Factors associated with emergency services use in Taiwanese advanced cancer patients receiving palliative home care services during out-of-hours periods: a retrospective medical record study

Reasons to Access the Emergency Department by Patients Who Receive Palliative Home Care: A Scoping Review

BACKGROUND

The progressive aging of society has increased the prevalence of chronic, incurable diseases, creating a critical need for palliative care programs. Palliative home care services are essential for patients facing severe symptoms and barriers to accessing health care facilities. Despite this, many patients receiving palliative home care services still access emergency departments (EDs).

OBJECTIVES

This scoping review aimed to investigate ED visits among patients under palliative home care services, examining factors influencing access, patient characteristics, and leading reasons for ED visits.

METHODS

A scoping review was conducted by performing a systematic search of Scopus, PubMed, CINAHL, and PsycINFO between 2013 and 2024. Studies focusing on emergency access among adult patients older than 18 years cared for by a palliative home care service were included.

RESULTS

Eight retrospective studies across Italy, China, Canada, Australia, and Ireland were included. The studies revealed significant variability in ED visit rates, ranging from 8.6% to 69.15%, with cancer as the predominant diagnosis among patients. Dyspnea, pain, and fever were commonly cited reasons for ED visits, indicating potential gaps in symptom management at home.

DISCUSSION

The review highlights the importance of early enrollment in palliative home care services, multidisciplinary care, and better caregiver education to reduce unnecessary ED visits. The findings underscore the need for further research on predictive factors, avoidable versus unavoidable ED visits, and strategies for optimizing home-based palliative care to enhance patient outcomes and quality of life.

Understanding oncologic emergencies and related emergency department visits and hospitalizations: a systematic review

BACKGROUND

Patients with cancer frequently visit the emergency department (ED) and are at high risk for hospitalization due to severe illness from cancer progression or treatment side effects. With an aging population and rising cancer incidence rates worldwide, it is crucial to understand how EDs and other acute care venues manage oncologic emergencies. Insights from other nations and health systems may inform resources necessary for optimal ED management and novel care delivery pathways. We described clinical management of oncologic emergencies and their contribution to ED visits and hospitalizations worldwide.

METHODS

We performed a systematic review of peer-reviewed original research studies published in the English language between January 1st, 2003, to December 31st, 2022, garnered from PubMed, Web of Science, and EMBASE. We included all studies investigating adult (≥ 18 years) cancer patients with emergency visits. We examined chief complaints or predictors of ED use that explicitly defined oncologic emergencies.

RESULTS

The search strategy yielded 49 articles addressing cancer-related emergency visits. Most publications reported single-site studies (n = 34/49), with approximately even distribution across clinical settings- ED (n = 22/49) and acute care hospital/ICU (n = 27/49). The number of patient observations varied widely among the published studies (range: 9 - 87,555 patients), with most studies not specifying the cancer type (n = 33/49), stage (n = 41/49), or treatment type (n = 36/49). Most studies (n = 31/49) examined patients aged ≥ 60 years. Infection was the most common oncologic emergency documented (n = 22/49), followed by pain (n = 20/49), dyspnea (n = 19/49), and gastrointestinal (GI) symptoms (n = 17/49). Interventions within the ED or hospital ranged from pharmacological management with opioids (n = 11/49), antibiotics (n = 9/49), corticosteroids (n = 5/49), and invasive procedures (e.g., palliative stenting; n = 13/49) or surgical interventions (n = 2/49).

CONCLUSION

Limited research specifically addresses oncologic emergencies despite the international prevalence of ED presentations among cancer patients. Patients with cancer presenting to the ED appear to have a variety of complaints which could result from their cancers and thus may require tailored diagnostic and intervention pathways to provide optimal acute care. Further acute geriatric oncology research may clarify the optimal management strategies to improve the outcomes for this vulnerable patient population.

The Economic Cost of Nursing Care of Palliative Patients in the Emergency Department

(1) Background: The economic cost of nursing care to palliative patients in avoidable hospital admission is unknown. (2) Methods: An observational, retrospective, and analytical study was used encompassing the economic cost of nursing care in a general hospital emergency department that uses descriptive and inferential statistical analysis. (3) Results: We have a sample of 273 palliative patients in preventable hospital admissions (76.3%, CI 95%: 71.7-80.8), deceased, in 2019. With a median of 84 years, about 80% were admitted home after 5 h of complaints, mainly due to respiratory symptoms. Patients remained for approximately 24 h in the emergency department, totaling a median of EUR 180.98 in nursing care costs per admission. (4) Conclusions: It was evident that with the knowledge obtained about palliative economic nursing costs, we could increase results, manage resources, and consolidate PC integration in health systems, as this study proved. This study was not registered.

Community out-of-hours palliative care - 'It's a patchwork of services': A qualitative study exploring care provision

BACKGROUND

People in receipt of community palliative care usually receive care from a range of services and require access to care 24/7. However, care outside of normal working hours varies, with little understanding of which models of care are optimal.

AIM

To identify and characterise current models of out-of-hours community palliative care in the UK and explore healthcare professionals' views on the barriers and facilitators to providing high quality community out-of-hours care.

DESIGN

Exploratory qualitative study using semi-structured interviews, analysed using reflexive thematic analysis.

SETTING AND PARTICIPANTS

We recruited 39 healthcare professionals from 20 geographic areas. Participants were service leads from community palliative care, district/community nursing and primary care providers.

RESULTS

Four overarching models of out-of-hours palliative care identified, characterised by levels of integration between services, balance between generalist and specialist providers, availability of care and type of care provided (hands-on clinical care/ advisory care). Analysis of barriers and facilitators generated three themes: (1) 'It's never one service': challenges of coordination of care across multiple services, (2) Need for timely skilled management of distressing symptoms, (3) 'We're just plugging gaps': prioritising patient care within limited resources. Patterns within the themes varied across the four models.

CONCLUSION

This study identifies key characteristics of four common models of out-of-hours palliative care, from the perspectives of professionals. Facilitators of high quality out-of-hours care include: a palliative care specific single point of access for patients; formal structures to integrate generalist/specialist services; and timely/skilled management of symptoms. We provide recommendations for a potential model incorporating these factors.

Outcomes of Specialist Palliative Care Consultation for Patients with Advanced Cancer in an Oncological Emergency Department: A Retrospective Analysis

Objectives

Research on palliative care (PC) consultation and its outcomes in the emergency department (ED) within a low-and middle-income country (LMIC) setting is limited. This study aimed to evaluate PC consultation outcomes, symptom burden and management, and referral patterns in patients with advanced cancer referred for specialist PC (SPC) in the ED of an urban tertiary care cancer centre in India.

Materials and Methods

Data of adult advanced cancer patients referred for SPC services in the ED between August 2017 and June 2019 were retrospectively screened. Patients' sociodemographic features, clinical characteristics, ED visit-related data, and treatment-related data were documented. Multinomial logistic regression, incorporating significant univariate factors, was performed to analyse the independent predictive factors of consultation outcomes in the ED.

Results

Of the 644 consultations, 366 (56.8%) were discharged home, 166 (25.8%) were admitted to various settings (hospital/respite care/hospice), 74 (11.5%) died in the ED, and 38 (5.9%) were unresponsive upon arrival. Sex, performance status (PS), gastrointestinal and cardiovascular events, pain, cancer progression, and receipt of pharmacological treatment were predictive of consultation outcomes. Male patients and those with poor PS were more likely to be admitted to the ED, whereas patients with poor PS and cancer progression were more likely to die. Discharge rates were higher among females, those with gastrointestinal symptoms and pain, and those receiving pharmacological treatment.

Conclusion

More than 50% of the patients referred for SPC consultations were discharged. In addition, we also identified predictors for each consultation outcome in the LMIC-ED setting. Future research should investigate advanced care planning and survival analyses in comparable ED settings.

Avoidable emergency admissions: defining the concept

BACKGROUND

The transfer of end-of-life patients to hospital via admission to an emergency service mainly happens because of a lack of community support nearby and a lack of resources in palliative care.

AIMS

This study aimed to define the concept of avoidable admission to an emergency department for palliative patients.

METHODS

An integrative literature review was performed. The results of this were put to a panel of palliative care experts via a Delphi process to determine their consensus and agreement with the statements.

FINDINGS

The results of the two-step Delphi process reached a high level of consensus and agreement that patients with palliative needs accompanied by home palliative care teams should not go to the emergency department. There was a low level of consensus and agreement about the appropriate admission of a patient in pain in the absence of any information about previous community support.

CONCLUSION

The findings allowed the definition of an 'avoidable emergency admission', which is an emergency admission for any symptom or condition that could be supported in a home context or primary health care, or any emergency admission that does not require immediate nursing or medical intervention, nor leads to greater comfort or quality of life for the patient.

Trend analysis of quality indicators in palliative home care among terminally ill cancer and non-cancer patients in Taiwan: a 6-year observational study

PURPOSE

Palliative home care services (PHCS) have been emerging for years. However, limited data exist regarding quality indicators for pain control, unplanned hospital readmissions, and household deaths among terminal cancer and non-cancer patients receiving PHCS.

METHODS

We conducted a retrospective collection and recording of data from 1242 terminally ill cancer and non-cancer patients receiving PHCS. The data were obtained from the Hospice-Palliative Clinical Database (HPCD) of Taichung Veterans General Hospital (TCVGH) for the period from 2016 to 2021. T test and chi-square test were applied for characteristics and the quality indicators among cancer and non-cancer groups. Chi-square test was used for trend analysis of the number of patients receiving PHCS and the quality indicators among cancer and non-cancer groups throughout the study period.

RESULTS

A total of 1242 terminally ill cancer and non-cancer patients who had received PHCS were documented by TCVGH from the years 2016 to 2021, including 221 non-cancer patients and 1021 cancer patients having an average age of 70. The number of terminally ill cancer and non-cancer patients receiving PHCS has increased annually since 2016. Another finding was that age was a statistically significant factor impacting quality indicators. On the other hand, compared to non-cancer patients, cancer patients had a higher likelihood of receiving treatment with analgesics when needed. Their odds of needing analgesics more than three times within 4 days after PHCS enrollment were significantly elevated [OR 4.188, 95% CI (1.002, 17.51)].

CONCLUSION

The results of this 6-year observational study indicate a substantial increase in the number of terminal cancer and non-cancer patients receiving PHCS over the past decade. Furthermore, aging plays an important role in life quality of terminal cancer and non-cancer patients.

Does Hospitalist Care Enhance Palliative Care and Reduce Aggressive Treatments for Terminally Ill Patients? A Propensity Score-Matched Study

BACKGROUND

Information on the use of palliative care and aggressive treatments for terminally ill patients who receive care from hospitalists is limited.

METHODS

This three-year, retrospective, case-control study was conducted at an academic medical center in Taiwan. Among 7037 patients who died in the hospital, 41.7% had a primary diagnosis of cancer. A total of 815 deceased patients who received hospitalist care before death were compared with 3260 patients who received non-hospitalist care after matching for age, gender, catastrophic illness, and Charlson comorbidity score. Regression models with generalized estimating equations were performed.

RESULTS

Patients who received hospitalist care before death, compared to those who did not, had a higher probability of palliative care consultation (odds ratio (OR) = 3.41, 95% confidence interval (CI): 2.63-4.41), and a lower probability to undergo invasive mechanical ventilation (OR = 0.13, 95% CI: 0.10-0.17), tracheostomy (OR = 0.14, 95% CI: 0.06-0.31), hemodialysis (OR = 0.70, 95% CI: 0.55-0.89), surgery (OR = 0.25, 95% CI: 0.19-0.31), and intensive care unit admission (OR = 0.11, 95% CI: 0.08-0.14). Hospitalist care was associated with reductions in length of stay (coefficient (B) = -0.54, 95% CI: -0.62--0.46) and daily medical costs.

CONCLUSIONS

Hospitalist care is associated with an improved palliative consultation rate and reduced life-sustaining treatments before death.

How is community based 'out-of-hours' care provided to patients with advanced illness near the end of life: A systematic review of care provision

BACKGROUND

Deaths in the community are increasing. However, community palliative care out-of-hours is variable. We lack detailed understanding of how care is provided out-of-hours and the associated outcomes.

AIM

To review systematically the components, outcomes and economic evaluation of community-based 'out-of-hours' care for patients near the end of life and their families.

DESIGN

Mixed method systematic narrative review. Narrative synthesis, development and application of a typology to categorise out-of-hours provision. Qualitative data were synthesised thematically and integrated at the level of interpretation and reporting.

DATA SOURCES

Systematic review searching; MEDLINE, EMBASE, PsycINFO, CINAHL from January 1990 to 1st August 2022.

RESULTS

About 64 publications from 54 studies were synthesised (from 9259 retrieved). Two main themes were identified: (1) importance of being known to a service and (2) high-quality coordination of care. A typology of out-of-hours service provision was constructed using three overarching dimensions (service times, focus of team delivering the care and type of care delivered) resulting in 15 categories of care. Only nine papers were randomised control trials or controlled cohorts reporting outcomes. Evidence on effectiveness was apparent for providing 24/7 specialist palliative care with both hands-on clinical care and advisory care. Only nine publications reported economic evaluation.

CONCLUSIONS

The typological framework allows models of out-of-hours care to be systematically defined and compared. We highlight the models of out-of-hours care which are linked with improvement of patient outcomes. There is a need for effectiveness and cost effectiveness studies which define and categorise out-of-hours care to allow thorough evaluation of services.

Free-text analysis of general practice out-of-hours (GPOOH) use by people with advanced cancer: an analysis of coded and uncoded free-text data

BACKGROUND

People with advanced cancer frequently use the GP out-of-hours (GPOOH) service. Considerable amounts of routine GPOOH data are uncoded. Therefore, these data are omitted from existing healthcare datasets.

AIM

To conduct a free-text analysis of a GPOOH dataset, to identify reasons for attendance and care delivered through GPOOH to people with advanced cancer.

DESIGN AND SETTING

An analysis of a GPOOH healthcare dataset was undertaken. It contained all coded and free- text information for 5749 attendances from a cohort of 2443 people who died from cancer in Tayside, Scotland, from 2013-2015.

METHOD

Random sampling methods selected 575 consultations for free-text analysis. Each consultation was analysed by two independent reviewers to determine the following: assigned presenting complaints; key and additional palliative care symptoms recorded in free text; evidence of anticipatory care planning; and free-text recording of dispensed medications. Inter-rater reliability concordance was established through Kappa testing.

RESULTS

More than half of all coded reasons for attendance (n = 293; 51.0%) were 'other' or 'missing'. Free-text analysis demonstrated that nearly half (n = 284; 49.4%) of GPOOH attendances by people with advanced cancer were for pain or palliative care. More than half of GPOOH attendances (n = 325; 56.5%) recorded at least one key or additional palliative care symptom in free text, with the commonest being breathlessness, vomiting, cough, and nausea. Anticipatory care planning was poorly recorded in both coded and uncoded records. Uncoded medications were dispensed in more than one- quarter of GPOOH consultations.

CONCLUSION

GPOOH delivers a substantial amount of pain management and palliative care, much of which is uncoded. Therefore, it is unrecognised and under-reported in existing large healthcare data analyses.

Emergency medical services: the next linking asset for public health approaches to palliative care?

Emergency medical services (EMS) are a unique workforce providing 24/7 emergency care across high-income countries (HICs) and low- and middle-income countries (LMICs). Although traditionally perceived as first responders to traumatic and medical emergencies, EMS scope of practice has evolved to respond to the changing needs of communities, including a growing demand for community-based palliative care. Public health provides a useful framework to conceptualise palliative and end-of-life care in community-based settings. However, countries lack public policy frameworks recognising the role EMS can play in initiating palliative approaches in the community, facilitating goals of care at end of life and transporting patients to preferred care settings. This article aims to explore the potential role of EMS in a public health palliative care approach in a critical discussion essay format by (1) discussing the utility of EMS within a public health palliative care approach, (2) identifying the current barriers preventing public health approaches to EMS palliative care provision and (3) outlining a way forward through priorities for future research, policy, education and practice. EMS facilitate equitable access, early provision, expert care and efficacious integration of community-based palliative care. However, numerous structural, cultural and practice barriers exist, appearing ubiquitous across both HICs and LMICs. A Public Health Palliative Care approach to EMS Framework highlights the opportunity for EMS to work as a linking asset to build capacity and capability to support palliative care in place; connect patients to health and community supports; integrate alternative pathways by engaging multidisciplinary teams of care; and reduce avoidable hospital admissions by facilitating home-based deaths. This article articulates a public health approach to EMS palliative and end-of-life care provision and offers a preliminary framework to illustrate the components of a potential implementation and policy strategy.

Co-designing Community Out-of-hours Palliative Care Services: A systematic literature search and review

BACKGROUND

In order to provide responsive, individualised and personalised care, there is now greater engagement with patients, families and carers in designing health services. Out-of-hours care is an essential component of community palliative care. However, little is known about how patients, families and carers have been involved in the planning and design of these services.

AIM

To systematically search and review the research literature that reports on how out-of-hours palliative care services are provided in the community and to identify the extent to which the principles of co-design have been used to inform the planning and design of these services.

DESIGN

Systematic literature search and review.

DATA SOURCES

A systematic search for published research papers from seven databases was conducted in MEDLINE, PsycINFO, Embase, Emcare, PubMed, CINAHL and Web of Science, from January 2010 and December 2021. Reference list searches of included papers were undertaken to source additional relevant literature. A manifest content analysis was used to analyse the data.

RESULTS

A total of 77 papers were included. The majority of out-of-hours services in the community were provided by primary care services. The review found little evidence that patients, families or carers were involved in the planning or development of out-of-hours services.

CONCLUSION

Incorporating patients, families and carers priorities and preferences in the planning and designing of out-of-hours palliative care service is needed for service providers to deliver care that is more patient-centred. Adopting the principles of co-design may improve how out-of-hours care scan be delivered.

Clinical Features of Hypoxemia Due to Infection Under Home-Based Medication During the COVID-19 Pandemic Period

BACKGROUND

Despite the growing demand for home-based medication during the COVID-19 pandemic period, there remains scarce evidence of hypoxemic infection in home-care settings. In this study, we investigated the clinical features of hypoxemic respiratory failure due to infection during the period under home-based medication (defined as 'home-care-acquired infection').

METHODS

This retrospective observational study enrolled patients with home-care-acquired infection, other than COVID-19, in two home-care clinics in Sapporo, Japan, between April 2020 and May 2021 (the early phase of the COVID-19 pandemic). The participants were divided into two groups according to whether they required additional home oxygen therapy, and were compared to assess the predictors of hypoxemic respiratory failure. Furthermore, the clinical features were compared with those in patients aged >60 years with COVID-19 who were admitted to Toyama University Hospital during the same period.

RESULTS

A total of 107 patients with home-care-acquired infections were included in the study (median age, 82 years). Twenty-two patients required home oxygen therapy, and 85 did not. Thirty-day mortality rates were 32% and 8%. Among the patients in the hypoxemia group, none had desired a care-setting transition, following the advanced care planning. Multivariable logistic regression analysis showed that initial antibiotic treatment failure and malignant disease were independently associated with hypoxemic respiratory failure (odds ratio, 7.28 and 7.10; p=0.023 and p<0.005, respectively). In comparison with hypoxemia in the COVID-19 cohort, the lower incidence of febrile co-habitants and earlier onset of hypoxemia were significant in those due to home-care-acquired infection.

CONCLUSION

This study demonstrated that hypoxemia due to home-care-acquired infection was characterized by distinct features, possibly different from those due to COVID-19 in the early pandemic period.

A study of the factors associated with emergency department visits in advanced cancer patients receiving palliative care

Purpose

Several studies demonstrated that cancer patients visited the emergency department (ED) frequently. This indicates unmet needs and poor-quality palliative care. We aimed to investigate the factors that contribute to ED visits among patients with advanced cancer in order to identify strategies for reducing unnecessary ED visits among these patients.

Methods

A retrospective study was conducted between January and December, 2019. Eligible patients were previously enrolled in the comprehensive palliative care program prior to their ED visit. All patients older than 18 were included. Patients were excluded if they had died at the initial consultation, were referred to other programs at the initial consultation, or had an incomplete record. The trial ended when the patients died, were referred to other palliative programs, or the study ended. The time between the initial palliative consultation and study endpoints was categorized into three groups: 16 days, 16–100 days, and > 100 days, based on the literature review. To investigate the factors associated with ED visits, a logistic regression analysis was conducted. The variables with a P value < 0.15 from the univariate logistic regression analysis were included in the multiple logistic regression analysis.

Results

Among a total of 227 patients, 93 visited the ED and 134 did not. Mean age was 65.5 years. Most prevalent cancers were colorectal (18.5%), lung (16.3%), and hepatobiliary (11.9%). At the end, 146 patients died, 45 were alive, nine were referred to other programs, and 27 were lost to follow-up. In univariate logistic regression analysis, patients with > 100 days from palliative consultation (OR 0.23; 95%CI 0.08, 0.66; p-value 0.01) were less likely to attend the ED. In contrast, PPS 50–90% (OR 2.02; 95%CI 1.18, 3.47; p-value 0.01) increased the ED visits. In the multiple logistic regression analysis, these two factors remained associated with ED visits:> 100 days from the palliative consultation (OR 0.18; 95%CI 0.06, 0.55; p-value 0.01) and PPS 50–90% (OR 2.62; 95%CI 1.44, 4.79; p-value 0.01).

Conclusions

There was reduced ED utilization among cancer patients with > 100 days of palliative care. Patients having a lower PPS were associated with a lower risk of ED visits.

Community prescribing trends and prevalence in the last year of life, for people who die from cancer

Background

People who die from cancer (‘cancer decedents’) may latterly experience unpleasant and distressing symptoms. Prescribing medication for pain and symptom control is essential for good-quality palliative care; however, such provision is variable, difficult to quantify and poorly characterised in current literature. This study aims to characterise trends in prescribing analgesia, non-analgesic palliative care medication and non-palliative medications, to cancer decedents, in their last year of life, and to assess any associations with demographic or clinical factors.

Methods

This descriptive study, analysed all 181,247 prescriptions issued to a study population of 2443 cancer decedents in Tayside, Scotland (2013–2015), in the last year of life, linking prescribing data to demographic, and cancer registry datasets using the unique patient-identifying Community Health Index (CHI) number. Anonymised linked data were analysed in Safe Haven using chi-squared test for trend, binary logistic regression and Poisson regression in SPSSv25.

Results

In their last year of life, three in four cancer decedents were prescribed strong opioids. Two-thirds of those prescribed opioids were also prescribed laxatives and/or anti-emetics. Only four in ten cancer decedents were prescribed all medications in the ‘Just in Case’ medication categories and only one in ten was prescribed breakthrough analgesia in the last year of life. The number of prescriptions for analgesia and palliative care drugs increased in the last 12 weeks of life. The number of prescriptions for non-palliative care medications, including anti-hypertensives, statins and bone protection, decreased over the last year, but was still substantial. Cancer decedents who were female, younger, or had lung cancer were more likely to be prescribed strong opioids; however, male cancer decedents had higher odds of being prescribed breakthrough analgesia. Cancer decedents who had late diagnoses had lower odds of being prescribed strong opioids.

Conclusions

A substantial proportion of cancer decedents were not prescribed strong opioids, breakthrough medication, or medication to alleviate common palliative care symptoms (including ‘Just in Case’ medication). Many patients continued to be prescribed non-palliative care medications in their last days and weeks of life. Age, gender, cancer type and timing of diagnosis affected patients’ odds of being prescribed analgesic and non-analgesic palliative care medication.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00996-3.

Predictors of the final place of care of patients with advanced cancer receiving integrated home-based palliative care: a retrospective cohort study

Background

Meeting patients’ preferences for place of care at the end-of-life is an indicator of quality palliative care. Understanding the key elements required for terminal care within an integrated model may inform policy and practice, and consequently increase the likelihood of meeting patients’ preferences. Hence, this study aimed to identify factors associated with the final place of care in patients with advanced cancer receiving integrated, home-based palliative care.

Methods

This retrospective cohort study included deceased adult patients with advanced cancer who were enrolled in the home-based palliative care service between January 2016 and December 2018. Patients with < 2 weeks’ enrollment in the home-based service, or ≤ 1-week duration at the final place of care, were excluded. The following information were retrieved from patients’ electronic medical records: patients’ and their families’ characteristics, care preferences, healthcare utilization, functional status (measured by the Palliative Performance Scale (PPSv2)), and symptom severity (measured by the Edmonton Symptom Assessment System). Multivariate logistic regression was employed to identify independent predictors of the final place of care. Kappa value was calculated to estimate the concordance between actual and preferred place of death.

Results

A total of 359 patients were included in the study. Home was the most common (58.2%) final place of care, followed by inpatient hospice (23.7%), and hospital (16.7%). Patients who were single or divorced (OR: 5.5; 95% CI: 1.1–27.8), or had older family caregivers (OR: 3.1; 95% CI: 1.1–8.8), PPSv2 score ≥ 40% (OR: 9.1; 95% CI: 3.3–24.8), pain score ≥ 2 (OR: 3.6; 95% CI: 1.3–9.8), and non-home death preference (OR: 23.8; 95% CI: 5.4–105.1), were more likely to receive terminal care in the inpatient hospice. Patients who were male (OR: 3.2; 95% CI: 1.0–9.9), or had PPSv2 score ≥ 40% (OR: 8.6; 95% CI: 2.9–26.0), pain score ≥ 2 (OR: 3.5; 95% CI: 1.2–10.3), and non-home death preference (OR: 9.8; 95% CI: 2.1–46.3), were more likely to be hospitalized. Goal-concordance was fair (72.6%, kappa = 0.39).

Conclusions

Higher functional status, greater pain intensity, and non-home death preference predicted institutionalization as the final place of care. Additionally, single or divorced patients with older family caregivers were more likely to receive terminal care in the inpatient hospice, while males were more likely to be hospitalized. Despite being part of an integrated care model, goal-concordance was sub-optimal. More comprehensive community networks and resources, enhanced pain control, and personalized care planning discussions, are recommended to better meet patients’ preferences for their final place of care. Future research could similarly examine factors associated with the final place of care in patients with advanced non-cancer conditions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00865-5.

Out-of-hours services and end-of-life hospital admissions: a complex intervention systematic review and narrative synthesis

BACKGROUND

Out-of-hours (OOH) hospital admissions for patients receiving end-of-life care are a common cause of concern for patients, families, clinicians, and policymakers. It is unclear what issues, or combinations of issues, lead OOH clinicians to initiate hospital care for these patients.

AIM

To investigate the circumstances, processes, and mechanisms of UK OOH services-initiated end-of-life care hospital admissions.

DESIGN AND SETTING

Systematic literature review and narrative synthesis.

METHOD

Eight electronic databases were searched from inception to December 2019 supplemented by hand-searching of the British Journal of General Practice. Key search terms included: 'out-of-hours services', 'hospital admissions', and 'end-of-life care'. Two reviewers independently screened and selected articles, and undertook quality appraisal using Gough's Weight of Evidence framework. Data was analysed using narrative synthesis and reported following PRISMA Complex Intervention guidance.

RESULTS

Searches identified 20 727 unique citations, 25 of which met the inclusion criteria. Few studies had a primary focus on the review questions. Admissions were instigated primarily to address clinical needs, caregiver and/or patient distress, and discontinuity or unavailability of care provision, and they were arranged by a range of OOH providers. Reported frequencies of patients receiving end-of-life care being admitted to hospital varied greatly; most evidence related to cancer patients.

CONCLUSION

Although OOH end-of-life care can often be readily resolved by hospital admissions, it comes with multiple challenges that seem to be widespread and systemic. Further research is therefore necessary to understand the complexities of OOH services-initiated end-of-life care hospital admissions and how the challenges underpinning such admissions might best be addressed.

Cancer related emergencies with the chief complaint of pain: Incidence, ED recognition, and quality of care

BACKGROUND

Pain is the most common reason for cancer-related emergency department (ED) visits and a precursor of the urgency of oncological emergencies.

PURPOSE

To identify the incidence of oncological emergencies with the chief complaint of pain and evaluate ED recognition and quality of care in managing the associated emergency.

METHODS

This was a retrospective observational study of cancer patients presented to three EDs during the four-year study period.

RESULTS

The study's sample consisted of 252 patients admitted with oncological emergencies with a chief complaint of pain. Some oncological emergencies were more likely to be prioritized appropriately, such as febrile neutropenia and increased intracranial pressure. However, most patients with spinal cord compression and cardiac tamponade were more likely to be triaged to less urgent triage categories. Timeliness of ED care was suboptimal for most patients, particularly among those assigned to less urgent triage categories. Indicators for the low quality of care extended beyond ED with multiple adverse events in the hospital.

CONCLUSION

Triage nurses are expected to use the oncological emergencies' prevalent symptoms to allocate the patients to high triage urgency accurately. Patient waiting to be seen expected to be reassessed periodically to ensure waiting remain safe. Hospitals can adopt or establish pathways, protocols, or standardized order sets to fast-track patients with oncological emergencies. The health information system should be available to monitor and improve the delivered care continuously.

Sinais e sintomas manifestados por pacientes em cuidados paliativos oncológicos na assistência domiciliar: uma revisão integrativa

Resumo Objetivo identificar os principais sinais e sintomas manifestados por pacientes em cuidados paliativos oncológicos na assistência domiciliar. Método revisão integrativa nas bases LILACS, MEDLINE e CINAHL em janeiro de 2020. Perguntou-se: “Quais os principais sinais e sintomas manifestados por pacientes em cuidados paliativos oncológicos destacados nos estudos abrangendo o contexto do domicílio?”. Foram descritores/termos: Sinais e Sintomas/Signs and Symptoms; Assistência Domiciliar/Home Care Services; Cuidados Paliativos/Palliative Care e Neoplasias/Neoplasms. Elencaram-se como critérios de elegibilidade: texto completo; entre 2015 e 2019; em inglês, português ou espanhol e idade adulta. Para o mapeamento dos dados, consideraram-se: título; país; ano; objetivo; método; sinais e sintomas. Os resultados foram categorizados em subgrupos, considerando a classificação conceitual predeterminada (sinal e sintoma). O elemento contagem facilitou a análise e a comparação de dados. Resultados foram selecionados 35 artigos, sendo identificados 25 sinais e 23 sintomas. Os mais frequentes foram: dor, náusea/vômito, dispneia, fadiga, depressão, ansiedade, constipação, perda de apetite, sonolência, bem-estar e insônia. A maioria (39) relacionou-se ao domínio físico. Conclusão a identificação dos principais sinais e sintomas, neste contexto, direciona a prática dos profissionais de saúde para as intervenções mais adequadas e o mais precocemente possível, contribuindo para viabilizar a assistência domiciliar, e alerta para a necessidade de educação permanente sobre este tema.

Factors associated with unscheduled care use by cancer decedents: a systematic review with narrative synthesis

BACKGROUND

People who die from cancer (cancer decedents) may experience unpleasant and distressing symptoms which cause them to present to unscheduled care. Unscheduled care is unplanned care delivered by general practitioner out-of-hours and emergency departments. Use of unscheduled care can disrupt treatment plans, leading to a disjointed patient care and suboptimal outcomes.

OBJECTIVES

This systematic review aimed to identify factors associated with unscheduled care use by cancer decedents.

METHOD

Systematic review with narrative synthesis of seven electronic databases (PubMed; Medline; Embase; Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials; Web of Science; Cumulative Index to Nursing and Allied Health Literature) from inception until 01 January 2020. All observational and experimental studies were included, irrespective of their research design.

RESULTS

The search yielded 238 publications included at full-text, of which 47 were included in the final review and synthesis. Unscheduled care use by cancer decedents was influenced by multiple factors, synthesised into themes: demography, clinical and patient, temporal, prescribing and systems. Cancer decedents who were older, men, had comorbidities, or lung cancer, were most likely to use unscheduled care. Unscheduled care presentations were commonly due to pain, breathlessness and gastrointestinal symptoms. Low continuity of care, and oncology-led care were associated with greater unscheduled care use. Access to palliative care, having an up-to-date palliative care plan, and carer education were associated with less unscheduled care use.

CONCLUSION

The review identifies multiple factors associated with unscheduled care use by cancer decedents. Understanding these factors can inform future practice and policy developments, in order to appropriately target future interventions, optimise service delivery and improve the patient journey.

PROSPERO REGISTRATION NUMBER

CRD42016047231.

Changes in 24-Hour Palliative Care Telephone Advice Service after the Introduction of Discharged End-of-Life Patients' Care Plans

Background: To provide a better quality of death for patients at the end of life who choose to die at home and their families, the hospice care team at Taipei Veterans General Hospital has promoted an personalized discharged end-of-life care plan since the initial of 2018. Methods: This study is a retrospective analysis of administrative data. All incoming calls of the 24-hour specialist palliative care emergency telephone advice service records were analyzed. Personal information of any callers or consultants was not registered in the content. Results: A total of 728 telephone consultations was registered during the study period. The content of the consultation of different callers was significantly different (p < 0.001). The decrease in the number of calls from the patients who were discharged from the hospice ward had the largest reduction in proportion, from 80 (19.0%) to 32 (10.5%), There was a significant difference in the identity of the callers between 2017 and 2018 (p = 0.025). The proportion of consultation calls for the management of near-death symptoms significantly reduced from 15.6% to 10.5% (p = 0.027). Conclusions: Though the evidence from this study is not enough to support that the personalized discharged end-of-life care plan might reduce the frequency of dialing 24-hour hotlines by the family members of discharged terminally ill patients. For patients who choose to die at home and their families, the hotlines provide a 24-hour humane support. Thus, we need to conduct relevant research to determine whether the service of this dedicated line meets the needs of patients and their families in the terminal stage.

End-of-Life Cancer Care Resource Utilisation in Rural Versus Urban Settings: A Systematic Review

BACKGROUND

Despite the advances in End-of-life (EOL) cancer care, disparities remain in the accessibility and utilisation of EOL cancer care resources. Often explained by socio-demographic factors, geographic variation exists in the availability and provision of EOL cancer care services among EOL cancer decedents across urban versus rural settings. This systematic review aims to synthesise mortality follow-back studies on the patterns of EOL cancer care resource use for adults (>18 years) during end-of-life cancer care.

METHODS

Five databases were searched and data analysed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria involved; a) original research; b) quantitative studies; c) English language; d) palliative care related service use in adults (>18 years) with any malignancy excluding non-melanoma skin cancers; e) exclusive end of life focus; f) urban-rural focus. Narrative reviews and discussions were excluded.

RESULTS

24 studies met the inclusion criteria. End-of-life cancer care service utilisation patterns varied by rurality and treatment intent. Rurality was strongly associated with higher rates of Emergency Department (ED) visits and hospitalisations and lower rates of hospice care. The largest inequities between urban and rural health service utilisation patterns were explained by individual level factors including age, gender, proximity to service and survival time from cancer diagnosis.

CONCLUSIONS

Rurality is an important predictor for poorer outcomes in end-of-life cancer care. Findings suggest that addressing the disparities in the urban-rural continuum is critical for efficient and equitable palliative cancer care. Further research is needed to understand barriers to service access and usage to achieve optimal EOL care for all cancer patient populations.