Place of death and factors associated with hospital death in patients who have died from liver disease in England: a national population-based study

Impact of COVID-19 on place of death for disease-related causes: a population-based study in Nanchang, China

Little is known about the place of death at the regional level in China. Furthermore, the impact of COVID-19 on the place of death remains unclear. We aimed to examine the place of death before and during COVID-19 in Nanchang, China, focusing on changes in home death across different causes, to determine whether these changes were disproportionately experienced among patients with different diseases. Using data from the National Death Registration System, Nanchang, China, this population-based, observational study examined all non-accidental deaths from 1 January 2014 to 31 December 2019 (pre-COVID-19), and 25 January 2020 to 31 December 2022 (during COVID-19). Modified Poisson regression models were employed to assess the association between underlying cause of death and home death, and interaction terms added to evaluate changes over periods. We used R version 4.2.2 for all analyses. The analysis included 198,383 deaths, with a median age of 78 years (IQR: 66-85); 58.2% were male and 41.8% were female. Home deaths rose from 72.7% pre-COVID-19 to 75.6% during COVID-19 (p < 0.0007). Before COVID-19, patients with renal failure (adjusted PR 0.74 [95% CI, 0.67-0.81]), liver disease (0.81 [0.76-0.86]), and hematological cancer (0.88 [0.84-0.92]) were less likely to die at home compared to those with solid cancer. During COVID-19, these disparities diminished, with a significant increase in home deaths among renal failure (1.32 [1.19-1.48]), liver disease (1.19 [1.10-1.29]), and hematological cancer (1.12 [1.05-1.20]). The majority of non-accidental deaths occurred at home, with a notable rise during COVID-19, underscoring the urgent need to strengthen community- and home-based end-of-life care services. Although home death rates for patients with renal failure, liver disease, and hematological cancer were lower before COVID-19, they increased significantly during the pandemic, highlighting disparities in end-of-life care that necessitate targeted improvements.

Factors affecting the place of death in patients with liver cancer in China, 2013-2020: A population-based study

Background

Despite the country's substantial liver cancer burden, there is limited research on the factors influencing the place of death (POD) of patients with liver cancer in China. This study aimed to delineate POD distribution among patients with liver cancer, identify the factors associated with hospital deaths, and offer valuable insights for the government to develop healthcare policies.

Methods

Data from 2013 to 2020 were obtained from the National Mortality Surveillance System (NMSS) of China. This analysis focused on the distribution of POD among individuals who succumbed to liver cancer. Variations in characteristic distributions across different categories were evaluated using a chi-squared test. We also applied a multilevel logistic regression analysis to identify the factors associated with hospital liver cancer deaths. The proportional change in variance was computed to evaluate the contributions of different factors in the model.

Results

From 2013 to 2020, the NMSS reported a total of 608,789 liver cancer-related deaths, of which 440,079 (72.29%) died at home, and 158,291 (26.00%) died in the hospital. Home remained the preferred POD among patients with liver cancer. The results demonstrated that female patients, aged between 0 and 14 years, of Han ethnicity, living in urban areas, unmarried, highly educated, and either employed in a professional, staff, or civil servant capacity, or retired patients tended to end their lives in the hospital.

Conclusions

In China, home continues to be the predominant POD for patients with liver cancer, with demographic and socioeconomic factors significantly influencing whether a hospital is their POD. Enhancing healthcare policymakers' understanding of the factors influencing the place of death for patients with liver cancer may assist in creating a more equitable distribution of healthcare resources and providing a variety of choices for minorities with distinct preferences for end-of-life care.

Effective palliation of refractory ascites in cirrhosis is challenging

BACKGROUND

Palliative care is often suboptimal for patients with end-stage liver disease (ESLD). Ascites remains the most common complication in ESLD. Though long-term abdominal drains (LTAD) are commonly used in refractory malignant ascites, the standard care for ESLD is hospital drainage (large volume paracentesis (LVP)). There is an ongoing National Institute for Health and Care Research (NIHR) funded trial (REDUCe 2 Study) (ISRCTN269936824) comparing palliative LTAD to LVP in ESLD. This 35-site trial is being conducted in England, Scotland and Wales.

AIM

To understand the views and experience of healthcare professionals (HCP) on the use of palliative LTAD in ESLD.

METHODS

An electronic survey comprised of seven questions with fixed quantitative options and three exploratory questions was used between August-December 2019. The survey was distributed electronically via the British Association for Study of Liver newsletter and to relevant hospital departments in Southeast England and Northeast London. An email reminder was sent at 4 and 8 weeks after the initial invitation to the survey.

RESULTS

There were 211 respondents (hepatologists (36.5%), specialist nurses (24.6%), gastroenterologists (16.6%), trainees (17%) and others (5.2%)). All respondents had access to LVP, 86% to a transjugular intrahepatic portosystemic shunt procedure for patients, 67% to LTADs and 10% to other options, such as the automated low-flow ascites (ALFA) pump. The majority of respondents to the survey (68%) reported their experience of using LTAD. Almost all respondents (91%) were willing to consider LTAD in ESLD. However, the main deterrents of this were the perceived risk of infection (90%), followed by LTAD management in community (57%). Some 51% of those with prior experience of using LTAD reported clinical complications for patients (including bleeding, infection and renal impairment), 41% reported technical issues and 35% inadequate community support.

CONCLUSIONS

Almost all HCPs are willing to consider palliative LTAD in refractory ascites due to ESLD, but the main deterrents are the perceived infection risk and lack of published data to guide community management. The REDUCe 2 trial will clarify if these concerns are real and provide conclusive evidence on role, if any, of palliative LTADs in this vulnerable and under researched cohort with ESLD.

Healthcare Resource Utilization and Goals of Care Discussions in Patients with Cirrhosis and Acute Kidney Injury

BACKGROUND

Patients with cirrhosis and acute kidney injury (AKI) are critically ill and have high health care resource utilization (HCRU). The impact and timing of goals of care discussions on HCRU are not well described.

METHODS

221 patients enrolled in a prospective cohort study of patients admitted with AKI and cirrhosis were reviewed. Documentation and timing of a goals of care discussions were analyzed as predictors of HCRU, defined as a composite outcome of intubation, initiation of renal replacement therapy, and/or admission to the intensive care unit.

RESULTS

Median MELD score was 26 [IQR 19, 33]. 29% patients were listed for liver transplant. 90-day mortality was 61%. 51% patients had at least one HCRU episode. Code status changed from admission to discharge from 91%/7%/0% to 68%/14%18% (full code/do not resuscitate/comfort measures, p < 0.001). 28% patients underwent goals of care discussions, with change in code status at a median of 16 [9, 22] days into admission. Only 18% of discussions were within 7 days of admission and all were after an HCRU event. Being listed for liver transplant was not associated with whether goals of care discussions occurred (23% listed vs. 31% non-listed, p = 0.24) but was associated with higher HCRU (69% vs. 43%; p < 0.001).

CONCLUSION

Goals of care discussions occurred late into the hospital course, after episodes of HCRU. Efforts should be made to engage in these discussions earlier in the hospital stay, which may decrease HCRU rates in this critically ill population and align with patients' goals of care.

Quality of end-of-life care with non-malignant liver disease: Analysis of the VOICES National Survey of Bereaved People

BACKGROUND AND AIMS

Patients with liver disease struggle to access palliative care. We aimed to compare carers' perceptions of end-of-life care for decedents with non-malignant liver disease, malignant liver disease and other non-malignant diseases, and to identify associated factors in non-malignant liver disease.

METHODS

A retrospective analysis of individual-level data from the National Survey of Bereaved People 2011-2015.

RESULTS

More decedents with non-malignant liver disease died in hospital than other diseases (76.9% vs. 40.9% vs. 50.2%, p < .001), despite 89% wishing to die at home. Fewer decedents received home/hospice specialist palliative care compared with those with malignant liver disease (10.0% vs. 54.6%, p < .001). Carers of decedents with non-malignant liver disease were less likely to rate overall end-of-life care quality as outstanding/excellent (29.3% vs. 43.9% vs. 42.3%, p < .001). For this group, poorer care was associated with younger (65-74 vs. 18-64 years, OR [odds ratio] 1.39, p = .01), more socially deprived decedents (OR .78, p = .02), and better care with greater social support (OR 1.82, p < .001) and community specialist palliative care involvement (OR 1.80, p < .001). There was no association between outstanding/excellent rating and underlying cause of non-malignant liver disease (alcohol-related vs. non-alcohol-related, p = .92) or place of death (hospital vs. non-hospital, p = .476).

CONCLUSIONS

End-of-life care could be improved by integrating hepatology and community services, particularly specialist palliative care, and advance care planning to facilitate care and death (where desired) at home. However, death in hospital may be appropriate for those with non-malignant liver disease.

Factors associated with place of death for terminal cancer patients who wished to die at home

A patient's desired place of death is an important indicator of the quality of dying. The purpose of this study was to investigate the actual places of death of terminal cancer patients who wished to die at home and the factors affecting their actual place of death. A retrospective survey was used to analyze the medical records of 143 terminal cancer patients who wanted to die at home among a population of 168 patients who used a home hospice care service more than once between March 2016 and December 2019. Patients who wanted to die at home represented 85.1% of the total study population (143 patients). Of these, 31.5% and 68.5% were home and hospital deaths, respectively. Factors associated with the actual place of death of patients who desired to die at home were marital status (odds ratio [OR] = 2.57, confidence interval [CI]: 1.08-6.13), the patient's status at the time of their enrollment in a home hospice care service (OR = 3.30, CI: 1.56-7.02), and the primary caregiver's relationship with the patient (OR = 2.52, CI: 1.12-5.66). Most terminal cancer patients studied did not die in their preferred place. Support from policies and hospice professionals is needed to decrease caregiver burden and help patients die wherever they want. Consequently, quality of end-of-life care can be improved.

Palliative long-term abdominal drains for the management of refractory ascites due to cirrhosis: a consensus document

Palliative care remains suboptimal in advanced cirrhosis, in part relating to a lack of evidence-based interventions. Ascites remains the most common cirrhosis complication resulting in hospitalisation. Many patients with refractory ascites are not candidates for liver transplantation or transjugular intrahepatic portosystemic shunt, and therefore, require recurrent palliative large volume paracentesis in hospital. We review the available evidence on use of palliative long-term abdominal drains in cirrhosis. Pending results of a national trial (REDUCe 2) and consistent with recently published national and American guidance, long-term abdominal drains cannot be regarded as standard of care in advanced cirrhosis. They should instead be considered only on a case-by-case basis, pending definitive evidence. This manuscript provides consensus to help standardise use of long-term abdominal drains in cirrhosis including patient selection and community management. Our ultimate aim remains to improve palliative care for this under researched and vulnerable cohort.

Illnesses and Symptoms in Older Adults at the End of Life at Different Places of Death in Korea

Context: A comprehensive plan has been launched by the Korean government to expand hospice and palliative care from hospital-based inpatient units to other services, such as palliative care at home, palliative consultation, and palliative care at a nursing home. Objective: To examine the illnesses and symptoms at the end of life associated with the place of death among older Korean adults. Methods: This secondary data analysis included a stratified random sample of 281 adults identified from the exit survey of the Korean Longitudinal Study of Aging aged ≥65 years and who died in 2017–2018. Results: Overall, 69% of the patients died at hospitals, 13% died at long-term care facilities (LTCF), and 18% died at home. In the multinomial logistic regression analysis adjusting for age, sex, and marital status, older adults who died in the hospital had higher odds (2.02–4.43 times) of having limitations in activities of daily living (ADL) as well as symptoms of anorexia, depression, weakness, dyspnea, and periodic confusion 1 month before death than those who died at home. Older adults who died in an LTCF were more likely to have limitations in ADL and instrumental ADL as well as a higher likelihood (2–5 times) of experiencing pain, anorexia, fatigue, depression, weakness, dyspnea, incontinence, periodic confusion, and loss of consciousness than those who died at home. Conclusion: Since the majority of subjects died either in a hospital or an LCTF, and this proportion is expected to increase, policy planning should focus on improving the palliative case in these settings. Future policies and clinical practices should consider the illness and symptoms of older patients at the end of life across different care settings.

Advance Care Planning and Goals of Care Discussions in Advanced Liver Disease

PURPOSE OF REVIEW

Advance care planning (ACP) has been shown to improve multiple outcomes in patients with serious illnesses; however, patients with advanced liver disease, or cirrhosis, rarely receive timely ACP. The purpose of this review is to evaluate the current state of ACP for patients with advanced liver disease and to provide practical guidance for integrating early ACP into routine outpatient hepatology care.

RECENT FINDINGS

Due to multiple patient-, physician-, and systems-level barriers, patients with advanced liver disease have low rates of timely ACP engagement. Early identification and preparation of a surrogate decision-maker, enhancing clinician ACP communication skills, use of patient-centered educational tools, optimizing outpatient processes for ACP documentation, and early referral to specialty palliative care may help to improve current deficits in ACP for this population.

SUMMARY

Provision of early ACP to patients with advanced liver disease may better ensure that patients receive medical care that is consistent with their goals and values.

Developing Priorities for Palliative Care Research in Advanced Liver Disease: A Multidisciplinary Approach

Individuals with advanced liver disease (AdvLD), such as decompensated cirrhosis (DC) and hepatocellular carcinoma (HCC), have significant palliative needs. However, little research is available to guide health care providers on how to improve key domains related to palliative care (PC). We sought to identify priority areas for future research in PC by performing a comprehensive literature review and conducting iterative expert panel discussions. We conducted a literature review using search terms related to AdvLD and key PC domains. Individual reviews of these domains were performed, followed by iterative discussions by a panel consisting of experts from multiple disciplines, including hepatology, specialty PC, and nursing. Based on these discussions, priority areas for research were identified. We identified critical gaps in the available research related to PC and AdvLD. We developed and shared five key priority questions incorporating domains related to PC. Conclusion: Future research endeavors focused on improving PC in AdvLD should consider addressing the five key priorities areas identified from literature reviews and expert panel discussions.

Palliative Long-Term Abdominal Drains Versus Large Volume Paracentesis in Refractory Ascites Due to Cirrhosis (REDUCe Study): Qualitative Outcomes

CONTEXT

Palliative care remains suboptimal in end-stage liver disease (ESLD).

OBJECTIVES

We report qualitative outcomes from the REDUCe study. We aimed to explore and contrast experiences/perceptions/care pathways of patients with refractory ascites due to ESLD randomized to either palliative long-term abdominal drains (LTADs) (allow home drainage) vs. large volume paracentesis (LVP) (hospital drainage).

METHODS

Concurrent embedded qualitative study in a 12-week feasibility randomized controlled trial. Telephone interviews were conducted, data being recorded, transcribed verbatim, and analyzed using applied thematic analysis, considered in terms of a pathway approach toward accessing health care. Quantitative outcomes were collected (integrated palliative outcome scale, short-form liver disease quality of life, EQ-5D-5 L, Zarit Burden Interview-12).

RESULTS

Fourteen patients (six allocated LTAD and eight LVP) and eight nurses participated in the qualitative study. The patient journey in the LVP group could be hindered by challenges along the entire care pathway, from recognizing the need for drainage to a lengthy wait in hospital for drainage and/or to be discharged. These issues also impacted upon caregivers. In contrast, LTADs appeared to transform this care pathway at all levels across the patient's journey by removing the need for hospital drainage. Additional benefits included personalized care, improved symptom control of ascites, being at home, and regular support from community nurses. Nurses also viewed the LTAD favorably, though expressed the need for additional support should this become standard of care.

CONCLUSION

Patients and nurses expressed acceptability of palliative LTAD in ESLD and preference for this approach in enabling care at home. Proceeding to a definitive trial is feasible.

TRIAL REGISTRATION

ISRCTN30697116, date assigned: 07/10/2015.

Randomised clinical trial: palliative long-term abdominal drains vs large-volume paracentesis in refractory ascites due to cirrhosis

BACKGROUND

Palliative care remains suboptimal in end-stage liver disease.

AIM

To inform a definitive study, we assessed palliative long-term abdominal drains in end-stage liver disease to determine recruitment, attrition, safety/potential effectiveness, questionnaires/interview uptake/completion and make a preliminary cost comparison.

METHODS

A 12-week feasibility nonblinded randomised controlled trial comparing large-volume paracentesis vs long-term abdominal drains in refractory ascites due to end-stage liver disease with fortnightly home visits for clinical/questionnaire-based assessments. Study success criteria were attrition not >50%, <10% long-term abdominal drain removal due to complications, the long-term abdominal drain group to spend <50% ascites-related study time in hospital vs large-volume paracentesis group and 80% questionnaire/interview uptake/completion.

RESULTS

Of 59 eligible patients, 36 (61%) were randomised, 17 to long-term abdominal drain and 19 to large-volume paracentesis. Following randomisation, median number (IQR) of hospital ascitic drains (long-term abdominal drain group vs large-volume paracentesis group) were 0 (0-1) vs 4 (3-7); week 12 serum albumin (g/L) and serum creatinine (μmol/L) were 29 (26.5-32.5) vs 30 (25-35) and 104.5 (81-115.5) vs 127 (63-158) respectively. Total attrition was 42% (long-term abdominal drain group 47%, large-volume paracentesis group 37%). Median (IQR) fortnightly community/hospital/social care ascites-related costs and percentage study time in hospital were lower in the long-term abdominal drain group, £329 (253-580) vs £843 (603-1060) and 0% (0-0.74) vs 2.75% (2.35-3.84) respectively. Self-limiting cellulitis/leakage occurred in 41% (7/17) in the long-term abdominal drain group vs 11% (2/19) in the large-volume paracentesis group; peritonitis incidence was 6% (1/17) vs 11% (2/19) respectively. Questionnaires/interview uptake/completion were ≥80%; interviews indicated that long-term abdominal drains could transform the care pathway.

CONCLUSIONS

The REDUCe study demonstrates feasibility with preliminary evidence of long-term abdominal drain acceptability/effectiveness/safety and reduction in health resource utilisation.

TRIAL REGISTRATION

ISRCTN30697116, date assigned: 07/10/2015.

Reducing variation in hospital mortality for alcohol-related liver disease in North West England

BACKGROUND

Variations in emergency care quality for alcohol-related liver disease (ARLD) have been highlighted.

AIM

To determine whether introduction of a regional quality improvement (QI) programme was associated with a reduction in potentially avoidable inpatient mortality.

METHOD

Retrospective observational cohort study using hospital administrative data spanning a 1-year period before (2014/2015) and 3 years after a QI initiative at seven acute hospitals in North West England. The intervention included serial audit of a bundle of process metrics. An algorithm was developed to identify index ("first") emergency admissions for ARLD (n = 3887). We created a standardised mortality ratio (SMR) to compare relative mortality and regression models to examine risk-adjusted odds of death.

RESULTS

In 2014/2015, three of seven hospitals had an SMR above the upper control limit ("outliers"). Adjusted odds of death for patients admitted to outlier hospitals was higher than non-outliers (OR 2.13, 95% CI 1.32-3.44, P = 0.002). Following the QI programme there was a step-wise reduction in outliers (none in 2017/2018). Odds of death was 67% lower in 2017/2018 compared to 2014/2015 at original outlier hospitals, but unchanged at other hospitals. Process audit performance of outliers was worse than non-outliers at baseline, but improved after intervention.

CONCLUSIONS

There was a reduction in unexplained variation in hospital mortality following the QI intervention. This challenges the pessimism that is prevalent for achieving better outcomes for patients with ARLD. Notwithstanding the limitations of an uncontrolled observational study, these data provide hope that co-ordinated efforts to drive adoption of evidence-based practice can save lives.