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Hu FY, Wang Y, Abbas M, Bollens-Lund E, Reich AJ, Lipsitz SR, Gray TF, Kim D, Ritchie C, Kelley AS, Cooper Z. Prevalence of unpaid caregiving, pain, and depression in older seriously ill patients undergoing elective surgery. J Am Geriatr Soc 2023; 71:2151-2162. [PMID: 36914427 PMCID: PMC10363213 DOI: 10.1111/jgs.18316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 01/22/2023] [Accepted: 02/07/2023] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Serious illness is a life-limiting condition negatively impacting daily function, quality of life, or excessively straining caregivers. Over 1 million older seriously ill adults undergo major surgery annually, and national guidelines recommend that palliative care be available to all seriously ill patients. However, the palliative care needs of elective surgical patients are incompletely described. Understanding baseline caregiving needs and symptom burden among seriously ill older surgical patients could inform interventions to improve outcomes. METHODS Using Health and Retirement Study data (2008-2018) linked to Medicare claims, we identified patients ≥66 years who met an established serious illness definition from administrative data and underwent major elective surgery using Agency for Healthcare Research and Quality (AHRQ) criteria. Descriptive analyses were performed for preoperative patient characteristics, including: unpaid caregiving (no or yes); pain (none/mild or moderate/severe); and depression (no, CES-D < 3, or yes, CES-D ≥ 3). Multivariable regression was performed to examine the association between unpaid caregiving, pain, depression, and in-hospital outcomes, including hospital days (days admitted between discharge date and one-year post-discharge), in-hospital complications (no or yes), and discharge destination (home or non-home). RESULTS Of the 1343 patients, 55.0% were female and 81.6% were non-Hispanic White. Mean age was 78.0 (SD 6.8); 86.9% had ≥2 comorbidities. Before admission, 27.3% of patients received unpaid caregiving. Pre-admission pain and depression were 42.6% and 32.8%, respectively. Baseline depression was significantly associated with non-home discharge (OR 1.6, 95% CI 1.2-2.1, p = 0.003), while baseline pain and unpaid caregiving needs were not associated with in-hospital or post-acute outcomes in multivariable analysis. CONCLUSIONS Prior to elective surgery, older adults with serious illnesses have high unpaid caregiving needs and a prevalence of pain and depression. Baseline depression alone was associated with discharge destinations. These findings highlight opportunities for targeted palliative care interventions throughout the surgical encounter.
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Affiliation(s)
- Frances Y Hu
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Yihan Wang
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Muhammad Abbas
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Evan Bollens-Lund
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amanda J Reich
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Tamryn F Gray
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Woman's Hospital, Boston, Massachusetts, USA
| | - Dae Kim
- Department of Medicine, Brigham and Woman's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amy S Kelley
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Woman's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Woman's Hospital, Boston, Massachusetts, USA
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Murali KP, Merriman JD, Yu G, Vorderstrasse A, Kelley AS, Brody AA. Complex Care Needs at the End of Life for Seriously Ill Adults With Multiple Chronic Conditions. J Hosp Palliat Nurs 2023; 25:146-155. [PMID: 37040386 PMCID: PMC10175220 DOI: 10.1097/njh.0000000000000946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
Understanding the complex care needs of seriously ill adults with multiple chronic conditions with and without cancer is critical for the delivery of high-quality serious illness and palliative care at the end of life. The objective of this secondary data analysis of a multisite randomized clinical trial in palliative care was to elucidate the clinical profile and complex care needs of seriously ill adults with multiple chronic conditions and to highlight key differences among those with and without cancer at the end of life. Of the 213 (74.2%) older adults who met criteria for multiple chronic conditions (eg, 2 or more chronic conditions requiring regular care with limitations of daily living), 49% had a diagnosis of cancer. Hospice enrollment was operationalized as an indicator for severity of illness and allowed for the capture of complex care needs of those deemed to be nearing the end of life. Individuals with cancer had complex symptomatology with a higher prevalence of nausea, drowsiness, and poor appetite and end of life and lower hospice enrollment. Individuals with multiple chronic conditions without cancer had lower functional status, greater number of medications, and higher hospice enrollment. The care of seriously ill older adults with multiple chronic conditions requires tailored approaches to improve outcomes and quality of care across health care settings, particularly at the end of life.
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Affiliation(s)
| | | | - Gary Yu
- New York University Rory Meyers College of Nursing
| | | | - Amy S. Kelley
- Icahn School of Medicine at Mount Sinai, Geriatrics and Palliative Medicine
| | - Abraham A. Brody
- New York University Rory Meyers College of Nursing
- New York University Grossman School of Medicine
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Kang JA, Barcelona V. A comparison of conceptual frameworks to examine health inequities in End-of-Life care. J Adv Nurs 2023; 79:2025-2041. [PMID: 35909090 PMCID: PMC9887096 DOI: 10.1111/jan.15393] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 07/11/2022] [Accepted: 07/20/2022] [Indexed: 02/02/2023]
Abstract
AIMS To discuss existing conceptual frameworks that can be applied to the examination of health inequities in end-of-life care and related health outcomes. We used the Fawcett and Desanto-Madeya evaluation technique modified by the National Institute on Minority Health and Health Disparities Research Framework to include individual, interpersonal, community, and societal levels of influence. DESIGN Discussion paper. DATA SOURCES We performed a systematic review of PubMed, CINAHL and Embase for conceptual frameworks of health inequities in end-of-life care and health outcomes published as of February 2022. IMPLICATIONS FOR NURSING There is a strong need for research that can address multiple factors influencing end-of-life care inequities and health outcomes. To mitigate the complex nature of social determinants of health and structural inequities, researchers, clinicians, educators and administrators should have solid conceptualizations of these multi-level factors. Based on sound and comprehensive frameworks, nurses with interdisciplinary partnerships can promote health equity with a broader health care scope through addressing social determinants of health. CONCLUSION We identified and reviewed three frameworks. We concluded all three frameworks have the potential for use in the examination of health inequities in end-of-life care and health outcomes. However, the Conceptual Framework of Minority Access to End-of-Life Care was more applicable to diverse studies and settings when adapted to include fundamental characteristics such as sex and gender. IMPACT Despite the substantial rise in end-of-life care delivery, health inequities persist in end-of-life care access and utilization. Though some studies have been conducted to promote health equity by addressing social determinants of health, progress is hampered by their complex and multi-faceted nature. Through a concrete conceptual framework, researchers can comprehensively examine multi-level factors influencing health inequities in end-of-life care. NO PATIENT OR PUBLIC CONTRIBUTION This discussion paper focused on reviewing existing evidence.
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Affiliation(s)
- Jung A Kang
- Columbia University School of Nursing, New York, New York, USA
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Cox CE, Olsen MK, Parish A, Gu J, Ashana DC, Pratt EH, Haines K, Ma J, Casarett DJ, Al-Hegelan MS, Naglee C, Katz JN, O'Keefe YA, Harrison RW, Riley IL, Bermejo S, Dempsey K, Wolery S, Jaggers J, Johnson KS, Docherty SL. Palliative care phenotypes among critically ill patients and family members: intensive care unit prospective cohort study. BMJ Support Palliat Care 2022; 14:bmjspcare-2022-003622. [PMID: 36167642 PMCID: PMC10085460 DOI: 10.1136/spcare-2022-003622] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 09/16/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Because the heterogeneity of patients in intensive care units (ICUs) and family members represents a challenge to palliative care delivery, we aimed to determine if distinct phenotypes of palliative care needs exist. METHODS Prospective cohort study conducted among family members of adult patients undergoing mechanical ventilation in six medical and surgical ICUs. The primary outcome was palliative care need measured by the Needs at the End-of-Life Screening Tool (NEST, range from 0 (no need) to 130 (highest need)) completed 3 days after ICU admission. We also assessed quality of communication, clinician-family relationship and patient centredness of care. Latent class analysis of the NEST's 13 items was used to identify groups with similar patterns of serious palliative care needs. RESULTS Among 257 family members, latent class analysis yielded a four-class model including complex communication needs (n=26, 10%; median NEST score 68.0), family spiritual and cultural needs (n=21, 8%; 40.0) and patient and family stress needs (n=43, 31%; 31.0), as well as a fourth group with fewer serious needs (n=167, 65%; 14.0). Interclass differences existed in quality of communication (median range 4.0-10.0, p<0.001), favourable clinician-family relationship (range 34.6%-98.2%, p<0.001) and both the patient centredness of care Eliciting Concerns (median range 4.0-5.0, p<0.001) and Decision-Making (median range 2.3-4.5, p<0.001) scales. CONCLUSIONS Four novel phenotypes of palliative care need were identified among ICU family members with distinct differences in the severity of needs and perceived quality of the clinician-family interaction. Knowledge of need class may help to inform the development of more person-centred models of ICU-based palliative care.
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Affiliation(s)
- Christopher E Cox
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Maren K Olsen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Jessie Gu
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | - Deepshikha Charan Ashana
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Elias H Pratt
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | - Krista Haines
- Department of Surgery, Division of Trauma and Critical Care and Acute Care Surgery, Duke University, Durham, NC, USA
| | - Jessica Ma
- Section of Palliative Care and Hospice Medicine, Duke University, Durham, NC, USA
| | - David J Casarett
- Section of Palliative Care and Hospice Medicine, Duke University, Durham, NC, USA
| | - Mashael S Al-Hegelan
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | - Colleen Naglee
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Neurology, Division of Neurocritical Care, Durham, North Carolina, USA
| | - Jason N Katz
- Department of Medicine, Division of Cardiology, Duke University, Durham, NC, USA
| | - Yasmin Ali O'Keefe
- Department of Neurology, Division of Neurocritical Care, Durham, North Carolina, USA
| | - Robert W Harrison
- Department of Medicine, Division of Cardiology, Duke University, Durham, NC, USA
| | - Isaretta L Riley
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | - Santos Bermejo
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Katelyn Dempsey
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Shayna Wolery
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Jennie Jaggers
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Kimberly S Johnson
- Division of Geriatrics, Center for Study of Aging and Human Development, Duke University, Durham, NC, USA
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