Where would Canadians prefer to die? Variation by situational severity, support for family obligations, and age in a national study

Motivations for choosing "home" as one's preferred place of death: A scoping review

OBJECTIVES

While dying at home is often described as desirable, to our knowledge, no reviews have focused specifically on people's reasons for wanting to die at home. This review describes the breadth of what is known about motivations, attitudes, ideas, and reasons underlying the decision to choose "home" as one's preferred placed of death.

METHODS

This review was guided by a scoping review methodology following a five-stage approach including: (1) identify the research question, (2) identify relevant studies, (3) select studies based on inclusion/exclusion criteria, (4) chart the data, and (5) summarize and report the results.

RESULTS

Seventeen articles were identified that met inclusion/exclusion criteria and discussed motivations underlying people's desires to die at home. Thirty-five percent of studies were from Canada (n = 6/17), 29% were from Europe (n = 5/17), and 29% were from Asia (n = 5/17). Most studies (n = 11/17) used methods that involved collecting and/or analyzing interview data from participants, while the remaining studies (n = 6/17) used methods that involved administering and analyzing surveys or questionnaires. Characteristics of participants varied, but most commonly, studies included people with advanced illnesses who were nearing death (35% of studies, n = 6/17). Motivations for choosing a home death included desires to preserve a sense of self, factors relating to interpersonal relationships, and topics such as culture, religion, socioeconomic status, living situation, and lived experience.

SIGNIFICANCE OF RESULTS

The many interconnected reasons that lead people to choose a home death vary, as individuals have a range of motivations for choosing to die at home, which are highly influenced by contextual and cultural factors. Ultimately, this review will provide a comprehensive description of factors which may inform end-of-life planning, highlighting needs to be considered when planning the preferred location of a death.

Meeting the Needs of Palliative Care Patients: General Practitioners' Survey on the Last Three Months of Life

CONTEXT

Evaluating palliative care is challenging. Quality and efficiency indicators are not standardized, especially in primary care.

OBJECTIVES

To assess the adequacy of care to the patients' needs and associated factors, during the last three months of life, for palliative care patients followed up in general practice.

METHODS

A quantitative study based on a mortality follow-back survey of general practitioners (GPs), in metropolitan France. From November 2020 to November 2021, GPs included adult patients who died a predictable death. For each patient, they retrospectively rated how well the care provided met the patient's needs using a numerical scale. A generalized mixed model of logistic regression was used to examine associations between a positive evaluation and GP, patient, and care characteristics.

RESULTS

Ninety-five GPs reported 295 patients. The median age was 85 years and 54% were women. The most common disease was cancer (41%) and 43% had dementia. Care assessment was mostly positive (76%). Cancer and hospitalization were negative factors (OR [95% CI] = 0.46 [0.25-0.86] and OR = 0.51 [0.26-0.98] respectively). Dementia, psychologist intervention and discussions with the family tended to be associated with positive evaluation but results were not significant due to a lack of statistical power (OR = 1.86 [0.98-3.52]; OR = 10.5 [2.12-51.8], OR = 2.74 [0.99-7.57] respectively).

CONCLUSION

In end-of-life, GPs' evaluation of care adequacy to patient's needs was mostly positive. Indicators for palliative care evaluation, in a patient-centered approach, should consider inequalities due to medical conditions such as dementia and consider all the different possible care settings. Communication, psychosocial and spiritual approaches should be encouraged.

How the COVID-19 pandemic shaped Canadians' preferences for setting of dying: Comparison of two panel surveys

The purpose of this article is to assess whether COVID-19 shaped Canadians' preferred settings of dying. We compared data collected using the same survey from two independent but comparable sets of panel respondents, prior to and after the onset of the pandemic. A vignette methodology was used to assess preferences for dying in each of four settings: home, acute/intensive care, palliative care, and long-term residential care. Although preferences for dying at home, in acute/intensive care and palliative care units did not change, preferences for dying in nursing homes significantly declined. In the pandemic's first and second waves, the spread of knowledge about problems of poor care, visitation restrictions, and fears of contagion in Canadian long-term residential care may have shaped public perceptions of and preferences for dying these settings. If this change persists, it may influence advance care planning decisions. That preferences for dying at home did not shift is noteworthy.

The instrumental value of advance directives: lesson learned from the COVID-19 pandemic for policymaking

Open conversations between patients and healthcare professionals (HCP) are required to evaluate which treatments are reasonable for the individual case, especially towards the end of life. Advance Care Planning (ACP), which often results in drafting an Advance Directive (AD), is a useful tool to help with decisions in these circumstances, but the rate of AD completion remains low. During the COVID-19 pandemic, ACP and AD gained popularity due to the alleged advantage that they could facilitate resource allocation, to the benefit of public health. In this article, which presents a theoretical reflection grounded in scientific evidence, we underline an even stronger ethical argument to support the implementation of AD in end-of-life care (eol-C) i.e. the instrumental value at the individual level. We show, with particular reference to lessons learned from the COVID-19 pandemic, that AD are instrumentally valuable in that they: (1) allow to thematise death; (2) ensure that overtreatment is avoided; (3) enable to better respect the wish of people to die at their preferred place; (4) help revive the "lost skill" of prognostication. We thus conclude that these arguments speak for promoting the territorially uniform implementation and accessibility of high-quality AD in care.

Short-term mortality and palliative care use after delayed hospital discharge: a population-based retrospective cohort study

OBJECTIVES

In Canada, patients whose acute medical issues have been resolved but are awaiting discharge from hospital are designated as alternate level of care (ALC). We investigated short-term mortality and palliative care use following ALC designation in Ontario, Canada.

METHODS

We conducted a population-based retrospective cohort study of adult, acute care hospital admissions in Ontario with an ALC designation between January and December 2021. Our follow-up window was until 90 days post-ALC designation or death. Setting of discharge and death was determined using admission and discharge dates from multiple databases. We measured palliative care using physician billings, inpatient palliative care records and palliative home care records. We compared the characteristics of ALC patients by 90-day survival status and compared palliative care use across settings of discharge and death.

RESULTS

We included 54 839 ALC patients with a median age of 80 years. Nearly one-fifth (18.4%) of patients died within 90 days. Patients who died were older, had more comorbid conditions and were more likely to be male. Among those who died, 35.1% were never discharged from hospital and 20.3% were discharged but ultimately died in the hospital. The majority of people who died received palliative care following their ALC designation (68.1%).

CONCLUSIONS

A significant proportion of patients experiencing delayed discharge die within 3 months, with the majority dying in hospitals despite being identified as ready to be discharged. Future research should examine the adequacy of palliative care provision for this population.

Care trajectories and transitions at the end of life: a population-based cohort study

BACKGROUND

End-of-life periods are often characterised by suboptimal healthcare use (HCU) patterns in persons aged 65 years and older, with negative effects on health and quality of life. Understanding care trajectories (CTs) and transitions in this period can highlight potential areas of improvement, a subject yet only little studied.

OBJECTIVE

To propose a typology of CTs, including care transitions, for older individuals in the 2 years preceding death.

DESIGN

Retrospective cohort study.

METHODS

We used multidimensional state sequence analysis and data from the Care Trajectories-Enriched Data (TorSaDE) cohort, a linkage between a Canadian health survey and Quebec health administrative data.

RESULTS

In total, 2080 decedents were categorised into five CT groups. Group 1 demonstrated low HCU until the last few months, whilst group 2 showed low HCU over the first year, followed by a steady increase. A gradual increase over the 2 years was observed for groups 3 and 4, though more pronounced towards the end for group 3. A persistent high HCU was observed for group 5. Groups 2 and 4 had higher proportions of cancer diagnoses and palliative care, as opposed to comorbidities and dementia for groups 3 and 5. Overall, 68.4% of individuals died in a hospital, whilst 27% received palliative care there. Care transitions increased rapidly towards the end, most notably in the last 2 weeks.

CONCLUSION

This study provides an understanding of the variability of CTs in the last two years of life, including place of death, a critical step towards quality improvement.

Association between opioid use disorder and palliative care: a cohort study using linked health administrative data in Ontario, Canada

BACKGROUND

People with opioid use disorder (OUD) are at risk of premature death and can benefit from palliative care. We sought to compare palliative care provision for decedents with and without OUD.

METHODS

We conducted a cohort study using health administrative databases in Ontario, Canada, to identify people who died between July 1, 2015, and Dec. 31, 2021. The exposure was OUD, defined as having emergency department visits, hospital admissions, or pharmacologic treatments suggestive of OUD within 3 years of death. Our primary outcome was receipt of 1 or more palliative care services during the last 90 days before death. Secondary outcomes included setting, initiation, and intensity of palliative care. We conducted a secondary analysis excluding sudden deaths (e.g., opioid toxicity, injury).

RESULTS

Of 679 840 decedents, 11 200 (1.6%) had OUD. Compared with people without OUD, those with OUD died at a younger age and were more likely to live in neighbourhoods with high marginalization indices. We found people with OUD were less likely to receive palliative care at the end of their lives (adjusted relative risk [RR] 0.84, 95% confidence interval [CI] 0.82-0.86), but this difference did not exist after excluding people who died suddenly (adjusted RR 0.99, 95% CI 0.96-1.01). People with OUD were less likely to receive palliative care in clinics and their homes regardless of cause of death.

INTERPRETATION

Opioid use disorder can be a chronic, life-limiting illness, and people with OUD are less likely to receive palliative care in communities during the 90 days before death. Health care providers should receive training in palliative care and addiction medicine to support people with OUD.

Community perspectives on structural barriers to dying well at home in Canada

OBJECTIVES

To analyze how structural determinants and barriers within social systems shape options for dying well at home in Canada, while also shaping preferences for dying at home.

METHODS

To inform a descriptive thematic analysis, 24 Canadian stakeholders were interviewed about their views, experiences, and preferences about dying at home. Participants included compassionate community advocates, palliative care professionals, volunteers, bereaved family caregivers, residents of rural and remote regions, service providers working with structurally vulnerable populations, and members of francophone, immigrant, and 2SLGBTQ+ communities.

RESULTS

Analysis of stakeholders' insights and experiences led to the conceptualization of several structural barriers to dying well at home: inaccessible public and community infrastructure and services, a structural gap in death literacy, social stigma and discrimination, and limited access to relational social capital.

SIGNIFICANCE OF RESULTS

Aging in Canada, as elsewhere across the globe, has increased demand for palliative care and support, especially in the home. Support for people wishing to die at home is a key public health issue. However, while Canadian policy documents normalize dying in place as ideal, it is uncertain whether these fit with the real possibilities for people nearing the end of life. Our analysis extends existing research on health equity in palliative and end-of-life care beyond a focus on service provision. Results of this analysis identify the need to expand policymakers' structural imaginations about what it means to die well at home in Canada.

The epidemiology of dying within 48 hours of presentation to emergency departments: a retrospective cohort study of older people across Australia and New Zealand

BACKGROUND

Emergency department (ED) clinicians are more frequently providing care, including end-of-life care, to older people.

OBJECTIVES

To estimate the need for ED end-of-life care for people aged ≥65 years, describe characteristics of those dying within 48 hours of ED presentation and compare those dying in ED with those dying elsewhere.

METHODS

We conducted a retrospective cohort study analysing data from 177 hospitals in Australia and New Zealand. Data on older people presenting to ED from January to December 2018, and those who died within 48 hours of ED presentation, were analysed using simple descriptive statistics and univariate logistic regression.

RESULTS

From participating hospitals in Australia or New Zealand, 10,921 deaths in older people occurred. The 48-hour mortality rate was 6.43 per 1,000 ED presentations (95% confidence interval: 6.31-6.56). Just over a quarter (n = 3,067, 28.1%) died in ED. About one-quarter of the cohort (n = 2,887, 26.4%) was triaged into less urgent triage categories. Factors with an increased risk of dying in ED included age 65-74 years, ambulance arrival, most urgent triage categories, principal diagnosis of circulatory system disorder, and not identifying as an Aboriginal or Torres Strait Islander person. Of the 7,677 older people admitted, half (n = 3,836, 50.0%) had an encounter for palliative care prior to, or during, this presentation.

CONCLUSIONS

Our findings provide insight into the challenges of recognising the dying older patient and differentiating those appropriate for end-of-life care. We support recommendations for national advanced care planning registers and suggest a review of triage systems with an older person-focused lens.

How initial policy responses to COVID-19 contributed to shaping dying at home preferences and care provision: key informant perspectives from Canada

OBJECTIVES

In response to COVID-19's first wave, provincial governments rapidly implemented several public health directives, including isolation measures and care facility visitor restrictions, which profoundly affected healthcare delivery at the end of life and dying experiences and perceptions. The objective of this study was to identify implications of early policy changes for dying at home.

METHODS

Analysis of interviews with 29 key informants with expertise in the policy and practice context of dying at home and care for those dying at home was conducted as part of a larger mixed-methods study on dying at home in Canada.

RESULTS

Initial pandemic policy responses, especially visitor restrictions and limitations to home care services, shaped dying at home in relation to three themes: (1) increasing preferences and demand for, yet constrained system ability to support dying at home; (2) reinforcing and illuminating systemic reliance on and need for family/friend caregivers and community organizations, while constraining their abilities to help people die at home; and (3) illuminating challenges in developing and implementing policy changes during a pandemic, including equity-related implications.

CONCLUSION

This study contributes to broader understanding of the multifaceted impacts of COVID-19 policy responses in various areas within Canadian healthcare systems. Implications for healthcare delivery and policy development include (1) recognizing the role of family/friend caregivers and community organizations in end-of-life care, (2) recognizing health inequities at the end of life, and (3) considering possible changes in future end-of-life preferences and public attitudes about dying at home and responsibility for end-of-life care.

Differences in trends in discharge location in a cohort of hospitalized patients with cancer and non-cancer diagnoses receiving specialist palliative care: A retrospective cohort study

BACKGROUND

Patients with and without cancer are frequently hospitalized, and have specialist palliative care needs. In-hospital mortality can serve as a quality indicator of acute care. Trends in acute care outcomes have not previously been evaluated in patients with confirmed specialist palliative care needs or between diagnostic groups.

AIM

To compare trends in discharge location between hospitalized patients with and without cancer who received specialist palliative care.

DESIGN

Retrospective cohort study. Association between diagnosis (cancer, non-cancer) and in-hospital mortality was assessed using multivariable logistic regression, controlling for demographic, clinical, and admission-specific information.

SETTING/PARTICIPANTS

Patients who received specialist palliative care at an academic tertiary hospital in Toronto, Canada from 2013 to 2019.

RESULTS

The cohort comprised 6846 patients, 5024 with and 1822 without cancer. A higher proportion of patients without cancer had a Palliative Performance Scale score <30%, anticipated prognosis of <1 month, and were referred for end-of-life care (all p < 0.001). The adjusted odds of dying in hospital was 1.24-times higher among patients without cancer (95% CI: 1.05-1.46; p = 0.011). Though the proportion of patients without cancer who died in hospital decreased by 8.4% from 2013 to 2019, this proportion (41.2%) remained substantially higher compared to patients with cancer (14.0%) in 2019.

CONCLUSIONS

Hospitalized patients without cancer were referred to specialist palliative care at a lower functional status, a poorer anticipated prognosis, and more likely for end-of-life care; and were more likely to die in hospital. Future studies are required to determine whether a proportion of hospital deaths in patients without cancer represent goal-discordant end-of-life care.

End-of-life doulas: international reflections on a transnational movement

This review article summarizes the findings from the first virtual International End-of-Life Doula Symposium, held over 3 days on 25-27 April 2022. More than 40 people attended from seven countries, predominantly from Australia, Canada, the United States and the United Kingdom, and they were primarily experienced practitioners. In this article, we focus on participants' topics of conversations and experiences that were relevant across international boundaries, organized through the symposium themes of developments, disruptions, dilemmas and directions. All authors took de-identified handwritten notes across the 3 days of discussion, as well as reflexive notes about our own thoughts and perspectives on the topics discussed. We then collated our notes and abductively focussed our analysis on topics that generated significant conversation and/or came up repeatedly within the overall symposium themes, as well as trying to capture any unexpected issues and perspectives. We identify and summarize a wide range of interests and concerns within the development of the end-of-life doula (EOLD) role. We provide a model for integration pathways within existing health care systems, as well as an innovative conceptual framework synthesizing key intersecting developmental issues that are relevant across regional and national boundaries. The symposium was the first opportunity for EOLDs to collectively discuss their work and interests within an international context. Our findings indicate that there are fundamentally similar developmental issues across countries, along with some variations. As the first international event of its kind, our 'state of the field' summary review of the symposium holds significant insights relevant to both national and international contexts, and to a diversity of stakeholders interested in the development of this new care role and emerging transnational movement.

'The beauty and the less beautiful': exploring the meanings of dying at 'home' among community and practitioner representatives and advocates across Canada

Background

Significant structural and normative pressures privilege the ideal of dying at home in Canada. At the same time, the social complexities and meanings associated with dying in particular locations remain critically unexamined.

Objective

The aim of this study is to explore how diverse community members, including health and social care stakeholders, talk about preferences for locations of dying, with a particular focus on meanings of dying at home.

Design

Semi-structured virtual interviews were conducted with 24 community and practitioner representatives and advocates across Canada during the Covid-19 pandemic. This included compassionate community advocates, palliative care professionals and volunteers, bereaved carers, and members of queer, rural, and immigrant communities. Participants were asked about their own preferences for location of dying and elaborated on these aspects with regard to their client population or community group.

Results

Our analysis illuminates how meanings of dying at home are connected to previous experiences and perceptions of institutional care. As such, participants' perspectives are often framed as a rejection of institutional care. Dying at home also often signals potential for preserving ontological security and relational connection in the face of life-threatening illness. However, participants' expertise simultaneously informs a sense that dying at home is often unattainable. At times, this awareness underpins interpretations of both preferences and choices as contingent on considerations of the nature and type of illness, concerns about impacts on families, and available resources.

Conclusion

The ideal of dying at home is nuanced by identity, relational, and structural contexts. Knowledge from this study can inform realistic and practical person-centered planning across care settings. It can also help create more representative public policy and health system quality indicators regarding a 'good death' that do not rely on or perpetuate undeveloped and unrealistic assumptions about dying, home, and family care.