Place of Death for Adults Receiving Specialist Palliative Care in Their Last 3 Months of Life: Factors Associated With Preferred Place, Actual Place, and Place of Death Congruence

Objectives: Congruence between the preferred and actual place of death is recognised as an important quality indicator in end-of-life care. However, there may be complexities about preferences that are ignored in summary congruence measures. This article examined factors associated with preferred place of death, actual place of death, and congruence for a sample of patients who had received specialist palliative care in the last three months of life in Ireland. Methods: This article analysed merged data from two previously published mortality follow-back surveys: Economic Evaluation of Palliative Care in Ireland (EEPCI); Irish component of International Access, Rights and Empowerment (IARE I). Logistic regression models examined factors associated with (a) preferences for home death versus institutional setting, (b) home death versus hospital death, and (c) congruent versus non-congruent death. Setting: Four regions with differing levels of specialist palliative care development in Ireland. Participants: Mean age 77, 50% female/male, 19% living alone, 64% main diagnosis cancer. Data collected 2011-2015, regression model sample sizes: n = 342-351. Results: Congruence between preferred and actual place of death in the raw merged dataset was 51%. Patients living alone were significantly less likely to prefer home versus institution death (OR 0.389, 95%CI 0.157-0.961), less likely to die at home (OR 0.383, 95%CI 0.274-0.536), but had no significant association with congruence. Conclusions: The findings highlight the value in examining place of death preferences as well as congruence, because preferences may be influenced by what is feasible rather than what patients would like. The analyses also underline the importance of well-resourced community-based supports, including homecare, facilitating hospital discharge, and management of complex (eg, non-cancer) conditions, to facilitate patients to die in their preferred place.

Put on the sidelines of palliative care: a qualitative study of important barriers to GPs' participation in palliative care and guideline implementation in Norway

BACKGROUND

Demographic changes, the evolvement of modern medicine and new treatments for severe diseases, increase the need for palliative care services. Palliative care includes all patients with life-limiting conditions, irrespective of diagnosis. In Norway, palliative care rests on a decentralised model where patient care can be delivered close to the patient's home, and the Norwegian guideline for palliative care describes a model of care resting on extensive collaboration. Previous research suggests that this guideline is not well implemented among general practitioners (GPs). In this study, we aim to investigate barriers to GPs' participation in palliative care and implementation of the guideline.

METHODS

We interviewed 25 GPs in four focus groups guided by a semi-structured interview guide. The interviews were recorded and transcribed verbatim. Data were analysed qualitatively with reflexive thematic analysis.

RESULTS

We identified four main themes as barriers to GPs' participation in palliative care and to implementation of the guideline: (1) different established local cultures and practices of palliative care, (2) discontinuity of the GP-patient relationship, (3) unclear clinical handover and information gaps and (4) a mismatch between the guideline and everyday general practice.

CONCLUSION

Significant structural and individual barriers to GPs' participation in palliative care exist, which hamper the implementation of the guideline. GPs should be involved as stakeholders when guidelines involving them are created. Introduction of new professionals in primary care needs to be actively managed to avoid inappropriate collaborative practices. Continuity of the GP-patient relationship must be maintained throughout severe illness and at end-of-life.

Quality-of-life outcomes in metastatic spinal cord compression: findings from the SCORAD trial

PURPOSE

This article reports detailed quality-of-life data including preferred and actual place of care from SCORAD, the only large prospective randomized trial in metastatic spinal cord compression (MSCC).

METHODS

SCORAD compared 2 doses of radiotherapy in patients with MSCC: 8 Gy single fraction and 20 Gy in 5 fractions. In total, 686 patients were randomized, of whom 590 had Health-Related Quality of Life (HRQoL) data collected at baseline and at least 1 later time point. HRQoL was measured using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 supplemented with the QLU-C10D and data on place of care at weeks 1, 4, 8, and 12 postrandomization. Quality-of-Life Adjusted Survival was computed by multiplying Kaplan-Meier survival probabilities with the UK utility weights obtained from the QLU-C10D.

RESULTS

Patients with a baseline physical functioning score of above 50 demonstrated a 28% reduction in the risk of death (hazard ratio [HR] = 0.72, 99% confidence interval [CI] = 0.54 to 0.95; P = .003). An increased risk of death was associated with fatigue (HR = 1.35, 99% CI = 1.03 to 1.76; P = .0040), dyspnea (HR = 1.61, 99% CI = 1.24 to 2.08; P < .001), and appetite loss (HR = 1.25, 99% CI = 0.99 to 1.59; P = .014). The preferred place of care for the majority was at home or with relatives (61%-74% across the 12 weeks) but achieved by only 53% at 8 weeks.

CONCLUSIONS

Prolonged survival in patients with MSCC was associated with better HRQoL. More than 60% of patients preferred to be cared for at home or with relatives, but only half were able to achieve this. There was no difference in HRQoL between the multifraction and single-fraction groups.

TRIAL REGISTRATION

ISRCTN97555949 and ISRCTN97108008.

Patient and Family Preferences About Place of End-of-Life Care and Death: An Umbrella Review

CONTEXT

The place where people are cared towards the end of their life and die is a complex phenomenon, requiring a deeper understanding. Honoring preferences is critical for the delivery of high-quality care.

OBJECTIVES

In this umbrella review we examine and synthesize the evidence regarding preferences about place of end-of-life care and death of patients with life-threatening illnesses and their families.

METHODS

Following the Joanna Briggs Institute methodology, we conducted a comprehensive search for systematic reviews in PsycINFO, MEDLINE, EMBASE, CINAHL, Epistemonikos, and PROSPERO without language restrictions.

RESULTS

The search identified 15 reviews (10 high-quality, three with meta-analysis), covering 229 nonoverlapping primary studies. Home is the most preferred place of end-of-life care for both patients (11%-89%) and family members (23%-84%). It is also the most preferred place of death (patient estimates from two meta-analyses: 51%-55%). Hospitals and hospice/palliative care facilities are preferred by substantial minorities. Reasons and factors affecting preferences include illness-related, individual, and environmental. Differences between preferred places of care and death are underexplored and the evidence remains inconclusive about changes over time. Congruence between preferred and actual place of death ranges 21%-100%, is higher in studies since 2004 and a meta-analysis shows noncancer patients are at higher risk of incongruence than cancer patients (OR 1.23, 95% CI: 1.01-1.49, I2 = 62%).

CONCLUSION

These findings are a crucial starting point to address gaps and enhance strategies to align care with patient and family preferences. To accurately identify patient and family preferences is an important opportunity to change their lives positively.

Feasibility of a Two-Step Palliative Screening Utilizing Existing Emergency Department Resources

BACKGROUND

Although the Emergency Department (ED) offers a unique setting to provide early palliative care, staffing limitations curtail hospitals from establishing ED-palliative partnerships.

MEASURES

Feasibility of a two-step ED-palliative screening protocol was defined by two criteria: a ≥ 50% increase in palliative consults originating from the ED and a ≥ 50% consultation completion rate for patients who screened positive for unmet palliative needs.

INTERVENTION

A clinical decision support tool identified patients with treatment/code status limitations and prompted a care coordination referral. Care coordinators screened patients for unmet palliative needs using a content-validated screening tool and consulted palliative care for positive screens.

OUTCOME

Palliative care consultations originating from the ED increased by 110% from 32 to 67 consultations, and 57% (40/70) of patients who screened positive for unmet palliative needs received a consultation.

CONCLUSIONS/LESSONS LEARNED

Our project demonstrated feasibility of a two-step ED-palliative protocol by increasing palliative care consultation without necessitating additional staff.

Potentially burdensome care at the end-of-life for cancer decedents: a retrospective population-wide study

BACKGROUND

Variation persists in the quality of end-of-life-care (EOLC) for people with cancer. This study aims to describe the characteristics of, and examine factors associated with, indicators of potentially burdensome care provided in hospital, and use of hospital services in the last 12 months of life for people who had a death from cancer.

METHOD

A population-based retrospective cohort study of people aged ≥ 20 years who died with a cancer-related cause of death during 2014-2019 in New South Wales, Australia using linked hospital, cancer registry and mortality records. Ten indicators of potentially burdensome care were examined. Multinominal logistic regression examined predictors of a composite measure of potentially burdensome care, consisting of > 1 ED presentation or > 1 hospital admission or ≥ 1 ICU admission within 30 days of death, or died in acute care.

RESULTS

Of the 80,005 cancer-related deaths, 86.9% were hospitalised in the 12 months prior to death. Fifteen percent had > 1 ED presentation, 9.9% had > 1 hospital admission, 8.6% spent ≥ 14 days in hospital, 3.6% had ≥ 1 intensive care unit admission, and 1.2% received mechanical ventilation on ≥ 1 occasion in the last 30 days of life. Seventeen percent died in acute care. The potentially burdensome care composite measure identified 20.0% had 1 indicator, and 10.9% had ≥ 2 indicators of potentially burdensome care. Compared to having no indicators of potentially burdensome care, people who smoked, lived in rural areas, were most socially economically disadvantaged, and had their last admission in a private hospital were more likely to experience potentially burdensome care. Older people (≥ 55 years), females, people with 1 or ≥ 2 Charlson comorbidities, people with neurological cancers, and people who died in 2018-2019 were less likely to experience potentially burdensome care. Compared to people with head and neck cancer, people with all cancer types (except breast and neurological) were more likely to experience ≥ 2 indicators of potentially burdensome care versus none.

CONCLUSION

This study shows the challenge of delivering health services at end-of-life. Opportunities to address potentially burdensome EOLC could involve taking a person-centric approach to integrate oncology and palliative care around individual needs and preferences.

Older persons' perceptions and experiences of community palliative care: a systematic review of qualitative evidence

OBJECTIVE

The objective of this review was to critically appraise and synthesize qualitative evidence of older persons' perceptions and experiences of community palliative care.

INTRODUCTION

Palliative care focuses on the relief of symptoms and suffering at the end of life and is needed by approximately 56.8 million people globally each year. An increase in aging populations coupled with the desire to die at home highlights the growing demand for community palliative care. This review provides an understanding of the unique experiences and perceptions of older adults receiving community palliative care.

INCLUSION CRITERIA

This review appraised qualitative studies examining the perceptions and experiences of older adults (65 years or older) receiving community palliative care. Eligible research designs included, but were not limited to, ethnography, grounded theory, and phenomenology.

METHODS

A search of the literature across CINAHL (EBSCOhost), MEDLINE (Ovid), Embase (Ovid SP), Web of Science Core Collection, and Scopus databases was undertaken in July 2021 and updated November 1, 2022. Included studies were published in English between 2000 and 2022. The search for unpublished studies included ProQuest Dissertations and Theses. Study selection, quality appraisal, and data extraction were performed by 2 independent reviewers. Findings from the included studies were pooled using the JBI meta-aggregation method.

RESULTS

Nine qualitative studies involving 98 participants were included in this review. A total of 100 findings were extracted and grouped into 14 categories. Four synthesized findings evolved from these categories: i) Older persons receiving palliative care in the community recognize that their life is changed and come to terms with their situation, redefining what is normal, appreciating life lived, and celebrating the life they still have by living one day at a time; ii) Older persons receiving palliative care in the community experience isolation and loneliness exacerbated by their detachment and withdrawal from and by others; iii) Older persons receiving palliative care in the community face major challenges managing prevailing symptoms, medication management difficulties, and costs of medical care and equipment; and iv) Older persons want to receive palliative care and to die at home; however, this requires both informal and formal supports, including continuity of care, good communication, and positive relationships with health care providers.

CONCLUSIONS

Experiences and perceptions of community palliative care vary among older adults. These are influenced by the individual's expectations and needs, available services, and cost. Older adults' input into decision-making about their care is fundamental to their needs being met and is contingent on effective communication between the patient, family, and staff across services. Policy that advocates for trained palliative care staff to provide care is necessary to optimize care outcomes, while collaboration between staff and services is critical to enabling holistic care, managing symptoms, and providing compassionate care and support.

The Impact of Continuous Use of Home Health Care Resources on End-of-Life Care at Home in Older Patients with Cancer: A Retrospective Cohort Study in Fukuoka, Japan

This study aimed at examining the effect of continued use of home health care resources on end-of-life care at home in older patients with cancer. This retrospective cohort study was conducted using medical and long-term care claims data of 6435 older patients with cancer who died between April 2016 and March 2019 in Fukuoka Prefecture. The main explanatory variables were enhanced home care support clinics and hospitals (HCSCs), enhanced HCSCs with beds, conventional HCSCs, other HCSCs, and home visit nursing care. The covariates were sex, age, required level of care, and the Charlson Comorbidity Index. A logistic regression model was used. The results of the multilevel logistic regression analysis showed that the following were significantly associated with end-of-life care at home: use of enhanced HCSCs with beds (odds ratio, OR: 8.66; 95% confidence interval, CI: [4.31-17.40]), conventional HCSCs (OR: 5.78; 95% CI: [1.86-17.94]), enhanced HCSCs (OR: 4.44; 95% CI: [1.47-13.42]), home-visit nursing care (OR: 1.86; 95% CI: [1.42-2.44]), and a severe need for care (OR: 3.89; 95% CI: [2.92-5.18]). The results suggest that the continued use of home health care resources in older patients with cancer who require out-of-hospital care may lead to increased end-of-life care at home. Particularly, use of enhanced HCSCs with beds is most strongly associated with end-of-life care at home.

Reduction in potentially inappropriate end-of-life hospital care for cancer patients during the COVID-19 pandemic: A retrospective population-based study

BACKGROUND

The COVID-19 pandemic impacted cancer diagnosis and treatment. However, little is known about end-of-life cancer care during the pandemic.

AIM

To investigate potentially inappropriate end-of-life hospital care for cancer patients before and during the COVID-19 pandemic.

DESIGN

Retrospective population-based cohort study using data from the Netherlands Cancer Registry and the Dutch National Hospital Care Registration. Potentially inappropriate care in the last month of life (chemotherapy administration, >1 emergency room contact, >1 hospitalization, hospitalization >14 days, intensive care unit admission or hospital death) was compared between four COVID-19 periods and corresponding periods in 2018/2019.

PARTICIPANTS

A total of 112,919 cancer patients (⩾18 years) who died between January 2018 and May 2021 were included.

RESULTS

Fewer patients received potentially inappropriate end-of-life care during the COVID-19 pandemic compared to previous years, especially during the first COVID-19 peak (22.4% vs 26.0%). Regression analysis showed lower odds of potentially inappropriate end-of-life care during all COVID-19 periods (between OR 0.81; 95% CI 0.74-0.88 and OR 0.92; 95% CI 0.87-0.97) after adjustment for age, sex and cancer type. For the individual indicators, fewer patients experienced multiple or long hospitalizations, intensive care unit admission or hospital death during the pandemic.

CONCLUSIONS

Cancer patients received less potentially inappropriate end-of-life care during the COVID-19 pandemic. Because several factors may have contributed, it is unclear whether this reflects better quality care. However, these findings raise important questions about what pandemic-induced changes in care practices can help provide appropriate end-of-life care for future patients in the context of increasing patient numbers and limited resources.

Dying at "home" - a qualitative study of end-of-life care in rural Northern Norway from the perspective of health care professionals

BACKGROUND

'Most patients want to die at home' is a familiar statement in palliative care. The rate of home deaths is therefore often used as a success criterion. However, providing palliative care and enabling patients to die at home in rural and remote areas may be challenging due to limited health care resources and geographical factors. In this study we explored health care professionals' experiences and reflections on providing palliative care to patients at the end of life in rural Northern Norway.

METHODS

This is a qualitative focus group and interview study in rural Northern Norway including 52 health care professionals. Five uni-professional focus group discussions were followed by five interprofessional focus group discussions and six individual interviews. Transcripts were analysed thematically.

RESULTS

Health care professionals did their utmost to fulfil patients' wishes to die at home. They described pros and cons of providing palliative care in rural communities, especially their dual roles as health care professionals and neighbours, friends or even relatives of patients. Continuity and carers' important contributions were underlined. When home death was considered difficult or impossible, nurses expressed a pragmatic attitude, and the concept of home was extended to include 'home place' in the form of local health care facilities.

CONCLUSIONS

Providing palliative care in patients' homes is professionally and ethically challenging, and health care professionals' dual roles in rural areas may lead to additional pressure. These factors need to be considered and addressed in discussions of the organization of care. Nurses' pragmatic attitude when transfer to a local health care facility was necessary underlines the importance of building on local knowledge and collaboration. Systematic use of advance care planning may be one way of facilitating discussions between patients, family carers and health care professionals with the aim of achieving mutual understanding of what is feasible in a rural context.

Prospective Study of Preferred Versus Actual Place of Death Among Swedish Palliative Cancer Patients

Background: The place of death of cancer patients is an important aspect of end-of-life care. However, little research has been conducted regarding factors that may influence the preferred and actual place of death in cancer patients and whether the patients die at their preferred place of death. In this study, we aimed to investigate the preferred and actual place of death for palliative cancer patients, and factors influencing these variables. Methods: Patients diagnosed with cancer and admitted to a palliative care team across three Swedish cities between 2019 and 2022 were asked for participation. Participants completed a questionnaire capturing sociodemographic data and preferred place of death. Further data regarding age, sex, and cancer type were collated at inclusion, and the actual place of death recorded for those deceased by 5-May-2023. Results: The study included 242 patients. A majority (79%) wanted to die at home which was the actual death location for 76% of the patients. When the place-of-death decision was made by the patient alone, 75% chose home, compared to 96% when decided jointly with relatives-a statistically significant variation (p = 0.0037). For the patients who wanted to die at home, 80% actually died at home, with insignificant disparities among subgroups. Conclusions: Most palliative cancer patients in this Swedish cohort preferred and achieved death at home. Involving relatives in decision-making may influence the preferred place of death, however larger studies are needed to comprehensively assess factors affecting the preferred and actual place of death in different subgroups of patients.

Early prediction of response to palliative chemotherapy in patients with stage-IV gastric and esophageal cancer

BACKGROUND

The goal of therapy for many patients with advanced stage malignancies, including those with metastatic gastric and esophageal cancers, is to extend overall survival while also maintaining quality of life. After weighing the risks and benefits of treatment with palliative chemotherapy (PC) with non-curative intent, many patients decide to pursue treatment. It is known that a subset of patients who are treated with PC experience significant side effects without clinically significant survival benefits from PC.

METHODS

We use data from 150 patients with stage-IV gastric and esophageal cancers to train machine learning models that predict whether a patient with stage-IV gastric or esophageal cancers would benefit from PC, in terms of increased survival duration, at very early stages of the treatment.

RESULTS

Our findings show that machine learning can predict with high accuracy whether a patient will benefit from PC at the time of diagnosis. More accurate predictions can be obtained after only two cycles of PC (i.e., about 4 weeks after diagnosis). The results from this study are promising with regard to potential improvements in quality of life for patients near the end of life and a potential overall survival benefit by optimizing systemic therapy earlier in the treatment course of patients.

Caregivers' experiences of end-of-life caregiving to severely ill relatives with cancer dying at home: A qualitative study in the Faroe Islands

BACKGROUND AND AIM

It is common among people with advanced cancer to wish to die at home, but only a few succeed in doing so. The willingness of family members to care for a person, who wants to die at home, is crucial This qualitative study aimed to provide insight into conditions that make dying at home possible in a small-scale society and to describe family caregivers' experiences of providing end-of-life care in a private home setting.

METHODS

Thirteen caregivers were interviewed, their ages varying from 39 to 84 years. A phenomenological approach, inspired by Giorgi, was applied.

RESULTS

Two essential structures captured the experience of caring at home until death: 'Managing end-of-life care' and 'meaningfulness in a time of impending death'. It was mainly the family, and especially family members with a healthcare background, together with the district nurses, who supported the caregivers in managing the care of a dying relative at home. Being able to fulfil their relative's wish to die at home and to come closer together as a family made the caregivers feel their efforts meaningful.

CONCLUSION

Our findings point to the importance of having access to home care day and night for the caregivers to feel secure during the night-time. As of now, this is only an option in larger towns in the Faroe Islands, which might also be the case in outskirts areas in other countries. Our findings also showed an unmet need for support to ease the mental load on caregivers. Establishing an outgoing interdisciplinary palliative team would help to increase the number of people who want to die at home and succeed in doing so by giving the caregivers emotional and advisory support.

Evaluating the Potential of Machine Learning and Wearable Devices in End-of-Life Care in Predicting 7-Day Death Events Among Patients With Terminal Cancer: Cohort Study

BACKGROUND

An accurate prediction of mortality in end-of-life care is crucial but presents challenges. Existing prognostic tools demonstrate moderate performance in predicting survival across various time frames, primarily in in-hospital settings and single-time evaluations. However, these tools may fail to capture the individualized and diverse trajectories of patients. Limited evidence exists regarding the use of artificial intelligence (AI) and wearable devices, specifically among patients with cancer at the end of life.

OBJECTIVE

This study aimed to investigate the potential of using wearable devices and AI to predict death events among patients with cancer at the end of life. Our hypothesis was that continuous monitoring through smartwatches can offer valuable insights into the progression of patients at the end of life and enable the prediction of changes in their condition, which could ultimately enhance personalized care, particularly in outpatient or home care settings.

METHODS

This prospective study was conducted at the National Taiwan University Hospital. Patients diagnosed with cancer and receiving end-of-life care were invited to enroll in wards, outpatient clinics, and home-based care settings. Each participant was given a smartwatch to collect physiological data, including steps taken, heart rate, sleep time, and blood oxygen saturation. Clinical assessments were conducted weekly. The participants were followed until the end of life or up to 52 weeks. With these input features, we evaluated the prediction performance of several machine learning-based classifiers and a deep neural network in 7-day death events. We used area under the receiver operating characteristic curve (AUROC), F1-score, accuracy, and specificity as evaluation metrics. A Shapley additive explanations value analysis was performed to further explore the models with good performance.

RESULTS

From September 2021 to August 2022, overall, 1657 data points were collected from 40 patients with a median survival time of 34 days, with the detection of 28 death events. Among the proposed models, extreme gradient boost (XGBoost) yielded the best result, with an AUROC of 96%, F1-score of 78.5%, accuracy of 93%, and specificity of 97% on the testing set. The Shapley additive explanations value analysis identified the average heart rate as the most important feature. Other important features included steps taken, appetite, urination status, and clinical care phase.

CONCLUSIONS

We demonstrated the successful prediction of patient deaths within the next 7 days using a combination of wearable devices and AI. Our findings highlight the potential of integrating AI and wearable technology into clinical end-of-life care, offering valuable insights and supporting clinical decision-making for personalized patient care. It is important to acknowledge that our study was conducted in a relatively small cohort; thus, further research is needed to validate our approach and assess its impact on clinical care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05054907; https://classic.clinicaltrials.gov/ct2/show/NCT05054907.

'It's not just about me': a qualitative study of couples' narratives about home death when one of the partners is dying of cancer

Background

Most cancer patients state a preference for home death. Care and support from primary caregivers are important to enable dying at home. A preference for home death from the perspective of couples has rarely been investigated.

Objectives

To explore how a preference for home death is understood and enacted in couples where one of the partners is dying of cancer.

Design

A qualitative interview research design with a narrative approach was used.

Methods

Five couples participated in dyad interviews. During the analysis, two interviews that particularly illuminated couples' shared and individual views were chosen as the primary cases.

Results

The interviews show, in two highly different ways, how a preference for home death is a significant relational matter. The interviews are presented as two cases: 'Struggles in an Unknown Terrain' and 'Reliance at the Kitchen Table'. They show how a preference for home death can be understood and enacted as a struggle or as reliance based on the couple's shared biography and the partner's ability to care for the partner during the end-of-life phase. The analysis highlighted the negotiations that underpin a preference for home death. In these negotiations, the couples drew on idealised understandings of home death. These ideas were supported by cultural values related to autonomy and independence as well as participation and citizenship. Thus, in the negotiations about being cared for and caring, legitimate dependency and the maintenance of a reciprocal relationship were balanced. The presence of healthcare professionals and medical devices in the home had to be balanced with the need to maintain a sense of self and an authentic home.

Conclusion

A relational perspective on a preference for home death made us attentive to couples' negotiations. These negotiations give couples the opportunity to re-evaluate and reconfirm individual and mutual needs in the end-of-life phase.

End of Life in Patients With Advanced Non-curable Cancer: Patient Considerations Around the Moment of Death

There is limited knowledge regarding Colombian patients with advanced cancer preferences regarding their final moments, place of death, and post-death wishes. To better understand these preferences, we conducted 23 in-depth interviews with patients between the ages of 28 and 78 receiving treatment at two academic hospitals and the National Cancer Institute. While many participants desired a peaceful death, few were comfortable discussing the topic of death directly. Some younger participants expressed an interest in euthanasia but had not received any guidance or support. While several participants preferred a home death, some expressed a desire to die in a hospital due to better symptom control. Additionally, when discussing post-death wishes, some participants expressed frustration about being unable to have these conversations with their loved ones and their preferences for funeral arrangements. Socioeconomic and geographical factors significantly impacted the wishes and preferences expressed, with many individuals hesitant to initiate difficult conversations.

Preference and actual place-of-death in advanced cancer: prospective longitudinal study

OBJECTIVES

To evaluate the preferred place-of-death (PPoD) among patients with advanced cancer over time, and the concordance between preferred and actual place-of-death.

METHODS

Prospective cohort study. A total of 190 patients with advanced cancer and their caregivers (n=190) were interviewed every 3 months, from study enrolment to 12 months (M0, M1, M2, M3, M4). PPoD data were obtained under four different end-of-life scenarios: (1) severe clinical deterioration without further specification; (2) clinical deterioration suffering from severe symptoms; (3) clinical deterioration receiving home-based visits; and (4) clinical deterioration receiving home-based visits and suffering from severe symptoms.

RESULTS

Home was the most common PPoD over time among patients in scenarios 1 (n=121, 63.7%; n=77, 68.8%; n=39, 57.4%; n=30, 62.5%; n=23, 60.5%) and 3 (n=147, 77.4%; n=87, 77.7%; n=48, 70.6%; n=36, 75.0%; n=30, 78.9%). PPoD in palliative care unit (PCU) and hospital were most frequent at baseline in scenario 2 (n=79, 41.6%; n=78, 41.1%), followed by hospital over time (n=61, 54.5%; n=45, 66.2%; n=35, 72.9%; n=28, 73.7%). During the curse of illness, 6.3% of patients change their PPoD in at least one of end-of-life scenario. About 49.7%, 30.6% and 19.7% of patients died in PCU, hospital and home, respectively. Living in rural area (OR=4.21), poor health self-perception (OR=4.49) and pain at the last days of life (OR=2.77) were associated with death in PPoD. The overall agreement between last preference and actual place-of-death was 51.0% (k=0.252).

CONCLUSION

Home death was not the preferred place for a large number of patients when this option was presented within a clinical context scenario. The PPoD and actual place-of-death were depending on the clinical situation.

Consultation-Liaison Case Conference: Suicidal Ideation in a Patient at the End-of-Life

Psychiatric comorbidities are common among patients approaching the end of life, often necessitating the involvement of consultation-liaison psychiatrists. We present the case of a patient with advanced metastatic prostate cancer and a complicated hospital course who made suicidal remarks and requested a hastened death. This common and challenging clinical scenario requires a multidisciplinary approach. In this article, experts in consultation psychiatry, palliative care, and psycho-oncology describe helpful diagnostic and therapeutic strategies for such cases. The key learning points are the differential diagnoses in end-of-life patients endorsing suicidal ideation, the psychiatric management of oncological and palliative care patients, the implementation of a safe discharge plan, and the role of the consultation-liaison psychiatrist in hospice care.

Survival Outcome and Prognostic Factors Among Patients With Hepatocellular Carcinoma: A Hospital-Based Study

Background

Hepatocellular carcinoma (HCC) is a leading cancer with very high incidence and mortality and low survival rate in Vietnam and worldwide. This study aimed to investigate the survival outcome and its prognostic factors among HCC patients.

Methods

This is a retrospective descriptive study on patients newly diagnosed with HCC at Hanoi Oncology Hospital, Vietnam from January 2018 to December 2020. Overall survival (OS) was calculated by the Kaplan-Meier method. Log-rank test and Cox regression were used to investigate the association among patients' OS and their diagnosis and treatment factors.

Results

A total of 674 patients were included. The median OS was 10.0 months. The survival rates at 6, 12, 24, and 36 months were 57.3%, 46.6%, 34.8%, and 29.7%, respectively. The initial performance status (PS), Child-Pugh score, and Barcelona Clinic Liver Cancer (BCLC) stage at the time of diagnosis are prognostic factors of HCC OS. A total of 451 (66.8%) patients have died, most of them (375 equally 83.1%) died at home, and only 76 (16.9%) died at hospital. Hepatocellular carcinoma patients living in the rural area more likely died at home than those living in the urban area (85.9% vs 74.8%, P = .007).

Conclusions

Hepatocellular carcinoma has a poor prognosis with low OS. Performance status, Child-Pugh score, and BCLC stage were the independent prognostic factors for the survival outcome of HCC patients. The fact that most HCC patients died at home suggested that home-based hospice care needs to be paid special attention.

Triggering palliative care referrals through the identification of poor prognosis in older patients presented to emergency departments in rural Australia

Background: Without objective screening for risk of death, the palliative care needs of older patients near the end of life may be unrecognised and unmet. Aim: This study aimed to estimate the usefulness of the Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL) tool in determining older patients' risk of death within 3-months after initial hospital admission. Methods: A prospective cohort study of 235 patients aged 70+ years, who presented to two rural emergency departments in two adjacent Australian states, was utilised. The 'risk of death' of each patient was screened with the CriSTAL prognostic tool. Their 3-month follow-up outcomes were assessed through telephone interviews and a clinical record review. Findings: A CriSTAL cut-off score of more than 7 yielded a sensitivity of 80.7% and specificity of 70.81% for a 3-month risk of death. Palliative care services were only used by 31% of the deceased in their last trimester of life. Conclusion: Prognostic tools provide a viable means of identifying individuals with a poor prognosis. Identification can trigger an earlier referral to palliative care, which will benefit the patient's wellbeing and quality of life.

The decision-making process of transferring patients home to die from an intensive care unit in mainland China: A qualitative study of family members' experiences

OBJECTIVES

To map the decision-making process of family members involved in transferring a critically ill patient home to die from an intensive care unit in mainland China and to explore the experiences of those family members.

DESIGN

A constructivist qualitative study.

SETTING

One hospitals intensive care unit in Southeast China.

METHODS

Thirteen adult family members (of ten patients) who participated in decision-making related to transferring a relative home to die from the intensive care unit were purposively selected. Data were collected via interviews and analysed applying thematic analysis.

FINDINGS

A two-stage decision-making process was identified. Family decision-making was mediated by factors including: accepting the impending death and hope that the patient would not die; time pressures in which decisions had to be made, and the challenges of meeting cultural expectations of a home death. Transfer home was a family-centred decision constrained by a gender-based hierarchy restricting the involvement of different family members.

CONCLUSION

The stages and key factors in the decision-making process of family members when involved in transferring a patient home to die from an intensive care unit in China are rooted and informed by cultural expectations and limits in the current healthcare system regarding end-of-life care options. Understanding the climate in which family members must make decisions will facilitate supportive interventions to be implemented by healthcare professionals. Further empirical research is needed to explore family members' needs when the patient has been transferred and dies at home in mainland China.

IMPLICATIONS FOR CLINICAL PRACTICE

Healthcare professionals need to understand the challenges family members face when deciding to transfer a relative home to die from an intensive care unit. For example time pressures can limit the choices of family members so that to provide them with timely, ongoing, realistic updates for a greater involvement of family members in generating end of life care plans could be beneficial.¹.

Timely Identification of Patients With Cancer and Family Caregivers in Need of End-of-Life Discussions by Home-Visit Nurses in Japan: A Qualitative Descriptive Study

End-of-life (EOL) discussions for patients with cancer are a key factor of successful EOL care; however, identifying the optimal timing for these discussions in Japanese home-care settings is difficult. To identify the time at which patients with cancer and their caregivers need EOL discussions, we explored when home-visit nurses start EOL discussions. We interviewed 23 home-visit nurses and analyzed the data using qualitative content analysis. Three themes were derived from the analysis. Participants identified the timing of EOL discussions as being sensitive to patients' changing health and care needs (increases in patient's total pain), changes in the family caregiver's physical or mental condition through daily care (increases in family caregiver distress), and the EOL process that patients follow (trajectory of disease). Developing a tool or in-service educational program that will enable inexperienced or new graduate home-visit nurses to implement EOL discussions at appropriate times is necessary.

Exploring Health Care Professionals' Perceptions Regarding Shared Clinical Decision-Making in Both Acute and Palliative Cancer Care

Developments in cancer care have resulted in improved survival and quality of life. Integration of acute and palliative cancer care is desirable, but not always achieved. Fragmented care is associated with sub-optimal communication and collaboration, resulting in unnecessary care transitions. The aim of this study was to explore how health care professionals, from both acute and palliative care, perceive clinical decision-making when caring for patients undergoing active cancer treatment in parallel with specialized palliative care at home.

METHODS

Qualitative explorative design, using online focus-group interviews, based on patient-cases, among health care professionals (physicians and nurses) and Framework Analysis.

RESULTS

Six online focus-group interviews were performed. Few signs of systematic integration were found, risking fragmented care, and putting the patients in a vulnerable situation. Different aspects of uncertainty related to mandates and goals-of-care impacted clinical decision-making. Organizational factors appeared to hinder mutual clinical decision-making as well as the uncertainty related to responsibilities. These uncertainties seemed to be a barrier to timely end-of-life conversations and clinical decisions on optimal care, for example, the appropriateness of transfer to acute care.

CONCLUSIONS

Lack of integration between acute and palliative care have negative consequences for patients (fragmented care), health care professionals (ethical stress), and the health care system (inadequate use of resources).

Relationships between bereaved families' decision-making regret about end-of-life care place for patients with cancer and relevant factors

Objective

Decision-making regarding end-of-life care (EOLC) place causes psychological burden on families and 70% of bereaved families have regrets. Healthcare professionals need to support families to prevent regrets. This study aims to clarify the relationship between the factors related to the decision-making methods used to choose a place of care for terminal cancer patients and the regret experienced by bereaved families.

Methods

Participants were 1110 bereaved family members of patients with cancer. The questionnaire items were as follows: the agreement between patients and their families regarding their preferred place of EOLC, decision-making methods, satisfaction with the factors involved in the decision-making processes, experience regarding communication with medical personnel, and regret experienced by the bereaved families.

Results

This analysis included 332 valid responses from 343 respondents. The regret score was significantly lower for the group wherein patients and their caregivers/families had similar preferences regarding the EOLC place (P ​< ​0.001). Regret scores were significantly higher in the physician-led decision-making group (vs. positive role group P ​= ​0.004, vs. shared role group P ​= ​0.014). The regret scores for the bereaved family members were negatively correlated with the satisfaction scores for "friend support," "relationship with doctor," "information," "explanation by doctor," "thought as oneself," and "participation in the decision" (ρ ​= ​-0.207-0.400, P ​≤ ​0.001).

Conclusions

To reduce bereaved families' regret, family members should know the patients' preferred place of EOLC, and patients and their families should be supported by physicians and nurses to understand their options and participate in the decision-making process.

The quality of end-of-life care for Danish cancer patients who have received non-specialized palliative care: a national survey using the Danish version of VOICES-SF

PURPOSE

About half of Danish patients dying from cancer have never been in contact with specialized palliative care. Non-specialized palliative care in Denmark, i.e., somatic hospital departments, community nurses, and general practitioners, has rarely been described or evaluated. We aim to assess how non-specialized palliative care was evaluated by bereaved spouses, and to test whether distress when completing the questionnaire and ratings of aspects of end-of-life care was associated with satisfaction with place of death and overall quality of end-of-life care.

METHODS

Bereaved spouses of 792 cancer patients who had received non-specialized palliative care were invited to answer the Views of Informal Carers-Evaluation of Services-Short Form (VOICES-SF) and the Hospital Anxiety and Depression Scale (HADS) 3-9 months after the patient's death.

RESULTS

A total of 280 (36%) of invited spouses participated. In the last 3 months of the patient's life, the quality of all services taken together was rated as good, excellent, or outstanding in 70% of the cases. Satisfaction was associated with respondent's current distress (p = 0.0004). Eighty percent of bereaved spouses believed that the patient had died in the right place. Satisfaction with place of death was associated with place of death (p = 0.012) and the respondent's current distress (p = 0.0016).

CONCLUSION

Satisfaction with place of death and overall quality of services was generally high but was rated lower by spouses reporting higher levels of distress when completing the questionnaire. Distress should be taken into account whenever services are evaluated by bereaved relatives.

Where do Brazilian cancer patients prefer to die? Agreement between patients and caregivers

Preferred place-of-death (PPoD) is considered an important outcome for the development of appropriate models of care and for improving health policies in countries with underdeveloped palliative care (PC) OBJECTIVES: To determine the concordance between the PPoD of a sample of Brazilian seriously-ill cancer patients and their caregivers, and its associated factors under four different end-of-life (EOL) scenarios: 1) health deterioration in the overall context; 2) health deterioration with severe and uncomfortable symptoms; 3) health deterioration receiving home-based visits as needed; 4) health deterioration receiving home-based visits as needed, when suffering severe and uncomfortable symptoms METHODS: Cross-sectional study at a large Brazilian cancer center, between February 2019 and July 2021. 190 adult cancer patients and their caregivers (n = 190) were analyzed RESULTS: Patient and/or caregiver PPoD concordance for EOL scenario one: 64% vs. 43% for death at home, 22% vs. 30% for death in a PC unit, 14% vs. 27% for death in hospital. Higher patient and/or caregiver PPoD concordance was found for death in hospital (41%; 49%) in EOL scenario two, and for death at home for scenario three (77%; 74%). Agreement coefficient was moderate for scenario two (k = 0.430; P < 0.001), and fair for EOL scenarios one, three and four (k = 0.237, P < 0.001; k = 0.296, P < 0.001; k = 0.307, P < 0.001, respectively). Associated disagreement factors were: performance status (OR:3.03), self-perceived health (OR: 6.99), marital status (OR:2.92), and hospital and/or emergency room proximity (OR:4.11). The presence of relevant persons (42.3% vs. 44.2%), followed by spirituality (38.5% vs. 27.9%) and the place-of-death (14.0% vs. 18.4%), were the most important factors in the EOL, when comparing patients and care givers opinions, respectively CONCLUSION: Low agreement between patients and caregivers on PPoD was identified. EOL clinical factors and deterioration, and PC support seem to influence PPoD.

Integration of Specialized Palliative Care with Oncological Treatment in Patients with Advanced Pancreatic Cancer

Introduction:

The incidence of pancreatic cancer is around 5 in 100,000, and the 5-year survival is poor. Pancreatic cancer patients have a high disease-specific burden of symptoms, and palliative chemotherapy has varying side effects. The American Society of Clinical Oncology (ASCO) suggests integrating specialized palliative care (SPC) with standard oncological treatment for pancreatic cancer patients at stage ≥III. This study investigated the effects of enrollment into SPC >30 days before death.

Materials and Methods:

This retrospective study included 170 patients with histopathologically verified pancreatic adenocarcinoma who received palliative chemotherapy at Skåne University Hospital and died between February 1, 2015, and December 31, 2017.

Results:

Of the 170 patients, 151 were enrolled within the SPC unit; 97 of them for >30 days before death (group A). The remainder (group B) received SPC for ≤30 days before death (n = 54) or not at all (n = 19). Patients in groups A and B lived a median of 73 and 44 days, respectively, after the last palliative chemotherapy treatment (p < 0.001), but did not differ in terms of median overall survival (11.2 months vs. 10.9 months). Death in the hospital occurred in 84% of patients never admitted to SPC and 2% of patients ever admitted to SPC.

Conclusion:

Enrollment in SPC for longer than 30 days may lower the risk of receiving futile palliative chemotherapy at the end of life, compared with patients enrolled in SPC for 30 days or less before death. Enrollment in SPC lowers the risk of dying in a hospital.

'No place like home?' A qualitative study of the experience of sense of place among cancer patients near the end of life

Only a few studies have examined the end-of-life experience in the context of the place of living and receiving care. Sense of place consists of emotional bonds, values, meaning, and symbols attached to a place. This study aimed to explore the experience of a sense of place among individuals at the end-of-life receiving care at home via home-hospice or in a hospital. In-depth semi-structured interviews were conducted with 20 cancer patients aged 31-77 near the end-of-life (prognosis of 6 months or less left to live). Data were analysed using thematic analysis. Three main themes emerged: (a) 'This is me stuck inside my body'-the sick body and the body as a place, focused on the experience of estrangement with and disappointment from the body; (b) 'In fantasy, everyone wants to be at home and die at home, but life isn't a fantasy'-the sense of home versus the hospital, focused on the sense of place towards home and hospital; and (c) 'I don't want to meet anyone or to be anywhere'-a lack of sense of place, focused on detachment from physical and social environments and loss of sense of place. The findings demonstrate the complexity of relations with the body as the centre of experience and with the care setting. In conclusion, professional awareness of experiences of sense of place is most relevant to psychosocial interventions with patients near the end-of-life and their families. Interventions focused on improving patients' sense of place should be developed to increase their peace and quality of life and death. Educating families about the various experiences related to the sense of place may foster better understanding and empathy for the person at the end-of-life and allow a more positive experience of separation and bereavement after death.

General Ward Nurses’ Self-Efficacy, Ethical Behavior, and Practice of Discharge Planning for End-Stage Cancer Patients: Path Analysis

General ward nurses play a key role in discharge planning for end-stage cancer patients. It is necessary to assess the factors regarding their practice to promote discharge planning in accordance with end-stage cancer patients’ wishes. This study aimed to investigate the relationships between general ward nurses’ practice of discharge planning for end-stage cancer patients, self-efficacy, ethical behavior, attitude, knowledge and experience, perceived skills, and perceived barriers. A total of 288 general ward nurses from nine hospitals in a city in Japan completed the questionnaire. Path analysis was conducted to test the hypotheses. The results showed that nurses’ self-efficacy, ethical behavior (do-no-harm, do-good), knowledge (experience of attending home care seminars), and perceived skills (assertiveness) were positively and directly related to the practice of discharge planning. Nursing experience and perceived skills (assertiveness) were positively associated with discharge planning practice, while perceived barriers (death discussion) and attitude (degree of leaving it to discharge planning nurses (DPNs)) were negatively associated, with self-efficacy acting as a mediator. Thus, our findings show that it is important to enhance self-efficacy and nursing ethical behavior to improve the practice of discharge planning. Accordingly, education regarding home care, assertive communication skills, death discussion, and ethics is needed for general ward nurses.

Public Health Perspective of Primary Palliative Care: A Review through the Lenses of General Practitioners

The rising trend of chronic life-threatening illnesses is accompanied by an exponential increase in serious health-related suffering. Palliative care is known to ameliorate physical and psychosocial suffering and restore quality of life. However, the contemporary challenges of palliative care delivery, such as changing demographics, social isolation, inequity in service delivery, and professionalisation of dying, have prompted many to adopt a public health approach to palliative care delivery. A more decentralised approach in which palliative care is integrated into primary care will ensure that the care is available locally to those who need it and at a cost that they can afford. General practitioners (GPs) play a pivotal role in providing primary palliative care in the community. They ensure that care is provided in alignment with patients’ and their families’ wishes along the trajectory of the life-threatening illness and at the patient’s preferred place. GPs use an interdisciplinary approach by collaborating with specialist palliative care teams and other healthcare professionals. However, they face challenges in providing end-of-life care in the community, which include identification of patients in need of palliative care, interpersonal communication, addressing patients’ and caregivers’ needs, clarity in roles and responsibilities between GPs and specialist palliative care teams, coordination of service with specialists and lack of confidence in providing palliative care in view of deficiencies in knowledge and skills in palliative care. Multiple training formats and learning styles for GPs in end-of-life care have been explored across studies. The research has yielded mixed results in terms of physician performance and patient outcomes. This calls for more research on GPs’ views on end-of-life care learning preferences, as this might inform policy and practice and facilitate future training programs in end-of-life care.

Predicting unplanned hospital readmission in palliative outpatients (PRePP) – study protocol of a longitudinal, prospective study to identify informal caregiver-related and structural predictors

Background

Although the majority of German patients in a palliative state prefer to die at home, the actual place of death is most often a hospital. Unplanned hospital readmissions (UHA) not only contradict most patients’ preferences but also increase the probability of an aggressive end-of-life treatment. As limited knowledge is available which factors contribute to an UHA, the PRePP-project aims to explore predictors related to informal caregivers (IC) as well as medical and structural factors.

Methods

This prospective, observational, mono-centric study will assess structural and medical factors as well as ICs’ psychological burden throughout seven study visits. Starting in April 2021 it will consecutively include 240 patients and their respective IC if available. Standardized measures concerning ICs’ Quality of Life (WHOQOL-BREF), psychological distress (NCCN-Distress Thermometer), anxiety (GAD-7) and depressiveness (PHQ-9) will be assessed. If participants prefer, assessment via phone, browser-based or paper-based will be conducted. Medical records will provide routinely assessed information concerning patient-related characteristics such as gender, age, duration of hospital stay and medical condition. Nurse-reported data will give information on whether hospitalization and death occurred unexpectedly. Data will be progressed pseudonymized. Multivariable regression models will help to identify predictors of the primary endpoint “unplanned hospital admissions”.

Discussion

The PRePP-project is an important prerequisite for a clinical risk assessment of UHAs. Nevertheless, it faces several methodological challenges: as it is a single center study, representativity of results is limited while social desirability might be increased as the study is partly conducted by the treatment team. Furthermore, we anticipated an underrepresentation of highly burdened participants as they might refrain from participation.

Trial registration

This study was retrospectively registered 19 October 2021 at clinicaltrials.gov (NCT05082389). https://clinicaltrials.gov/ct2/show/NCT05082389

Preferences for home care to enable home death among adult patients with cancer in late palliative phase - a grounded theory study

BACKGROUND

The wish to be cared for and to die at home is common among people with end-stage cancer in the western world. However, home deaths are declining in many countries. The aim of this study was to explore the preferences for home care over time to enable home death among adult patients with cancer in the late palliative phase.

METHODS

A qualitative method was applied according to grounded theory (Corbin & Strauss, 2008). Data was collected using individual interviews (n = 15) with nine adult patients. One to two follow up interviews were conducted with four patients. Sampling, data collection and constant comparative analysis were undertaken simultaneously.

RESULTS

The findings are presented as a conceptual model of patients' preferences for care to enable home death. The core category "Hope and trust to get the care I need to die at home" showed that the preference to die at home seemed stable over time and did not change with deterioration in health status and progression in illness. Five categories were related to the core category. The categories "being in the present", "be safe and in charge" and "be seen and acknowledged" describe the patients' preferences to live a meaningful life until death and be the same person as always. These preferences depended on the categories describing characteristics of healthcare personnel and the organisation of care: "reliable, compassionate and competent healthcare personnel" and "timely, predictive, continuous and adaptive organisation".

CONCLUSION

An important preference over time was to be here and now and to live as meaningful a life as possible until death. Moreover, the patients preferred to retain control over their lives, to be autonomous and to be seen as the person they had always been. To achieve this, person-centred care provided by healthcare personnel with competence, skills and enough/ample time were required. In addition, home care needed to be organised in a way that ensured continuity and predictability. Systematic implementation of a person-centred care model and the use of advanced home care plans with continued re-evaluation for patients' preferences of home care were proposed measures to enable home death.

Evaluation of Whole Brain Radiotherapy among Lung Cancer Patients with Brain Metastases in Relation to Health Care Level and Survival

Whole-brain radiotherapy (WBRT) as a treatment for brain metastases has been questioned over the last years. This study aimed to evaluate health care levels and survival after WBRT in a cohort of lung cancer patients with brain metastases receiving WBRT in Stockholm, Sweden, from 2008 to 2019 (n = 384). If the patients were able to come home again was estimated using logistic regression and odds ratios (OR) and survival by using Cox regression. The median age in the cohort was 65.6 years, the median survival following WBRT was 2.4 months (interquartile range (IQR) 1.2–6.2 months), and 84 (22%) patients were not able to come home after treatment. Significantly more males could come home again after WBRT compared to women (OR = 0.37, 95%CI 0.20–0.68). Patients with performance status scores WHO 3–4 had a median survival of 1.0 months, hazard ratio (HR) = 4.69 (95%CI 3.31–6.64) versus WHO score 0–1. Patients admitted to a palliative ward before WBRT had a median survival of 0.85 months, HR = 2.26 (95%CI 1.53–3.34) versus being at home. In conclusion, patients treated with WBRT had a short median survival and 20% could not be discharged from the hospital following treatment. Significantly more women did not come home again.

End-of-life intravenous chemotherapy administration patterns in the treatment of Queensland lung and pancreas cancer patients: a 10-year retrospective analysis

BACKGROUND

End-of-life (EOL) chemotherapy administration rates for solid tumours are 12-20% and are associated with a reduced quality of life, increased hospitalisation and incidence of death within an acute care facility.

AIM

We sought to determine the rate of EOL chemotherapy in government and private hospitals and determine the impact on hospitalisations and location of death in lung and pancreatic cancer patients.

METHODS

Data were obtained from the Queensland Oncology Repository between 2005 and 2014. Lung (n = 16 501) and pancreatic cancer (n = 4144) deaths were analysed. EOL chemotherapy was determined to be within 30 days of death. Demographics, location of treatment and death are reported.

RESULTS

Chemotherapy was administered to 6518 (40%) lung cancer and 1694 (41%) pancreatic cancer patients. A total of 1474 (9%) and 477 (12%) patients, respectively, received EOL chemotherapy. EOL chemotherapy was more common in males and those with distant metastatic disease, while less likely in the elderly and those with a lower socioeconomic status. EOL chemotherapy was more prevalent in large hospitals and was more common in private compared with government hospitals for pancreatic cancer (30 vs 26%; P < 0.001), while it was similar for lung cancer (24 vs 22%; P = 0.115). Death after EOL chemotherapy compared with all cancer deaths was more common in an acute care facility (lung cancer: 60 vs 37%; P < 0.001; pancreatic cancer: 53 vs 36%; P < 0.001).

CONCLUSIONS

EOL chemotherapy rates were similar to Australian yet marginally lower than international rates, with variation dependent on the size and type of facility and increased the rate of deaths within an acute care facility.

The quality of end of life care for Danish cancer patients who have received specialized palliative: a national survey using the Danish version of VOICES-SF

BACKGROUND

National recommendations state that Danish patients with complex palliative needs should have access to specialized palliative care but little is known about the perceived quality of this care or end of life care in general.

AIM

To assess how end of life care was evaluated by the bereaved spouses and to investigate whether the perceived quality was associated with (1) quantity of specialized palliative care provided, (2) place of death, and (3) emotional state when completing the questionnaire.

DESIGN

The bereaved spouses of 1584 cancer patients who had received specialized palliative care were invited to answer the Views Of Informal Carers - Evaluation of Services - Short Form (VOICES-SF) and the Hospital Anxiety and Depression Scale (HADS) approximately 3-9 months after the patient's death.

RESULTS

A total of 787 (50%) of the invited spouses participated. In the last 3 months of the patient's life, the quality of all services taken together was rated as good, excellent, or outstanding in 83% of the cases and it was significantly associated with place of death (p = 0.0051, fewest considered it "fair" or "poor" if the patient died at home). In total, 93% reported that the patient died at the right place although only 74% died at the patient's preferred place. Higher levels of anxiety (p = 0.01) but not depression at the time of questionnaire completion was associated with lower satisfaction with the overall quality of care.

CONCLUSION

The quality of care was rated very highly by bereaved spouses of patients receiving specialized palliative care.

Levels and Determinants of Place-Of-Death Congruence in Palliative Patients: A Systematic Review

Introduction: Congruence, understood as the agreement between the patient's preferred place of death and their actual place of death, is emerging as one of the main variables indicating the quality of end-of-life care. The aim of this research was to conduct a systematic literature review on levels and determinants of congruence in palliative patients over the period 2010-2021. Method: A systematic review of the literature in the databases of PubMed, Scopus, Web of Science, PsycINFO, CINAHL, Cuiden, the Cochrane Library, CSIC Indexes, and IBECS. Information was extracted on research characteristics, congruence, and associated factors. Results: A total of 30 studies were identified, mainly of retrospective observational design. The congruence values varied substantially between the various studies, ranging from 21 to 100%. The main predictors of congruence include illness-related factors (functional status, treatments and diagnosis), individual factors (age, gender, marital status, and end of life preferences), and environmental factors (place of residence, availability of health, and palliative care services). Conclusion: This review, in comparison with previous studies, shows that treatment-related factors such as physical pain control, marital status, having a non-working relative, age, discussing preferred place of death with a healthcare professional, and caregiver's preference have been associated with higher levels of congruence. Depending on the study, other factors have been associated with either higher or lower congruence, such as the patient's diagnosis, gender, or place of residence. This information is useful for designing interventions aimed towards greater congruence at the end of life.

Delivering end-of-life care for patients with cancer at home: Interviews exploring the views and experiences of general practitioners

Many patients with terminal cancer wish to die at home and general practitioners in the United Kingdom have a critical role in providing this care. However, it has been suggested general practitioners lack confidence in end-of-life care. It is important to explore with general practitioners their experience and perspectives including feelings of confidence delivering end-of-life care to people with cancer. The aim of this study was to explore general practitioners experiences of providing end-of-life care for people with cancer in the home setting and their perceptions of confidence in this role as well as understanding implications this has on policy design. A qualitative study design was employed using semi-structured interviews and analysed using thematic analysis. Nineteen general practitioners from London were purposively sampled from eight general practices and a primary care university department in 2018-2019, supplemented with snowballing methods. Five main themes were constructed: (a) the subjective nature of defining palliative and end-of-life care; (b) importance of communication and managing expectations; (c) complexity in prescribing; (d) challenging nature of delivering end-of-life care; (e) the unclear role of primary care in palliative care. General practitioners viewed end-of-life care as challenging; specific difficulties surrounded communication and prescribing. These challenges coupled with a poorly defined role created a spread in perceived confidence. Experience and exposure were seen as enabling confidence. Specialist palliative care service expansion had important implications on deskilling of essential competencies and reducing confidence levels in general practitioners. This feeds into a complex cycle of causation, leading to further delegation of care.

Effectiveness of the Online Daily Diary (ONDIARY) program on family caregivers of advanced cancer patients: A home-based palliative care trial

OBJECTIVES

There are many effective palliative care programs for patients with advanced cancer. However, little is known about effective programs for family caregivers of patients with advanced cancer, especially in home-based palliative care settings. This study aimed to determine the effect of the Online Daily Diary (ONDIARY) program on the quality of life (QOL) of family caregivers of patients with advanced cancer in home-based palliative care settings.

METHODS

This study used a quasi-experimental design with a control group. The sample comprised 60 family caregivers (intervention group n = 30, control group n = 30) of patients with advanced cancer receiving home-based palliative care. The intervention group was assigned to the ONDIARY program in addition to usual care, and the control group was assigned to usual care. Group allocation was not randomized. The ONDIARY program is a 7-day online diary intervention program that aims to enhance emotional competence. Outcome measures were feasibility assessment, and primary and secondary outcome assessment. Primary and secondary outcome measures were the Caregiver Quality of Life Index-Cancer (CQOLC) and the six-item Kessler Psychological Distress Scale (K6). Repeated measures analysis of variance was performed on each measure, with group and group × time interactions.

RESULTS

There was a significant group × time interaction in CQOLC scores (F = 9.324, P = 0.003). The CQOLC scores of family caregivers in the intervention group were maintained after the intervention, whereas those in the control group declined. There was no significant difference in K6 scores between the two groups.

CONCLUSION

The results suggest that the ONDIARY program in addition to usual care has potential to be effective in preventing decline and maintaining QOL of family caregivers of patients with advanced cancer in home-based palliative care settings.

Patterns of stress and support in social support networks of in-home hospice cancer family caregivers

Family caregivers of home hospice cancer patients often experience burden and distress, which can be mitigated by perceived social support. However, less attention has been paid to the non-family sources of support within social networks, or to how sources of support may also be sources of stress. We describe support and stress in social networks of hospice family caregivers and identify caregiving characteristics associated with classes identified in our data. We collected demographic and psychosocial self-report data from family caregivers providing in-home hospice care for advanced cancer patients (N = 90). Caregivers also reported perceived support and stress from specific family and non-family relationships. We identified three classes with unique patterns of stress and support within caregivers' support networks using a latent class analysis. Classes include: 1) high support, low stress across family and non-family network members ("supportive"; 53% of caregivers); 2) high support, high stress across family and non-family network ("ambivalent maximizers"; 26%); and 3) high support, high stress across family network only ("family-focused ambivalent"; 21%). Caregivers in the ambivalent maximizer class reported more burden than caregivers in the supportive class (p = .024). This is one of the first studies to systematically explore the role of non-family support, as well as how stress and support co-occur within relationships and across networks. As informal support networks of hospice family caregivers are complex and multifaceted, understanding the patterns of support and stress across various network members is essential to offer services to more effectively manage caregiver burden.

End-of-Life Care in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation

Background: Patients receiving allogeneic hematopoietic cell transplantation (HCT) have high morbidity and mortality risk, but literature is limited on factors associated with end-of-life (EOL) care intensity. Objectives: Describe EOL care in patients after allogeneic HCT and examine association of patient and clinical characteristics with intense EOL care. Design: Retrospective chart review. Setting/Subjects: A total of 113 patients who received allogeneic HCT at Mayo Clinic Arizona between 2013 and 2017 and died before November 2019. Measurements: A composite EOL care intensity measure included five markers: (1) no hospice enrollment, (2) intensive care unit (ICU) stay in the last month, (3) hospitalization >14 days in last month, (4) chemotherapy use in the last two weeks, and (5) cardiopulmonary resuscitation, hemodialysis, or mechanical ventilation in the last week of life. Multivariable logistic regression modeling assessed associations of having ≥1 intensity marker with sociodemographic and disease characteristics, palliative care consultation, and advance directive documentation. Results: Seventy-six percent of patients in our cohort had ≥1 intensity marker, with 43% receiving ICU care in the last month of life. Median hospital stay in the last month of life was 15 days. Sixty-five percent of patients died in hospice; median enrollment was 4 days. Patients with higher education were less likely to have ≥1 intensity marker (odds ratio 0.28, p = 0.02). Patients who died >100 days after HCT were less likely to have ≥1 intensity marker than patients who died ≤100 days of HCT (p = 0.04). Conclusions: Death within 100 days of HCT and lower educational attainment were associated with higher likelihood of intense EOL care.

Symptom Prevalence and Place of Death Preference in Advanced Cancer Patients: Factors Associated With the Achievement of Home Death

Objectives:

Achievement of patients’ preferred place of death is recognized as a component of a good death. This study aimed to investigate the symptom burden in advanced cancer patients, achievement of their place of death preferences and factors associated with home death.

Methods:

In this retrospective review of 287 patient deaths, we examined patients’ symptom prevalence, preferred and actual place of death and achievement of their place of death preferences using descriptive statistics. Associations between patient factors, home death preference and actual home death were further analyzed using multivariate logistic regression.

Results:

The most prevalent symptoms were weakness, pain and poor appetite, with a mean of 5.77(SD: 2.37) symptoms per patient. The median interval from palliative care referral to death was 21 (IQR: 74) days. Of the 253 patients with documented place of death preference, 132 (52.1%) preferred home death, 111(43.9%) preferred hospital death, 1 (0.4%) preferred to die at a temple and 9(3.6%) expressed no preference. Overall, 221 of 241(91.7%) patients with known actual place of death achieved their preference. Older patients were more likely to prefer home death (OR 1.021; 95% CI 1.004-1.039, p = 0.018) and die at home (OR 1.023; 95% CI 1.005-1.041, p = 0.014). Gender, marital status, cancer diagnosis and symptoms were not associated with preference for or actual home death.

Conclusion:

Despite a high symptom burden, most patients preferred and achieved a home death. Late palliative care referral and difficult symptom management contributed to failure to fulfill home death preference. Preference for home death should be considered when managing terminally ill geriatric patients.

Healthcare professionals' perspectives of patient and family preferences of patient place of death: a qualitative study

BACKGROUND

Home death is one of the key performance indicators of the quality of palliative care service delivery. Such a measure has direct implications on everyone involved at the end of life of a dying patient, including a patient's carers and healthcare professionals. There are no studies that focus on the views of the team of integrated inpatient and community palliative care service staff on the issue of preference of place of death of their patients. This study addresses that gap.

METHODS

Thirty-eight participants from five disciplines in two South Australian (SA) public hospitals working within a multidisciplinary inpatient and community integrated specialist palliative care service, participated in audio-recorded focus groups and one-on-one interviews. Data were transcribed and thematically analysed.

RESULTS

Two major and five minor themes were identified. The first theme focused on the role of healthcare professionals in decisions regarding place of death, and consisted of two minor themes, that healthcare professionals act to: a) mediate conversations between patient and carer; and b) adjust expectations and facilitate informed choice. The second theme, healthcare professionals' perspectives on the preference of place of death, comprised three minor themes, identifying: a) the characteristics of the preferred place of death; b) home as a romanticised place of death; and c) the implications of idealising home death.

CONCLUSION

Healthcare professionals support and actively influence the decision-making of patients and family regarding preference of place of death whilst acting to protect the relationship between the patient and their family/carer. Further, according to healthcare professionals, home is neither always the most preferred nor the ideal place for death. Therefore, branding home death as the ideal and hospital death as a failure sets up families/carers to feel guilty if a home death is not achieved and undermines the need for and appropriateness of death in institutionalised settings.

Health care utilization at end of life among patients with lung or pancreatic cancer. Comparison between two Swedish cohorts

Objectives

The purpose was to analyze trends in intensity of care at End-of-life (EOL), in two cohorts of patients with lung or pancreatic cancer.

Setting

We used population-based registry data on health care utilization to describe proportions and intensity of care at EOL comparing the two cohorts (deceased in the years of 2010 and 2017 respectively) in the region of Stockholm, Sweden.

Primary and secondary outcomes

Main outcomes were intensity of care during the last 30 days of life; systemic anticancer treatment (SACT), emergency department (ED) visits, length of stay (LOS) > 14 days, intensive care (ICU), death at acute care hospital and lack of referral to specialized palliative care (SPC) at home. The secondary outcomes were outpatient visits, place of death and hospitalizations, as well as radiotherapy and major surgery.

A multivariable logistic regression analysis was used for associations. A moderation variable was added to assess for the effect of SPC at home between the cohorts.

Results

Intensity of care at EOL increased over time between the cohorts, especially use of SACT, increased with 10%, p<0.001, (n = 102/754 = 14% to n = 236/972 = 24%), ED visits with 7%, p<0.001, (n = 25/754 = 3% to n = 100/972 = 10%) and ICU care, 2%, p = 0.04, (n = 12/754 = 2% to n = 38/972 = 4%). High intensity of care at EOL were more likely among patients with lung cancer. The difference in use of SACT between the years, was moderated by SPC, with an increase of SACT, unstandardized coefficient β; 0.87, SE = 0.27, p = 0.001, as well as the difference between the years in death at acute care hospitals, that decreased (β = 0.69, SE = 0.26, p = 0.007).

Conclusion

These findings underscore an increase of several aspects regarding intensity of care at EOL, and a need for further exploration of the optimal organization of EOL care. Our results indicate fragmentation of care and a need to better organize and coordinate care for vulnerable patients.

Transferring home to die from critical care units: A scoping review of international practices

PURPOSE

To identify and characterise the international practices of transferring a dying patient home to die from critical care units.

MATERIALS AND METHODS

A systematic scoping review following the Joanne Briggs Institute methodology was applied searching fifteen data sources to identify papers published in English and Chinese from 1970 to 2019.

RESULTS

Of the 28 papers meeting eligibility criteria 19 were published in the West and seven in China. The number of patients being transferred home to die was larger in China (74/184-96/159) than in the West (1-7). Clinical characteristics of patients transferred included: consciousness, with or without intubation and ventilation, and clinical stability. Reported key barriers to transfer included: Lack of evidence guiding transfer practice, the CCU environment and culture, Practical and logistical factors and Family members expectations and reactions. Key facilitators of transfer were reported as: Engagement with the multidisciplinary team and Personal patient and family wishes.

CONCLUSIONS

Transferring patients home to die from critical care is a complex practice varying significantly across countries. Further research to address current knowledge gaps is important to inform policy and practice.

Socioeconomy as a prognostic factor for location of death in Swedish palliative cancer patients

Background

An important aspect of end-of-life care is the place of death. A majority of cancer patients prefer home death to hospital death. At the same time, the actual location of death is often against patient’s last-known wish. The aim of this study was to analyze whether socioeconomic factors influence if Swedish palliative cancer patients die at home or at a hospital. There is no previous study on location of death encompassing several years in Swedish cancer patients.

Methods

Data was collected from the Swedish Register of Palliative Care for patients diagnosed with brain tumor, lung, colorectal, prostate or breast cancer recorded between 2011 and 2014. The data was linked to the Swedish Cancer Register, the Cause of Death Register and the Longitudinal Integration Database for health-insurance and labor-market studies. A total of 8990 patients were included.

Results

We found that marital status was the factor that seemed to affect the place of death. Lack of a partner, compared to being married, was associated with a higher likelihood of dying at a hospital.

Conclusion

Our findings are in line with similar earlier studies encompassing only 1 year and based on patients in other countries. Whether inequalities at least partly explain the differences remains to be investigated. Patients dying of cancer in Sweden, who do not have a life partner, may not have the option of dying at home due to lack of informal support. Perhaps the need of extensive community support services to enable home death have to improve, and further studies are warranted to answer this question.

Preferred and actual place of death in haematological malignancies: a report from the UK haematological malignancy research network

OBJECTIVES

Hospital death is comparatively common in people with haematological cancers, but little is known about patient preferences. This study investigated actual and preferred place of death, concurrence between these and characteristics of preferred place discussions.

METHODS

Set within a population-based haematological malignancy patient cohort, adults (≥18 years) diagnosed 2004-2012 who died 2011-2012 were included (n=963). Data were obtained via routine linkages (date, place and cause of death) and abstraction of hospital records (diagnosis, demographics, preferred place discussions). Logistic regression investigated associations between patient and clinical factors and place of death, and factors associated with the likelihood of having a preferred place discussion.

RESULTS

Of 892 patients (92.6%) alive 2 weeks after diagnosis, 58.0% subsequently died in hospital (home, 20.0%; care home, 11.9%; hospice, 10.2%). A preferred place discussion was documented for 453 patients (50.8%). Discussions were more likely in women (p=0.003), those referred to specialist palliative care (p<0.001), and where cause of death was haematological cancer (p<0.001); and less likely in those living in deprived areas (p=0.005). Patients with a discussion were significantly (p<0.05) less likely to die in hospital. Last recorded preferences were: home (40.6%), hospice (18.1%), hospital (17.7%) and care home (14.1%); two-thirds died in their final preferred place. Multiple discussions occurred for 58.3% of the 453, with preferences varying by proximity to death and participants in the discussion.

CONCLUSION

Challenges remain in ensuring that patients are supported to have meaningful end-of-life discussions, with healthcare services that are able to respond to changing decisions over time.

A qualitative study of bereaved family caregivers: feeling of security, facilitators and barriers for rural home care and death for persons with advanced cancer

BACKGROUND

For cancer patients and their family, an important factor that determines the choice to die at home is the caregivers' feeling of security when caring for the patient at home. Support to caregivers from healthcare professionals is important for the feeling of security. In rural areas, long distances and variable infrastructure may influence on access to healthcare services. This study explored factors that determined the security of caregivers of patients with advanced cancer who cared for the patients at home at the end of life in the rural region of Sogn og Fjordane in Norway, and what factors that facilitated home death.

METHODS

A qualitative study using semi-structured in-depth interviews with bereaved with experience from caring for cancer patients at home at the end of life was performed. Meaning units were extracted from the transcribed interviews and divided into categories and subcategories using Kvale and Brinkmann's qualitative method for analysis.

RESULTS

Ten bereaved caregivers from nine families where recruited. Five had lived together with the deceased. Three main categories of factors contributing to security emerged from the analysis: "Personal factors", "Healthcare professionals" and "Organization" of healthcare. Healthcare professionals and the organization of healthcare services contributed most to the feeling of security.

CONCLUSION

Good competence in palliative care among healthcare professionals caring for patients with advanced cancer at home and well- organized palliative care services with defined responsibilities provided security to caregivers caring for advanced cancer patients at home in Sogn og Fjordane.

Where Do Cancer Patients in Receipt of Home-Based Palliative Care Prefer to Die and What Are the Determinants of a Preference for a Home Death?

Understanding the preferred place of death may assist to organize and deliver palliative health care services. The study aims to assess preference for place of death among cancer patients in receipt of home-based palliative care, and to determine the variables that affect their preference for a home death. A prospective cohort design was carried out from July 2010 to August 2012. Over the course of their palliative care trajectory, a total of 303 family caregivers of cancer patients were interviewed. Multivariate regression analysis was employed to assess the determinants of a preferred home death. The majority (65%) of patients had a preference of home death. The intensity of home-based physician visits and home-based personal support worker (PSW) care promotes a preference for a home death. Married patients, patients receiving post-graduate education and patients with higher Palliative Performance Scale (PPS) scores were more likely to have a preference of home death. Patients reduced the likelihood of preferring a home death when their family caregiver had high burden. This study suggests that the majority of cancer patients have a preference of home death. Health mangers and policy makers have the potential to develop policies that facilitate those preferences.

Late decisions about treatment limitation in patients with cancer: empirical analysis of end-of-life practices in a haematology and oncology unit at a German university hospital

Background

Decisions to limit treatment (DLTs) are important to protect patients from overtreatment but constitute one of the most ethically challenging situations in oncology practice. In the Ethics Policy for Advance Care Planning and Limiting Treatment study (EPAL), we examined how often DLT preceded a patient’s death and how early they were determined before (T1) and after (T2) the implementation of an intrainstitutional ethics policy on DLT.

Methods

This prospective quantitative study recruited 1.134 patients with haematological/oncological neoplasia in a period of 2×6 months at the University Hospital of Munich, Germany. Information on admissions, discharges, diagnosis, age, DLT, date and place of death, and time span between the initial determination of a DLT and the death of a patient was recorded using a standardised form.

Results

Overall, for 21% (n=236) of the 1.134 patients, a DLT was made. After implementation of the policy, the proportion decreased (26% T1/16% T2). However, the decisions were more comprehensive, including more often the combination of ‘Do not resuscitate’ and ‘no intense care unit’ (44% T1/64% T2). The median time between the determination of a DLT and the patient’s death was similarly short with 6 days at a regular ward (each T1/T2) and 10.5/9 (T1/T2) days at a palliative care unit. For patients with solid tumours, the DLTs were made earlier at both regular and palliative care units than for the deceased with haematological neoplasia.

Conclusion

Our results show that an ethics policy on DLT could sensitise for treatment limitations in terms of frequency and extension but had no significant impact on timing of DLT. Since patients with haematological malignancies tend to undergo intensive therapy more often during their last days than patients with solid tumours, special attention needs to be paid to this group. To support timely discussions, we recommend the concept of advance care planning.