULTS

Of 284 patients identified, 184 patients received PC consultation, whereas 15 patients died before receiving a PC consult. Median follow-up time until an event or censor was 257 days (range: 1900). Patients in the most recent cohort had a shorter median time to first PC consult (57 days) compared to those in the first (374 days) and second (186 days) cohorts. On multivariable analysis, patients in the third cohort were more likely to undergo a PC consultation earlier in their metastatic illness (hazard ratio: 1.8, 95% CI: 1.2-2.8).

CONCLUSION

Over a six-year period, palliative care consultation occurred earlier for metastatic patients treated with PRT at our institution.

Pilot Randomized Phase II Trial of the Enhancing Quality of Life in Patients (EQUIP) Intervention for Patients With Advanced Lung Cancer

Context:

New models of care that are effective and feasible for widespread implementation need to be developed for the delivery of early palliative care to patients with advanced cancer.

Objectives:

The objectives were to determine the feasibility and acceptability of the Enhancing Quality of Life in Patients (EQUIP) intervention, data completion rate of patient-reported outcome measures in the context of the EQUIP trial, and the estimated effect of the EQUIP intervention on quality of life and mood.

Methods:

In this pilot randomized phase II trial, eligible patients had newly diagnosed advanced lung cancer and an Eastern Cooperative Oncology Group performance status of 0, 1, or 2. Randomization was to the control group that received standard oncology care or to the intervention group where patients individually received the EQUIP intervention, comprising 4 face-to-face educational sessions with a nurse.

Results:

A total of 69 patients were recruited. In the intervention group, 30 (85.7%) of 35 patients completed all 4 EQUIP sessions. All patients were satisfied with the topics shared and felt they were useful. However, there was no significant difference between intervention and control groups in terms of quality of life and mood at 12 weeks after baseline.

Conclusion:

This pilot study showed that nurse-directed face-to-face educational sessions were feasible and acceptable to patients with advanced lung cancer. However, there was no indication of benefit of the EQUIP intervention on quality of life and mood. This could be due in part to a low prevalence of targeted symptoms.

Predictors of care for patients with cancer of unknown primary site in three Australian hospitals

AIM

Cancer of unknown primary site (CUP) is a medically challenging malignancy with a poor prognosis. We describe an incident tertiary CUP patient cohort and identify factors predictive of specific types of health care.

METHODS

We reviewed the medical records of 217 patients diagnosed with CUP (2006-2011) in three public hospitals in New South Wales, Australia. We systematically abstracted data and performed multivariable logistic regression to identify factors predictive of tumor biopsy, surgery, chemotherapy, radiotherapy and palliative care.

RESULTS

The median age at CUP diagnosis was 75 years (range 23-98) and 52% were male. The most common mode of presentation was emergency department admission (57%). Serum tumor markers were performed in 42%, fine needle aspiration alone in 15% and core biopsy in 52%. Younger age, health service referral, oncologist review and a family history of cancer predicted receipt of a biopsy (77%). Cancer-related surgery (17%) was more likely in younger patients, those presenting with pain, and those with single lymph node metastases. Younger age and good performance score predicted receipt of chemotherapy (22%). The location of metastases predicted receipt of radiotherapy (28%). Older age, emergency presentation, poor performance score and no oncology review predicted receipt of palliative care only (52%); 77% were referred for palliative care during hospitalization.

CONCLUSION

The determinants of care were generally consistent with international CUP clinical guidelines. Areas of future research include potential underinvestigation and undertreatment of older patients, overuse of certain low-value diagnostic tests, suboptimal use of immunohistochemistry and mammography and underreferral to palliative care.

Factors predicting a home death among home palliative care recipients

Awareness of factors affecting the place of death could improve communication between healthcare providers and patients and their families regarding patient preferences and the feasibility of dying in the preferred place.This study aimed to evaluate factors predicting home death among home palliative care recipients.This is a population-based study using a national representative sample retrieved from the National Health Insurance Research Database. Subjects receiving home palliative care, from 2010 to 2012, were analyzed to evaluate the association between a home death and various characteristics related to illness, individual, and health care utilization. A multiple-logistic regression model was used to assess the independent effect of various characteristics on the likelihood of a home death.The overall rate of a home death for home palliative care recipients was 43.6%. Age; gender; urbanization of the area where the patients lived; illness; the total number of home visits by all health care professionals; the number of home visits by nurses; utilization of nasogastric tube, endotracheal tube, or indwelling urinary catheter; the number of emergency department visits; and admission to intensive care unit in previous 1 year were not significantly associated with the risk of a home death. Physician home visits increased the likelihood of a home death. Compared with subjects without physician home visits (31.4%) those with 1 physician home visit (53.0%, adjusted odds ratio [AOR]: 3.23, 95% confidence interval [CI]: 1.93-5.42) and those with ≥2 physician home visits (43.9%, AOR: 2.23, 95% CI: 1.06-4.70) had higher likelihood of a home death. Compared with subjects with hospitalization 0 to 6 times in previous 1 year, those with hospitalization ≥7 times in previous 1 year (AOR: 0.57, 95% CI: 0.34-0.95) had lower likelihood of a home death.Among home palliative care recipients, physician home visits increased the likelihood of a home death. Hospitalizations ≥7 times in previous 1 year decreased the likelihood of a home death.

End of life care for glioblastoma patients at a large academic cancer center

Glioblastoma (GBM) is a universally fatal disease, complicated by significant cognitive and physical disabilities, inherent to the disease course. The purpose of this study was to retrospectively analyze end-of-life care for GBM patients at an academic center and compare utilization of these services to national quality of care guidelines, with the goal of identifying opportunities to improve end-of-life care. Single center retrospective cohort study of GBM patients at Johns Hopkins Hospital (JHH) between 2009 and 2014, using electronic medical records and hospice records. Comprehensive medical record review of 100 randomly selected patients with GBM, who were actively treated at JHH. Secondary analysis of all JHH GBM patients (n = 45) who received hospice care at Gilchrist Services, our largest provider, during this time period. Of 100 patients, 76 were referred to hospice. Despite the poor survival and changes in mental capacity associated with this disease, only 40% of individuals had documentation of code status and only 17% had any documentation of advance directives (ADs). None had documentation by a health care provider of a formal symptom, psychosocial, or spiritual assessment at greater than 50% of clinic visits. Only 17% used chemotherapy in their last month of life. 37% were hospitalized in the last month of life for an average of 9 days. Of the Gilchrist Services patients, the median length of stay in hospice was 21 days and 64% of these patients died in their residence with hospice services. Documentation of palliative care and end-of-life measures could improve quality of care for GBM patients, especially in the use of ADs, symptom, spiritual, and psychosocial assessments, with earlier use of hospice to prevent end-of-life hospitalizations.

What determines duration of palliative care before death for patients with advanced disease? A retrospective cohort study of community and hospital palliative care provision in a large UK city

OBJECTIVE

For patients with advanced cancer, several randomised controlled trials have shown that access to palliative care at least 6 months before death can improve symptoms, reduce unplanned hospital admissions, minimise aggressive cancer treatments and enable patients to make choices about their end-of-life care, including exercising the choice to die at home. This study determines in a UK population the duration of palliative care before death and explores influencing factors.

DESIGN

This retrospective cohort study analysed referrals to three specialist palliative care services; a hospital-based inpatient palliative care team, and two community-based services (hospices). For each patient referred to any of the above services we identified the date of first referral to that team and calculated the median interval between first referral and death. We also calculated how referral time varied by age, sex, diagnosis and type of palliative care service.

PARTICIPANTS

4650 patients referred to specialist palliative care services in Leeds UK between April 2012 and March 2014.

RESULTS

Median age of the sample was 75 years. 3903 (84.0%) patients had a diagnosis of cancer. Age, diagnosis and place of referral were significant predictors of duration of palliative care before death. Age was independently associated (J=2 672 078, z=-392046.14, r=0.01) with duration of palliative care regardless of diagnosis. Patients over 75 years have 29 fewer days of palliative care than patients under 50. Patients with non-cancer diagnoses have 13 fewer days of palliative care than patients with cancer. Additionally, patients referred to hospital palliative care receive 24.5 fewer days palliative care than those referred to community palliative care services.

CONCLUSIONS

The current timing of referral to palliative care may limit the benefits to patients in terms of improvements in end-of-life care, particularly for older patients and patients with conditions other than cancer.

A Study of the Association Between Multidisciplinary Home Care and Home Death Among Thai Palliative Care Patients

PURPOSE

Many terminally ill patients would prefer to stay and die in their own homes, but unfortunately, some may not be able to do so. Although there are many factors associated with successful home deaths, receiving palliative home visits from the multidisciplinary care teams is one of the key factors that enable patients to die at home. Our study was aimed to find whether there was any association between our palliative home care program and home death.

METHODS

A retrospective study was conducted in the Department of Family Medicine at Ramathibodi Hospital between January 2012 and May 2014. All of the patients who were referred to multidisciplinary palliative care teams were included. The data set comprised of patient's profile, disease status, functional status, patient's symptoms, preferred place of death, frequency of home visits, types of team interventions, and patient's actual place of death. Multiple logistic regression was applied in order to determine the association between the variables and the probability of dying at home.

RESULTS

A total of 142 patients were included into the study. At the end of the study, 50 (35.2%) patients died at home and 92 (64.8%) patients died in the hospital. The multivariate logistic regression analysis demonstrated a strong association between multidisciplinary home care and home death (odds ratio 6.57, 95% confidence interval [CI] 2.48-17.38).

CONCLUSION

Palliative home care was a significant factor enabling patients who want to die at home. We encourage health policy makers to promote the development of community-based palliative care programs in Thailand.

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

Background

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

Methods

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

Results

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

Conclusions

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

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

Electronic supplementary material

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

Timing and Outcome of Referral to the First Stand-Alone Palliative Care Center in the Eastern Mediterranean Region, the Palliative Care Center of Kuwait

BACKGROUND

Compared to other regions of the world, palliative care (PC) in the Eastern Mediterranean region is at an earlier stage of development. The Palliative Care Center of Kuwait (PCC-K) was established a few years ago as the first stand-alone PC center in the region. This study was conducted to investigate the timing of referral to the PCC-K and its outcome.

METHODS

Retrospective review of referrals to the PCC-K during its first 3 years of action. Late referral was defined as referral during the last 30 days of life.

RESULTS

During the 3-year period, 498 patients with cancer were referred to the PCC-K of whom 467 were eligible for analysis. Referral was considered late in 58% of patients. Nononcology facilities were more likely to refer patients late when compared to oncology facilities ( P = .033). The palliative performance scale (PPS) was ≤30 in 59% of late referrals and 21% in earlier referrals ( P < .001). Among 467 referred patients, 342 (73%) were eligible for transfer to the PCC-K, 102 (22%) were ineligible, and 23 (5%) died before assessment by the PCC-K consultation team. From the 342 eligible patients, the family caregivers refused the transfer of 64 (19%) patients to the PCC-K.

CONCLUSION

Patients are frequently referred late to the PCC-K. Further research to identify barriers to PC and its early integration in Kuwait is required. The PPS may be useful in identifying late referrals.

Predictors of Place of Death for Those in Receipt of Home-Based Palliative Care Services in Ontario, Canada

Many cancer patients die in institutional settings despite their preference to die at home. A longitudinal, prospective cohort study was conducted to comprehensively assess the determinants of home death for patients receiving home-based palliative care. Data collected from biweekly telephone interviews with caregivers (n = 302) and program databases were entered into a multivariate logistic model. Patients with high nursing costs (odds ratio [OR]: 4.3; confidence interval [CI]: 1.8-10.2) and patients with high personal support worker costs (OR: 2.3; CI: 1.1-4.5) were more likely to die at home than those with low costs. Patients who lived alone were less likely to die at home than those who cohabitated (OR: 0.4; CI: 0.2-0.8), and those with a high propensity for a home-death preference were more likely to die at home than those with a low propensity (OR: 5.8; CI: 1.1-31.3). An understanding of the predictors of place of death may contribute to the development of effective interventions that support home death.

Metastatic non-small cell lung cancer: a benchmark for quality end-of-life cancer care?

OBJECTIVES

To investigate the quality of end-of-life care for patients with metastatic non-small cell lung cancer (NSCLC).

DESIGN AND PARTICIPANTS

Retrospective cohort study of patients from first hospitalisation for metastatic disease until death, using hospital, emergency department and death registration data from Victoria, Australia, between 1 July 2003 and 30 June 2010.

MAIN OUTCOME MEASURES

Emergency department and hospital use; aggressiveness of care including intensive care and chemotherapy in last 30 days; palliative and supportive care provision; and place of death.

RESULTS

Metastatic NSCLC patients underwent limited aggressive treatment such as intensive care (5%) and chemotherapy (< 1%) at the end of life; however, high numbers died in acute hospitals (42%) and 61% had a length of stay of greater than 14 days in the last month of life. Although 62% were referred to palliative care services, this occurred late in the illness. In a logistic regression model adjusted for year of metastasis, age, sex, metastatic site and survival, the odds ratio (OR) of dying in an acute hospital bed compared with death at home or in a hospice unit decreased with receipt of palliative care (OR, 0.25; 95% CI, 0.21-0.30) and multimodality supportive care (OR, 0.65; 95% CI, 0.56-0.75).

CONCLUSION

Because early palliative care for patients with metastatic NSCLC is recommended, we propose that this group be considered a benchmark of quality end-of-life care. Future work is required to determine appropriate quality-of-care targets in this and other cancer patient cohorts, with particular focus on the timeliness of palliative care engagement.

"I was ready to take him home": next-of-kin's accounts of loved one's death during hospice and palliative care discussions in Veterans Affairs Medical Centers

This study explored next-of-kin's retrospective accounts of hospice and palliative care discussions for hospitalized veterans. In-depth, face-to-face interviews were used to generate narrative accounts of 78 next-of-kin's experience of their loved one's hospital care during the last days of the patient's life. One-third of participants reported taking part in a hospice or palliative care discussion during the patient's final hospitalization. In over one-half of those cases, the patients died before discharge or transfer to hospice or palliative care was accomplished. Hospice and palliative care discussions in the hospital setting shaped family perceptions of the patients' care, directed family efforts in the days prior to death, and engendered anticipation of remaining quality time with the patient. Discussions about hospice or palliative care have meaning, emotional impact, practical effects, and unintended consequences for next-of-kin. Social workers in hospital settings can play a critical role in supporting family members through the hospice and palliative care discussion process and facilitate timely care transitions. They also can attend to the psychosocial concerns of family members, particularly when death occurs prior to discharge to hospice or transfer to an inpatient palliative care service.

Length of home hospice care, family-perceived timing of referrals, perceived quality of care, and quality of death and dying in terminally ill cancer patients who died at home

PURPOSE

This study aims to clarify the length of home hospice care, family-perceived timing of referrals, and their effects on the family-perceived quality of care and quality of death and dying of terminally ill cancer patients who died at home and identify the determinants of perceived late referrals.

METHODS

A multicenter questionnaire survey was conducted involving 1,052 family members of cancer patients who died at home supported by 15 home-based hospice services throughout Japan.

RESULTS

A total of 693 responses were analyzed (effective response rate, 66 %). Patients received home-based hospice care for a median of 35.0 days, and 8.0 % received home hospice care for less than 1 week. While 1.5 % of the families reported the timing of referrals as early, 42 % reported the timing as late or too late. The families of patients with a length of care of less than 4 weeks were more likely to regard the timing of referrals as late or too late. The patients of family members who regarded the timing of referrals as late or too late had a significantly lower perceived quality of care (effect size, 0.18; P = 0.039) and lower quality of death and dying (effect size, 0.15, P = 0.063). Independent determinants of higher likelihoods of perceived late referrals included: frequent visits to emergency departments, patient being unprepared for worsening condition, and patient having concerns about relationship with new doctor. Discharge nurse availability was independently associated with lower likelihoods of perceived late referrals.

CONCLUSIONS

A significant number of bereaved families regarded the timing of referrals to home hospices as late, and the perceived timing was associated with the family-perceived quality of care and quality of death and dying. Systematic strategies to overcome the barriers related to perceived late referrals are necessary.

Patterns of pain medication use during last months of life in HIV-infected populations: the experience of an academic outpatient clinic

INTRODUCTION

This article describes the patterns of use of pain medicines of HIV-infected patients during last months of life in an HIV university-affiliated outpatient clinic.

METHODS

We retrospectively reviewed our databases and identified patients who died over the last 12 months in our clinic. Demographic, clinical, and laboratory information were abstracted.

RESULTS

A total of 41 patients died in our HIV outpatient clinic in a period of 12 months. Opioid analgesics were prescribed for 21 (51%) patients, with 10 (48%) of these patients prescribed short-acting opioid analgesics alone, In all, 11 patients (52%) were on a short-acting and long-acting opioid combination, and 30 (73%) patients experienced pain that was not adequately controlled.

DISCUSSION

Pain control during the last months of life for this population appears to be suboptimal. Better strategies are needed.