Dying at home: a prospective comparative study of home death rates in a private health insured palliative care community programme

BACKGROUND

Despite preferring end-of-life care at home, only a small percentage of deaths in Australia occur in private homes.

AIM

This study evaluates a private health insurance-funded support programme (provided in addition to the standard level of community palliative care), the rates of home death, the percentage of patients who died in their preferred location and the satisfaction with the care provided.

METHODS

This prospective study enrolled patients in two cohorts: the Medibank cohort (with private health insurance, a prognosis of less than 3 months, a preference for home death) and the standard cohort (publicly funded patients, with no limitation to prognosis or preferred place of death). Demographics and preferences for place of death were collected.

RESULTS

The first 12 months of the study are reported here with 132 patients (Medibank cohort, n = 67; standard cohort, n = 65). Medibank patients that died had significantly shorter contact with the service compared with the standard cohort (median 13.5 days vs 39 days), a higher home death rate (79% vs 44%) and a higher rate of preference for a home death (97% vs 59%). The proportion of deaths in the patients' preferred location was similar for both groups.

CONCLUSION

The high home death rate observed in the Medibank cohort highlights the potential benefit of enhanced palliative care support at the end of life. This support should be dedicated, accessible and resourced with in-home nursing assistance and allied health interventions.

End-of-life care in hematological malignancies - a nationwide comparative study on the Swedish Register of Palliative Care

BACKGROUND

Patients with hematological malignancies are less likely to be referred to specialized palliative care, and more likely to receive aggressive end-of-life care than patient with solid tumors. The Swedish Register of Palliative Care (SRPC) collects end-of-life care quality data from a majority of health facilities in Sweden. We here use the national data from the SRPC to evaluate the quality of end-of-life care in patients with hematological malignancies in Sweden.

METHODS

In a retrospective, observational registry study all adult registered cancer deaths in the years 2011-2019 were included. For the main analysis, patients with unexpected deaths or co-morbidities were excluded. Descriptive statistics and multiple logistic regression, adjusting for age and sex, were used.

RESULTS

A total of 119 927 patients were included, 8 550 with hematological malignancy (HM) and 111 377 with solid tumor (ST), corresponding to 43% of all deaths due to HM and 61% of ST deaths during the observed period. Significantly more ST patients than HM received end-of-life care in a specialized palliative unit (hospice, palliative ward or specialized home care), 54% vs 42% (p<0.001), and this difference could be seen also in the very old (80+). End-of-life care quality measures were significantly worse for HM patients than ST patients, which could partly be explained by the lower receipt of specialized palliative care. The most common symptom in both groups were pain, followed by anxiety. HM patients were less likely to achieve complete symptom relief (p<0.001) which appears to be related to the receipt of specialized palliative care.

CONCLUSION

Patients with hematological malignancies are more likely to die in emergency hospital and less likely to receive specialized palliative competence in end-of-life. This also translates into less qualitative end-of-life care and less efficient symptom relief.

Hospital function-associated deaths among patients with cancer: a comprehensive national study using death records in Japan

BACKGROUND

In Japan, about 70%-80% of cancer deaths occur in hospitals. The actual number of cancer patients who die in hospitals where palliative care is available is not clear. This study aimed to examine whether hospitals where cancer patients died offered palliative care.

METHODS

Patients aged ≥20 who died of cancer in 2018 were included. We used the Japanese death records and publicly available data on hospital functions. Cancer death numbers and hospitals were summarized according to hospital function and age group. Logistic regression analysis was performed to examine the death influence in patients with cancer in designated cancer hospitals.

RESULTS

The study included 302 511 patients, and 168 835 patients (55.8%) died in hospitals with palliative care. In hospitals without palliative care, those with 100-199 and 200-499 beds had more deaths than hospitals not in these ranges of beds. Their median number of deaths per year was 17 and 26, respectively. Categorized by the death numbers per hospital without palliative care, hospitals with 20-49 cancer deaths were common. In the designated cancer hospitals, younger patients aged 20-29 had a higher odds ratio (OR) for death (4.28) than those aged 70-79. Blood cancer had a higher OR (2.36) than colorectal and rectal cancer.

CONCLUSION

Our findings suggest that outreach of palliative care to hospitals with 100-199 or 200-499 beds and 20-49 deaths lacking palliative care could effectively improve end-of-life cancer care.

Immune Checkpoint Inhibitors and Palliative Care at the End of Life: An Irish Multicentre Retrospective Study

Background and Objectives: Immune checkpoint inhibitors (ICIs) have less toxicity than standard chemotherapy and are now standard of care for many patients with advanced cancer. A manageable side effect profile and potential for durable responses may lead to aggressive care of the palliative patient. We sought to evaluate palliative care input and ICI use at the end of life at two Irish cancer centres. Methods: We identified deceased patients who received at least one dose of an ICI between first of January 2013 to 31st of December 2018. A retrospective electronic chart review was performed. Results: The electronic records of 102 patients were analysed. Fifty eight percent were male and the median age of diagnosis of advanced disease was 60 years (range 17-78). Median time from last dose of ICI to death was 57 days (range 8-574) and 20% of patients died within 30 days of last dose of ICI. Most patients, 92%, were referred to palliative care. The median time from palliative care referral to death was 64 days (range 1- 1010). In the last 30 days of life, 39% of patients attended the emergency department (ED) and 46% had at least one hospital admission. Late palliative care referrals, ≤3 months before death, were associated with hospitalisations in the last month of life (64% vs. 36%, P = .02). Timing of palliative care referral did not affect ICI prescribing at the end of life (P = 0.38). ICI use in the last 30 days of life was not associated with increased ED presentations or hospitalisations at the end of life. Patients who received ICI in the last month had a higher likelihood of in-hospital death (43% vs. 16%, P = 0.02). Conclusions: ICI within 30 days of death was associated with dying in hospital but did not lead to more hospitalisations and emergency department presentations. Early palliative care did not affect ICI use but reduced hospitalisations at the end of life.

Gender differences in quality of dying and death among older adults: a cross-sectional study in China

Background

The aging of China is deepening year by year, and improving the quality of dying and death (QODD) is increasingly becoming an urgent and realistic need. This study explores the gender differences in the quality of dying and death and its influencing factors among Chinese older adults, aiming to provide assistance to the relevant authorities in formulating end-of-life care policies for the older adults, and to adapt to the needs of an aging society.

Methods

Based on the data of the Chinese Longitudinal Health Longevity Survey (CLHLS) during 2008-2018, a total of 7,341 respondents were included. Chi-square test and logistic regression analysis were used to analyze the quality of dying and death among Chinese older adults and its influencing factors. In addition, A Fairlie decomposition analysis (FDA) was conducted to ascertain the degree of influence exerted by various contributing factors.

Results

The proportion of high QODD among female older adults (63.80%) was significantly higher than male older adults (56.00%), which was statistically significant. Logistic regression showed that age, residence, home facilities score, place of death, medical costs, got timely treatment, number of chronic diseases and unconsciousness were the factors influencing QODD among male older adults. Meanwhile, residence, marital status, home facilities score, place of death, got timely treatment, bedridden, suffered from serious illness, unconsciousness and drinking were the factors influencing QODD among female older adults. FDA showed that 47.89% of the differences in QODD were caused by the observed variables, while 52.11% of the differences were caused by gender differences and unmeasured variables.

Conclusion

Chinese men have a poorer QODD compared to women. The main factors contributing to this difference were age, the number of chronic diseases, suffered from serious illness, unconsciousness, place of death, residence and home facilities scores. To ensure successful aging, the relevant departments should focus on these factors and work toward reducing the gender differences in QODD.

Caregivers influence preferred place of death for patients with an advanced cancer

OBJECTIVES

Family caregivers influence realization of home death among advanced cancer patients. However, little is known about the caregiver factors influencing patients' preferred and actual place of death. We aimed to assess caregiver factors associated with both caregivers' and patients' preferred place of death, and the association between their preferred and actual place of death.

METHODS

From a prospective cohort of 600 patients with stage IV solid malignancy, and 311 caregivers, we analyzed data for 227 patient-caregiver dyads of deceased patients who responded to the question on preferred place of death for patients at least once within the last 3 years before death. We assessed the association of patients' and caregivers' preferred place of death for patients with caregivers' competency, employment, relationship quality with the patient, their relationship with the patient, family support, and the presence of a domestic helper. We controlled for relevant patient factors and utilized the actor-partner interdependence framework for analysis.

RESULTS

Overall, 67% patients and 74% caregivers preferred a home death for patients during the last 3 years prior to patient's death. Patients whose caregivers reported greater caregiving competency were more likely to prefer a home death (average marginal effect: 0.02; 95% confidence interval, 0.003-0.04). Spousal caregivers were less likely to prefer a home death (-0.10 (-0.19, -0.004)). Caregivers lacking family support were more likely to prefer an institutional death (0.04 (0.002-0.08)). While caregivers' preferences had a marginally significant association with patients' actual place of death (p-value < 0.10), we did not find any association between patients' preferred and actual place of death.

SIGNIFICANCE OF RESULTS

Caregivers play a crucial role in shaping patients' preferred and actual place of death. Supporting caregivers, particularly spousal caregivers, and enhancing their caregiving competency could potentially help achieve a home death for the patient.

Assessing the relationship between the distress levels in patients with irreversible terminal delirium and the good quality of death from the perspective of bereaved family

BACKGROUND

Research on achieving a good death for terminally delirious patients is scarce, with limited knowledge about the level of good death and influencing factors. This study investigates the level of good death among delirium patients, factors influencing it, and the correlation between distress, end-of-life care needs, and achieving a good death by surveying bereaved family members of deceased patients in Chinese hospitals.

METHODS

This cross-sectional study from January 2022 to January 2024 was conducted among bereaved family members of patients using an online questionnaire. The questionnaires consisted of (1) participants' demographic and disease-related questionnaires; (2) the Good Death Inventory (GDI) China version; (3) Terminal Delirium-Related Distress Scale (TTDS) China version; (4) the Care Evaluation Scale - short form (CES) China version. All data were analyzed using descriptive statistics, and the associated factors influencing good death were analyzed by multiple linear regression analyses.

RESULT

A total of 263 subjects were enrolled. More males (63.5%) participated than females (36.5%), the mean age was 75.35 ± 13.90 years. Good quality of death was significantly and negatively related to the distress in patients with irreversible terminal delirium (r = -0.458, P<0.01).The multiple linear regression model indicates that TDDS score, CES score, types of diseases, smoking history, nutritional deficiency are important factor affecting the good quality of death.

CONCLUSIONS

The good quality of death from the perspective of bereaved family, a negative correlation was found between the distress in patients with irreversible terminal delirium and good death. Medical staff should be more aware of good quality of death in patients, future research should expand sample sizes to include more demographic data, and explore the concept of a good death across different cultural contexts.

Social factors affecting home-based end-of-life care for patients with cancer and primary caregivers

OBJECTIVE

This study aimed to explore the social factors of patients and caregivers, including those related to their wishes for home-based end-of-life care that influence its fulfillment.

METHODS

A secondary analysis was conducted using the dataset (home-based end-of-life care N = 625, hospital end-of-life care N = 7603) Comprehensive patient-based survey conducted by The Study on Quality Evaluation of Hospice and Palliative Care by Bereaved Caregivers (J-HOPE 4) and multivariate analysis (multiple logistic regression) to explore the impact of social factors of patients and caregivers on the fulfillment of home-based end-of-life care. The explanatory variables included 11 social factors of patients, such as age and sex, and 18 social factors of primary caregivers.

RESULTS

For patients with medical expenses less than 900 USD (OR, 2.05), annual income of fewer than 36,000 USD (OR 0.669), preferences for home care (OR 1.49), preferences to die at home (OR 1.58), wish to die at home (OR 1.52), and lack of patient's financial well-being (OR 0.72) were significant factors associated with home-based end-of-life care. Significant factors relating to caregivers included male caregivers (OR 0.66), poor mental state (OR 0.79), ability to provide daily care (OR 3.02), experience of caring for a deceased family member (OR 0.66), presence of alternative caregivers (OR 0.78), and cohabitation with caregivers (OR 1.47).

CONCLUSION

Patient preferences, social situations, primary caregivers' social situations, and mental states influenced home-based end-of-life care.

Place of care and death preferences among recently bereaved family members: a cross-sectional survey

OBJECTIVES

The aim was: (1) to investigate preferred place for end-of-life care and death for bereaved family members who had recently lost a person with advanced illness and (2) to investigate associations between bereaved family members' preferences and individual characteristics, health-related quality of life, as well as associations with their perception of the quality of care that the ill person had received, the ill person's preferred place of death and involvement in decision-making about care.

METHODS

A cross-sectional survey with bereaved family members, employing descriptive statistics and multinominal logistic regression analyses.

RESULTS

Of the 485 participants, 70.7% were women, 36.1% were ≥70 years old, 34.5% were partners and 51.8% were children of the deceased. Of the bereaved family members, 52% preferred home for place of end-of-life care and 43% for place of death. A higher likelihood of preferring inpatient palliative care was associated with being female and having higher education, whereas a lower likelihood of preferring a nursing home for the place of care and death was associated with higher secondary or higher education. Partners were more likely to prefer hospital for place of care and nursing home for place of death.

CONCLUSIONS

Home was the most preferred place for end-of-life care and death. Bereaved people's experiences of end-of-life care may impact their preferences, especially if they had a close relationship, such as a partner who had a higher preference for nursing home and hospital care. Conversations about preferences for the place of care and death considering previous experience are encouraged.

Nursing care to patients who have the home as the preferred place of death: a scoping review

BACKGROUND

The existing literature on nursing care for patients who choose home as their preferred place of death is scattered and lacks a coherent overview. This scoping review aimed to explore and categorize the available evidence on how nurses provide care for patients preferring to die at home.

METHODS

Studies that included nurses and were focused on nursing care for patients who choose the home as their preferred place of death were included in the review. The scoping review considered studies with quantitative, qualitative, or mixed method designs; systematic reviews; and meta-analyses. No time restrictions were added. Key information sources were Medline, CINAHL (EBSCO), Scopus (Elsevier) and Google Scholar. Systematic reviews were searched for in the Cochrane Database of Systematic Reviews. Unpublished studies and grey literature were searched for in ProQuest Dissertations and Theses. The reference list of the studies included was searched.

RESULTS

A total of 13 studies were deemed eligible for inclusion in the review, of which (n = 11) were qualitative and (n = 2) were both qualitative and quantitative. The studies were published between 2008 and 2023 and were conducted in the United Kingdom (n = 5), Norway (n = 4), Australia, Sweden, Canada and Japan. The studies included in this review highlighted issues of competence, resource limitations, flexibility as a coping mechanism, as well as collaboration and family caregivers.

CONCLUSIONS

This review identified significant challenges in delivering nursing care for patients who prefer to die at home, including staff shortages, resource limitations, and educational deficiencies. Despite these barriers, nurses showed a strong commitment to patient care, highlighting the need for increased support and collaboration with family caregivers to improve home-based end-of-life care.

IMPLICATIONS FOR RESEARCH

To improve care for patients who wish to die at home, it is crucial to address staff shortages and enhance nurse training to close knowledge gaps and ensure consistent, high-quality care. Healthcare systems must also allocate adequate resources to ensure that nurses have the necessary tools to deliver safe and effective care in home settings. Strengthening interdisciplinary collaboration will further enhance patient outcomes by supporting both nurses and family caregivers in end-of-life care.

Dying Patients' Quality of Care for Five Common Causes of Death: A Nationwide Mortality Follow-Back Survey

Background: The importance of high-quality care for terminal patients is being increasingly recognized; however, quality of care (QOC) and quality of death and dying (QOD) for noncancer patients remain unclear. Objectives: To clarify QOC and QOD according to places and causes of death. Design, Subjects: A nationwide mortality follow-back survey was conducted using death certificate data for cancer, heart disease, stroke syndrome, pneumonia, and kidney failure in Japan. The questionnaire was distributed to 115,816 bereaved family members between February 2019 and February 2020. Measurements included QOC, QOD, and symptoms during the last week of life. Analyses used generalized estimating equations adjusting for age, sex, and region. Results: Valid responses were returned by 62,576 (54.0%). Family-reported QOC and QOD by the place of death were significantly higher at home than in other places across all causes of death (for all combinations with hospital p < 0.01). In stroke syndrome and pneumonia, QOD significantly differed between hospital and home (stroke syndrome: 57.1 vs. 72.4, p < 0.001, effect size 0.77; pneumonia: 57.3 vs. 71.1, p < 0.001, effect size 0.78). No significant differences were observed in QOC and QOD between cancer and noncancer. The prevalence of symptoms was higher for cancer than for other causes of death. Conclusions: QOC and QOD were higher at home than in other places of death across all causes of death. The further expansion of end-of-life care options is crucial for improving QOC and QOD for all terminal patients.

Comparison of inpatient and outpatient palliative sedation practice - A prospective observational study

INTRODUCTION

Palliative sedation (PS) is an intrusive measure to relieve patients at the end of their life from otherwise untreatable symptoms. Intensive discussion of the advantages and limitations of palliative care with the patients and their relatives should precede the initiation of PS since PS is terminated by the patient's death in most cases. Drugs for PS are usually administered intravenously. Midazolam is widely used, either alone or in combination with other substances. PS can be conducted in both inpatient and outpatient settings; however, a quality analysis comparing both modalities was missing so far.

PATIENTS AND METHODS

This prospective observational study collected data from patients undergoing PS inpatient at the palliative care unit (PCU, n = 26) or outpatient at a hospice (n = 2) or at home (specialized outpatient palliative care [SAPV], n = 31) between July 2017 and June 2018. Demographical data, indications for PS, and drug protocols were analyzed. The depth of sedation according to the Richmond Agitation Sedation Scale (RASS) and the degree of satisfaction of staff members and patient's relatives were included as parameters for quality assessment.

RESULTS

Patients undergoing PS at the PCU were slightly younger compared to outpatients (hospice and SAPV combined). Most patients suffered from malignant diseases, and midazolam was the backbone of sedation for inpatients and outpatients. The median depth of sedation was between +1 and -3 according to the RASS with a trend to deeper sedation prior to death. The median degree of satisfaction was "good," scored by staff members and by patient's relatives. Significant differences between inpatients and outpatients were not seen in protocols, depth of sedation, and degree of satisfaction.

CONCLUSION

The data support the thesis that PS is possible for inpatients and outpatients with comparable results. For choosing the best place for PS, other aspects such as patient's and relative's wishes, stress, and medical reasons should be considered.

Bereaved family members' perspectives on quality of death in deceased acute cardiovascular disease patients compared with cancer patients - a comparison of the J-HOPE3 study and the quality of palliative care in heart disease (Q-PACH) study

BACKGROUND

Outcome measures during acute cardiovascular disease (CVD) phases, such as quality of death, have not been thoroughly evaluated. This is the first study that compared the family members' perceptions of quality of death in deceased CVD patients and in deceased cancer patients using a bereaved family survey.

METHODS

Retrospectively sent questionnaire to consecutive family members of deceased patients with CVD from ten tertiary hospitals from October 2017 to August 2018. We used the short version of the Good Death Inventory (GDI) and assessed overall care satisfaction. Referencing the GDI, the quality of death was compared between CVD patients admitted to a non-palliative care unit (non-PCU) and cancer patients in palliative care units (PCU) and non-PCUs in the Japan Hospice and Palliative Care Evaluation Study (J-HOPE Study). Additionally, in the adjusted analysis, multivariable linear regression was performed for total GDI score adjusted by the patient and participant characteristics to estimate the difference between CVD and other patients.

RESULTS

Of the 243 bereaved family responses in agreement (response rate: 58.7%) for CVD patients, deceased patients comprised 133 (54.7%) men who were 80.2 ± 12.2 years old on admission. The GDI score among CVD patients (75.0 ± 15.7) was lower (worse) than that of cancer patients in the PCUs (80.2 ± 14.3), but higher than in non-PCUs (74.4 ± 15.2). After adjustment, the total GDI score for CVD patients was 7.10 points lower [95% CI: 5.22-8.97] than for cancer patients in PCUs and showed no significant differences compared with those in non-PCUs (estimates, 1.62; 95% CI [-0.46 to 5.22]).

CONCLUSIONS

The quality of death perceived by bereaved family members among deceased acute CVD patients did not differ significantly from that of deceased cancer patients in general wards, however, was significantly lower than that of deceased cancer patients admitted in PCUs.

Disability and Place of Death in Older Americans: The Moderating Role of Household Wealth

CONTEXT

Home-based deaths are increasing, yet, how wealth influences where people die in the presence of disability remains unknown.

OBJECTIVE

To examine place of death by help with (instrumental) activities of daily living (I/ADLs) at the end of life (EOL) and the modifying role of wealth.

METHODS

Retrospective study of decedents from the Health and Retirement Study (n = 13,210). The exposure was intensity of help with I/ADLs at the EOL (no help/ lower intensity/higher intensity). The outcome was place of death (hospital/nursing home/home). Household wealth was an effect modifier with six categories: ≤$0, first-fifth quintile. Covariates included age, gender, race, marital status at the EOL, last place of residence, and receipt of hospice care. We used multinomial logit regression models with estimates reported as average marginal effects (AMEs).

RESULTS

Mean age was 79.8 years; 53.2% were female. In the adjusted models, compared to not receiving help at EOL, receiving higher-intensity help was associated with a lower probability of dying in a hospital (AME = -3.8 percentage points (pp), 95% CI = -6.3 to -1.3) and a higher probability of dying at home (AME = 3.6 pp, 95% CI = 1.4-5.7). Associations were most pronounced among decedents in the top two wealth quintiles; older adults who received higher-intensity help had a lower probability of dying in a hospital (AME = -9.0 pp, 95% CI = -14.8 to -3.1), and a higher probability of dying at home (AME = 8.4 pp, 95% CI = 3.8-13.0).

CONCLUSION

Receiving higher intensity of help with I/ADLs was associated with lower likelihood of dying in a hospital, and higher likelihood of dying at home, particularly among older adults with greater wealth.

Comparing the use of aggressive end-of life care among frail and non-frail patients with cancer using a claims-based frailty index

INTRODUCTION

Despite mounting consensus that end-of-life (EOL) care for patients with cancer should focus on improving quality of life, many patients continue to receive aggressive, disease-oriented treatment until death. Within this group, patients with increased frailty may be at higher risk of adverse treatment-related outcomes. We therefore examined the relationship between degree of frailty and receipt of aggressive EOL care among Medicare-insured patients with cancer in Ohio.

MATERIALS AND METHODS

From the Ohio Cancer Incidence Surveillance System (OCISS) linked with Medicare claims, we identified patients diagnosed with breast, colorectal, lung, or prostate cancer who died between 2012 and 2016. Frailty was operationalized using a validated claims-based frailty index. Six quality indicators reflecting receipt of aggressive EOL care were identified from claims: (1) any cancer-directed treatment, (2) >1 emergency department (ED) visit, (3) >1 hospital admission, (4) any intensive care unit (ICU) admission in the last 30 days of life, (5) entry to hospice in the last three days of life, and (6) in-hospital mortality. Multivariable logistic regression analysis was performed to control for demographic factors, Medicare and Medicaid dual enrollment, and cancer type and stage in the relationship between frailty and aggressive EOL care.

RESULTS

Overall, 31,465 patients met selection criteria. Patients with moderate/severe frailty were less likely than non-/pre-frail patients to receive any aggressive EOL care (adjusted odds ratio [aOR] 0.92 [95% confidence interval 0.86-0.99]). This group was also less likely to undergo cancer-directed treatment in their last 30 days or to enter hospice in their last three days. Increasing frailty was associated with lower odds of admission to the ICU in the last 30 days of life (mild frailty: aOR 0.88 [0.83-0.94]; moderate/severe frailty: aOR 0.85 [0.78-0.92]) or of dying in-hospital (mild frailty: 0.85 [0.79-0.91]; moderate/severe frailty: aOR 0.74 [0.67-0.82]), but higher odds of having >1 ED visit in the last 30 days of life (mild frailty: aOR 1.43 [1.32-1.53]; moderate/severe frailty: aOR 1.61 [1.47-1.77]).

DISCUSSION

These findings suggest the need for more explicit discussion of emergency care seeking for patients with cancer at the end of life.

The experience of patients with hematological malignancy in their terminal stage: a phenomenological study from Jordan's perspective

BACKGROUND

Patients diagnosed with hematological malignancies residing in low-middle-income countries undergo significant physical and psychological stressors. Despite this, only 16% of them receive proper care during the terminal stages. It is therefore crucial to gain insight into the unique experiences of this population.

AIM

To have a better understanding of the needs and experiences of adult patients with advanced hematological malignancy by exploring their perspectives.

METHODS

A qualitative interpretive design was employed to collect and analyze data using a phenomenological approach. The study involved in-depth interviews with ten participants aged between 49 and 65 years, utilizing a semi-structured approach.

RESULTS

Two primary themes emerged from the participants' experiences of reaching the terminal stage of illness: "Pain, Suffering, and Distress" and "Spiritual Coping." The first theme encompassed physical and emotional pain, suffering, and distress, while the second theme was centered on the participants' spiritual coping mechanisms. These coping mechanisms included seeking comfort in religious practices, relying on spiritual support from family and friends, and finding solace in their beliefs and faith.

CONCLUSION

Patients with hematological malignancies in the terminal stages of their disease experience severe pain, considerable physical and psychosocial suffering, and spiritual distress. While they require support to cope with their daily struggles, their experiences often go unnoticed, leading to disappointment and loss of dignity. Patients mainly rely on their spirituality to cope with their situations. Healthcare providers must acknowledge these patients' needs and provide more holistic and effective care.

Socioeconomic Status, Palliative Care, and Death at Home Among Patients With Cancer Before and During COVID-19

Importance

The COVID-19 pandemic had a profound impact on the delivery of cancer care, but less is known about its association with place of death and delivery of specialized palliative care (SPC) and potential disparities in these outcomes.

Objective

To evaluate the association of the COVID-19 pandemic with death at home and SPC delivery at the end of life and to examine whether disparities in socioeconomic status exist for these outcomes.

Design, Setting, and Participants

In this cohort study, an interrupted time series analysis was conducted using Ontario Cancer Registry data comprising adult patients aged 18 years or older who died with cancer between the pre-COVID-19 (March 16, 2015, to March 15, 2020) and COVID-19 (March 16, 2020, to March 15, 2021) periods. The data analysis was performed between March and November 2023.

Exposure

COVID-19-related hospital restrictions starting March 16, 2020.

Main Outcomes and Measures

Outcomes were death at home and SPC delivery at the end of life (last 30 days before death). Socioeconomic status was measured using Ontario Marginalization Index area-based material deprivation quintiles, with quintile 1 (Q1) indicating the least deprivation; Q3, intermediate deprivation; and Q5, the most deprivation. Segmented linear regression was used to estimate monthly trends in outcomes before, at the start of, and in the first year of the COVID-19 pandemic.

Results

Of 173 915 patients in the study cohort (mean [SD] age, 72.1 [12.5] years; males, 54.1% [95% CI, 53.8%-54.3%]), 83.7% (95% CI, 83.6%-83.9%) died in the pre-COVID-19 period and 16.3% (95% CI, 16.1%-16.4%) died in the COVID-19 period, 54.5% (95% CI, 54.2%-54.7%) died at home during the entire study period, and 57.8% (95% CI, 57.5%-58.0%) received SPC at the end of life. In March 2020, home deaths increased by 8.3% (95% CI, 7.4%-9.1%); however, this increase was less marked in Q5 (6.1%; 95% CI, 4.4%-7.8%) than in Q1 (11.4%; 95% CI, 9.6%-13.2%) and Q3 (10.0%; 95% CI, 9.0%-11.1%). There was a simultaneous decrease of 5.3% (95% CI, -6.3% to -4.4%) in the rate of SPC at the end of life, with no significant difference among quintiles. Patients who received SPC at the end of life (vs no SPC) were more likely to die at home before and during the pandemic. However, there was a larger immediate increase in home deaths among those who received no SPC at the end of life vs those who received SPC (Q1, 17.5% [95% CI, 15.2%-19.8%] vs 7.6% [95% CI, 5.4%-9.7%]; Q3, 12.7% [95% CI, 10.8%-14.5%] vs 9.0% [95% CI, 7.2%-10.7%]). For Q5, the increase in home deaths was significant only for patients who did not receive SPC (13.9% [95% CI, 11.9%-15.8%] vs 1.2% [95% CI, -1.0% to 3.5%]).

Conclusions and Relevance

These findings suggest that the COVID-19 pandemic was associated with amplified socioeconomic disparities in death at home and SPC delivery at the end of life. Future research should focus on the mechanisms of these disparities and on developing interventions to ensure equitable and consistent SPC access.

Patients' Trajectory With Lung Cancer From Treatment Initiation to End-Of-Life: A Retrospective Cohort Study Using Claims Data in Japan

INTRODUCTION

This study aimed to describe the course of patients with lung cancer from treatment initiation to end-of-life.

METHODS

This retrospective cohort study used Claims Data from the National Health Insurance and Advanced Elderly Medical Service System. We analyzed data from patients newly diagnosed with lung cancer between April 2013 and March 2021 who had been hospitalized at our University Hospital in urban area. We evaluated (1) treatment courses of these patients, and (2) end-of-life care and clinical factors related to end-of-life care.

RESULTS

A total of 818 patients who were diagnosed with lung cancer and received lung cancer treatment were included, of whom 200 were assessed for end-of-life. During the study period, 464 patients underwent surgery, while 308 received chemotherapy without undergoing surgery. The patients generally received lung cancer treatment within 2 years. The median time from initial treatment to death was 13 months for deceased patients. Patients in the palliative care unit (PCU) constituted 9% at 30 days before death, 25% at 7 days before death, and 40.5% on the day of death, whereas only 15% died at home. The prevalence of end-of-life care in the home/PCU was elevated among patients receiving molecular targeted drugs and in the female group.

CONCLUSION

This study highlighted the patterns of end-of-life care following lung cancer treatment by using Claims Data. PCU utilization was concentrated in the period shortly before death, with fewer patients passing away at home. End-of-life care may be influenced by clinical factors, including the type of lung cancer treatment received, which may change the place of care.

Discharge to home from a palliative care unit: impact on survival and factors associated with home death after the discharge: a cohort study

BACKGROUND

Staying at home during the dying process is important for many patients; and palliative care units (PCUs) can help facilitate home death. This study compared patient survival between those who were discharged to home from a palliative care unit and those who were not, and aimed to identify the factors associated with home death after the discharge.

METHODS

This retrospective cohort study used a database of patients admitted to a palliative care unit at Kouseiren Takaoka Hospital in Japan. All consecutive patients admitted to the hospital's PCU between October 2016 and March 2020 were enrolled. Patient survival and factors potentially associated with survival and place of death were obtained. A total of 443 patients with cancer were analyzed, and 167 patients were discharged to home and 276 were not.

RESULTS

Propensity score matching analyses revealed that median survival time was significantly longer in patients who were discharged to home than those who were not (57 vs. 27 days, P < 0.001). Multiple logistic regression analysis identified that worse Palliative Prognostic Index (odds ratio [OR] = 1.21, 95% confidence interval [CI] = 1.03-1.44, p = 0.025) and family members' desire for home death (OR = 6.30, 95% CI = 2.32-17.1, p < 0.001) were significantly associated with home death after their discharge.

CONCLUSIONS

Discharge to home from palliative care units might have some positive impacts on patient survival.

Patients receiving allogeneic haematopoietic stem-cell transplantation and clinical outcomes after early access to palliative care

Allogeneic haematopoietic stem-cell transplantation is a potential curative therapy for otherwise fatal haematological diseases. This treatment modality is complex, burdensome, and can involve considerable or life-threatening adverse events requiring high-quality symptom control. In contrast to patients with solid tumours, the transition to end-of-life care can be abrupt if the underlying disease relapses or other severe transplantation-related complications occur. This Viewpoint elucidates the relationships between transplantation and palliative care teams and discusses why patients who have undergone transplantation might benefit considerably from early admittance to palliative care, even when the treatment goal is clearly curative. Close and early collaboration between transplantation teams and palliative care teams is clearly endorsed.

Place of Death From Cancer in US States With vs Without Palliative Care Laws

Importance

In the US, improving end-of-life care has become increasingly urgent. Some states have enacted legislation intended to facilitate palliative care delivery for seriously ill patients, but it is unknown whether these laws have any measurable consequences for patient outcomes.

Objective

To determine whether US state palliative care legislation is associated with place of death from cancer.

Design, Setting, and Participants

This cohort study with a difference-in-differences analysis used information about state legislation combined with death certificate data for 50 US states (from January 1, 2005, to December 31, 2017) for all decedents who had any type of cancer listed as the underlying cause of death. Data analysis for this study occurred between September 1, 2021, and August 31, 2022.

Exposures

Presence of a nonprescriptive (relating to palliative and end-of-life care without prescribing particular clinician actions) or prescriptive (requiring clinicians to offer patients information about care options) palliative care law in the state-year where death occurred.

Main Outcomes and Measures

Multilevel relative risk regression with state modeled as a random effect was used to estimate the likelihood of dying at home or hospice for decedents dying in state-years with a palliative care law compared with decedents dying in state-years without such laws.

Results

This study included 7 547 907 individuals with cancer as the underlying cause of death. Their mean (SD) age was 71 (14) years, and 3 609 146 were women (47.8%). In terms of race and ethnicity, the majority of decedents were White (85.6%) and non-Hispanic (94.1%). During the study period, 553 state-years (85.1%) had no palliative care law, 60 state-years (9.2%) had a nonprescriptive palliative care law, and 37 state-years (5.7%) had a prescriptive palliative care law. A total of 3 780 918 individuals (50.1%) died at home or in hospice. Most decedents (70.8%) died in state-years without a palliative care law, while 15.7% died in state-years with a nonprescriptive law and 13.5% died in state-years with a prescriptive law. Compared with state-years without a palliative care law, the likelihood of dying at home or in hospice was 12% higher for decedents in state-years with a nonprescriptive palliative care law (relative risk, 1.12 [95% CI 1.08-1.16]) and 18% higher for decedents in state-years with a prescriptive palliative care law (relative risk, 1.18 [95% CI, 1.11-1.26]).

Conclusions and Relevance

In this cohort study of decedents from cancer, state palliative care laws were associated with an increased likelihood of dying at home or in hospice. Passage of state palliative care legislation may be an effective policy intervention to increase the number of seriously ill patients who experience their death in such locations.

Association between types of home healthcare and emergency house calls, hospitalization, and end-of-life care in Japan

BACKGROUND

To meet the increasing demand for home healthcare in Japan, as part of the national healthcare system, home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in 2006 and 2012 respectively. This study aimed to evaluate whether HCSCs has succeeded in providing 24-h home care services through the end of life.

METHODS

A retrospective cohort study was conducted using the national database in Japan. Participants were ≥ 65 years of age, had newly started regular home visits between July 2014 and September 2015, and used general clinics, conventional HCSCs, or enhanced HCSCs. Each patient was followed up for 6 months after the first visit. The outcome measures were (i) emergency house call(s), (ii) hospitalization(s), and (iii) end-of-life care defined as in-home death. Multivariable logistic regression analyses were performed for statistical analysis.

RESULTS

The analysis included 160,674 patients, including 13,477, 64,616, and 82,581 patients receiving regular home visits by general clinics, conventional HCSCs, and enhanced HCSCs respectively. Compared to general clinics, the use of conventional and enhanced HCSCs was associated with an increased likelihood of emergency house calls (adjusted odds ratio [aOR] and 95% confidence intervals [CIs] of 1.62 [1.56-1.69] and 1.86 [1.79-1.93], respectively) and a decreased likelihood of hospitalizations (aOR [95% CIs] of 0.86 [0.82-0.90] and 0.88 [0.84-0.92] respectively). Among 39,082 patients who died during the follow-up period, conventional and enhanced HCSCs had more in-home deaths (aOR [95% CIs] of 1.46 [1.33-1.59] and 1.60 [1.46-1.74], respectively) compared to general clinics.

CONCLUSIONS

HCSCs (especially enhanced HCSCs) provided more emergency house calls, reduced hospitalization, and enabled expected deaths at home, suggesting that further promotion of HCSCs (especially enhanced HSCSs) would be advantageous.

Effect of the COVID-19 Pandemic on Place of Death Among Medicaid and Commercially Insured Patients With Cancer in Washington State

PURPOSE

The COVID-19 pandemic-related disruptions in health care delivery might have affected end-of-life care in patients with cancer. We examined changes in place of death and hospice support for Medicaid and commercially insured patients during the pandemic.

PATIENTS AND METHODS

We linked Washington State cancer registry records with claims from Medicaid and two commercial insurers for patients with solid tumor age 18-64 years. The study included 322 Medicaid and 162 commercial patients who died between March 2017 and June 2019 (pre-COVID-19), along with 90 Medicaid and 47 commercial patients who died between March and June 2020 (COVID-19). Place of death was categorized as hospital, hospice (home or nonhospital facility), and home without hospice. Place of death was compared using adjusted multinomial logistic regressions stratified by payer and time period (pre-COVID-19 v COVID-19). The clinical and sociodemographic factors associated with dying at home without hospice were examined, and adjusted marginal effects (ME) are reported.

RESULTS

In the adjusted pre-COVID-19 analysis, Medicaid patients were more likely than commercially insured patients to die in hospital (48% v 36%; adjusted ME, 11%; P = .02). In the pre-COVID-19/COVID-19 analysis, Medicaid patients' place of death shifted from hospital (48% v 32%; ME, -16%; P < .01) to home without hospice (19.9% v 38.0%; ME, 16.5%; P < .01). However, there were no statistically significant changes pre-COVID-19/COVID-19 for commercial patients. As a result, during COVID-19, Medicaid patients were more likely than commercial patients to die at home without hospice (38% v 22%; ME, 16%; P = .04) as were male versus female patients (ME, 16%; P < .01).

CONCLUSION

The pandemic might have disproportionately worsened the end-of-life experience for Medicaid enrollees with cancer. Attention should be paid to societal and health system factors that decrease access to care for Medicaid patients.

Evaluation of enhanced home care support clinics regarding emergency home visits, hospitalization, and end-of-life care: a retrospective cohort study in a city of Japan

BACKGROUND

To meet the increasing demand for home healthcare in Japan as the population ages, home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in 2006 and 2012, respectively. This study aimed to evaluate whether enhanced HCSCs fulfilled the expected role in home healthcare.

METHODS

We conducted a retrospective cohort study using linked medical and long-term care claims data from a municipality in Japan. Participants were ≥ 65 years of age, had newly started regular home visits between July 2014 and March 2018, and used either conventional or enhanced HCSCs. Patients were followed up for one year after they started regular home visits or until the month following the end of the regular home visits if they ended within one year. The outcome measures were (i) emergency home visits at all hours and on nights and holidays at least once, respectively, (ii) hospitalization at least once, and (iii) end-of-life care, which was evaluated based on the place of death and whether a physician was present at the time of in-home death. Multivariable logistic regression analyses were conducted for the outcomes of emergency home visits and hospitalizations.

RESULTS

The analysis included 802 patients, including 405 patients in enhanced HCSCs and 397 patients in conventional HCSCs. Enhanced HCSCs had more emergency home visits at all hours than conventional HCSCs (65.7% vs. 49.1%; adjusted odds ratio 1.70, 95% CI [1.26-2.28]), more emergency home visits on nights and holidays (33.6% vs. 16.7%; 2.20 [1.55-3.13]), and fewer hospitalizations (21.5% vs. 32.2%; 0.55 [0.39-0.76]). During the follow-up period, 229 patients (152 patients in enhanced HCSCs and 77 patients in HCSCs) died. Deaths at home were significantly more common in enhanced HCSCs than in conventional HCSCs (80.9% vs. 64.9%; p < .001), and physician-attended deaths among those who died at home were also significantly more common in enhanced HCSCs (99.2% vs. 78.0%; p < .001).

CONCLUSIONS

This study confirms that enhanced HCSCs are more likely to be able to handle emergency home visits and end-of-life care at home, which are important medical functions in home healthcare. Further promotion of enhanced HCSCs would be advantageous.

End-of-Life Care of Acute Myeloid Leukemia Compared with Aggressive lymphoma in Patients Who Are Eligible for Intensive Chemotherapy: An Observational Study in a Japanese Community Hospital

Background

Patients with hematological malignancies (HMs) are reported to receive more aggressive care at the end of life (EOL) than patients with solid tumors. However, the reasons behind this occurrence are not fully understood.

Objectives

To examine whether the care at EOL for HMs is mainly because of the disease characteristics or hematologists' attitudes and systems of care, we compared the EOL care of patients with acute myeloid leukemia (AML) and diffuse large B cell lymphoma (DLBCL).

Design

We retrospectively analyzed the EOL care of patients with AML and DLBCL younger than 80 years who were receiving combination chemotherapy at a city hospital in Japan.

Results

Fifty-nine patients with AML and 65 with DLBCL were included. Those with AML received chemotherapy more often within their last 30 days (48% vs. 19%, p < 0.001) and 14 days (37% vs. 1.5%, p < 0.001) of life, and consulted the palliative team less frequently (5.3% vs. 29%, p < 0.001). In the last 3 years, the mortality rate in hematological wards decreased from 74% to 29% in the DLBCL group, but only from 95% to 90% in the AML group. In multivariate analysis, AML (odds ratio [OR] 0.065) and death before 2018 (OR, 0.077) were significant factors associated with reduced referrals to specialized palliative teams.

Conclusion

Patients with AML tend to have lesser access to specialized palliative care and fewer options for their place of death than those with DLBCL. Detailed EOL care plans are needed for these patients, considering the characteristics of the disease.

Factors related to a sense of security with medical and long-term care services among community-dwelling middle-aged and older adults in Japan

AIM

The aim of this study was to identify factors related to a sense of security with regard to medical and long-term care services among middle-aged and older adults. These are for consideration of strategies for the establishment of a community-based integrated care system.

METHODS

A cross-sectional survey was conducted in 2400 men and women aged ≥40 years in two cities. Survey items included a scale for sense of security for medical and long-term care, experience of medical and long-term care services, and social and demographic factors. Data were analyzed using univariate and multiple regression analyses.

RESULTS

In total, 945 respondents were included in the analysis. In multiple regression analysis, sense of security was significantly higher with ability to consult with medical professionals on medical and long-term care, availability of emotional and instrumental support, norm of reciprocity in the community, community attachment, economic comfort, higher age and male gender, and significantly lower with experience of bereavement at a hospital and depression.

CONCLUSIONS

These findings stress the importance of facilitating consultation with medical professionals, support for caregivers of terminally ill patients, and mutual support in the community in a community-based integrated care system. Geriatr Gerontol Int 2022; ••: ••-••.

Experience of the temporary discharge from the inpatient palliative care unit: A nationwide post-bereavement survey for end-of-life cancer patients

Objective

Inpatient palliative care units (PCUs) have two roles: place of death and symptom control. In case of symptom control, most patients whose distressing symptoms could be relieved would be temporarily discharged back home. However, the experience of the patient and their family during temporary discharge is unclear.

Methods

This study is a part of the Japan HOspice and Palliative Care Evaluation Study 3, a nationwide cross-sectional post-bereavement survey. We sent questionnaires to bereaved relatives of cancer patients who died in PCUs in 2018.

Results

Among 968 questionnaires sent, 571 questionnaires were analyzed (59%). Sixteen percent of patients experienced temporary discharge from PCUs. Seventy-two percent of bereaved family members reported that patients said "I am happy to be discharged home." Overall, 22%-37% of participants reported improvement in the patient's condition after discharge. The caregiver's recognition of better patient's quality of life at home and the doctor's assurance of re-hospitalization, if necessary, were significantly associated with positive experience.

Conclusions

Bereaved family members recognized temporal discharge as positive experiences for patients and families. Appropriate home palliative care and discharge planning would contribute to positive experience after discharge.

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.

Factors That Facilitate Discussion and Documentation of End-of-Life Care among Community-Dwelling Older Adults: A Cross-Sectional Study

We aimed to clarify the regional cultural characteristics in areas with different death rates at home, and to identify factors that influence the discussion and documentation of end-of-life care (EOLC) among community-dwelling older adults. This study was a cross-sectional study using a self-administered questionnaire survey, and participants were Japanese older adults. A chi-square test and multiple regression analysis were conducted. Among the 227 respondents, 143 were analyzed. There were no statistical differences by area. Participants who had intentions to discuss EOLC tended to discuss EOLC with their families and family doctors and tended to create documents to show their wills on EOLC (p < 0.05). The following factors that influence the intentions to discuss EOLC were extracted: experience in providing EOLC; information on EOLC; having religious and spiritual beliefs, and not avoiding the subject of death as part of beliefs related to life and death. These results indicate that beliefs and intentions regarding EOLC may be similar across Japan. Moreover, our findings suggest that to increase the interest of older adults on EOLC, it is important to provide opportunities for older adults to share and discuss information about EOLC with healthcare professionals and others who have experience providing EOLC.

Risk factors associated with poorer experiences of end-of-life care and challenges in early bereavement: Results of a national online survey of people bereaved during the COVID-19 pandemic

BACKGROUND

Experiences of end-of-life care and early bereavement during the COVID-19 pandemic are poorly understood.

AIM

To identify clinical and demographic risk factors for sub-optimal end-of-life care and pandemic-related challenges prior to death and in early bereavement, to inform clinical practice, policy and bereavement support.

DESIGN

Online national survey of adults bereaved in the UK (deaths between 16 March 2020 and 2 January 2021), recruited via media, social media, national associations and organisations.

SETTING/PARTICIPANTS

711 participants, mean age 49.5 (SD 12.9, range 18-90). 628 (88.6%) were female. Mean age of the deceased was 72.2 (SD 16.1, range miscarriage to 102 years). 311 (43.8%) deaths were from confirmed/suspected COVID-19.

RESULTS

Deaths in hospital/care home increased the likelihood of poorer experiences at the end of life; for example, being unable to visit or say goodbye as wanted (p < 0.001). COVID-19 was also associated with worse experiences before and after death; for example, feeling unsupported by healthcare professionals (p < 0.001), social isolation/loneliness (OR = 0.439; 95% CI: 0.261-0.739), and limited contact with relatives/friends (OR = 0.465; 95% CI: 0.254-0.852). Expected deaths were associated with a higher likelihood of positive end-of-life care experiences. The deceased being a partner or child also increased the likelihood of positive experiences, however being a bereaved partner strongly increased odds of social isolation/loneliness, for example, OR = 0.092 (95% CI: 0.028-0.297) partner versus distant family member.

CONCLUSIONS

Four clear risk factors were found for poorer end-of-life care and pandemic-related challenges in bereavement: place, cause and expectedness of death, and relationship to the deceased.

Association between temporary discharge from the inpatient palliative care unit and achievement of good death in end-of-life cancer patients: A nationwide survey of bereaved family members

AIM

To explore the unclear association between temporary discharge home from the palliative care unit and achievement of good death, in the background of increases in discharge from the palliative care unit. Association between experiences and circumstances of patient and family and duration of temporary discharge was also examined.

METHODS

This study was a secondary analysis of data from a nationwide post-bereavement survey.

RESULTS

Among 571 patients, 16% experienced temporary discharge home from the palliative care unit. The total good death inventory score (p < .05) and sum of 10 core attributes (p < .05) were significantly higher in the temporarily discharged and stayed home ≥2 weeks group. Among all attributes, "Independent in daily activities" (p < .001) was significantly better in the temporarily discharged and stayed home ≥2 weeks group. Regarding the experience and circumstance of patient and family, improvement of patient's appetite (p < .05), and sleep (p < .05) and peacefulness (p < .05) of family caregivers, compared to the patient being hospitalized, were associated with longer stay at home after discharge.

CONCLUSIONS

Patient's achievement of good death was better in the temporarily discharged and stayed home longer group, but this seemed to be affected by high levels of independence of the patient. Temporary discharge from the palliative care unit and staying home longer was associated with improvement of appetite of patients and better sleep and mental health status of family caregivers. Discharging home from palliative care unit is worth being considered even if it is temporary.

Instruments to assess the burden of care for family caregivers of adult palliative care patients

BACKGROUND

A primary caregiver shares the illness experience of the patient and undertakes vital care work, alongside managing the patient's emotions, and is actively involved in care process without being paid. When faced with the palliative care patient's needs, caregivers are affected on multiple levels (physical, psychological and socio-economic), thereby experiencing a moderate or severe burden of care.

AIM

To identify assessment instruments for the burden of care for family caregivers that are suitable to be used in clinical practice.

METHOD

A narrative review was conducted using an electronic search in Pubmed, PsychINFO, CINAHL of articles published in English between 2009-2019, using the search terms: 'caregiver/family, caregiver/carer and burden and palliative care/hospice/end of life'. An assessment grid was developed to appraise the clinical use of identified instruments.

RESULTS

Of the 568 articles identified, 40 quantitative studies were selected using 31 instruments to measure the caregiver burden of cancer, noncancer and terminally ill patients. Most instruments 23 (74.11%) evaluate the psycho-emotional and, 22 (70.96%) the social domain, 12 instruments (38.7%) focused on the physical domain, three (9.67%) on the spiritual field and six instruments (19.35%) on economic aspects. For the multidimensional instruments, the assessment grid scored highest for the Burden Scale for Family Caregiver (BSFC).

CONCLUSION

The BSFC is the tool that seems to meet the most requirements, being potentially the most useful tool in clinical practice.

Home care nurses more positive about the palliative care that is provided and their own competence than hospital nurses: a nationwide survey

BACKGROUND

People often prefer to stay at home until the end of life, but hospital admissions are quite common. In previous research bereaved relatives were found to be less positive about palliative care in hospital. However, it was not known how the content and quality of palliative care differ between home care and hospitals from the perspectives of hospital nurses and home care nurses and how palliative care in these settings could be improved.

METHODS

A survey was held among hospital and home care nurses, recruited from a nationwide Nursing Staff Panel and through open calls on social media and in an online newsletter. The pre-structured online survey included questions on the palliative care provided, the quality of this care and the respondent's perceived competence in providing palliative care. The questionnaire was completed by 229 home care nurses and 106 hospital nurses.

RESULTS

Most nurses provided palliative care in the physical and psychological domains, fewer provided care in the social and spiritual domains. A higher percentage of home care nurses stated that they provided care in these domains than hospital nurses. Overall, 70% of the nurses rated the quality of palliative care as very good to excellent. This percentage was higher among home care nurses (76.4%) than hospital nurses (59.4%). Moreover, a higher percentage of home care nurses (94.4%) stated they felt competent to a great extent to provide palliative care compared to hospital nurses (84.7%). Competencies regarding the physical domain were perceived as better compared to the competencies concerning the other domains. The nurses recommended paying more attention to inter-professional collaboration and communication, timely identification of the palliative phase and advance care planning, and more time available for palliative care patients.

CONCLUSION

Although the quality of palliative care was rated as very good to excellent by nurses, improvements can still be made, particularly regarding palliative care in hospitals. Although patients often prefer to die at home rather than in hospital, still a considerable number of people do die in hospital; therefore hospital nurses must also be trained and be able to provide high-quality palliative care.

Acute Palliative Physical Therapy Services for a Patient With Metastatic Rectal Cancer and Subsequent Spinal Cord Compression

Colorectal cancer is the third most common cause of cancer-related deaths with approximately 40%-50% of people diagnosed experiencing subsequent metastases. Surgery is the only curative treatment for colorectal cancer, although chemotherapy and radiation are often used neoadjuvantly or adjuvantly to decrease recurrence rates and improve survival. Many individuals experience adverse effects and physical impairments secondary to extensive medical treatment. Therefore, the purpose of this case is to signify the important role of physical therapy in the continuum of care of a patient diagnosed with metastatic rectal cancer and subsequent spinal cord compression. The patient was a 70-year-old male admitted to the hospital for lower extremity (LE) numbness and weakness secondary to metastatic rectal cancer. Seventeen months prior to hospitalization, he was diagnosed with rectal cancer and underwent neoadjuvant chemotherapy and radiation followed by laparoscopic abdominoperineal resection with posterior prostatectomy en bloc with a colostomy. Adjuvant chemotherapy included FOLFIRI. While hospitalized, the patient experienced spinal cord compression secondary to metastasis and elected decompressive laminectomy with discectomy for palliation. Due to the poor prognosis of metastatic rectal cancer, the patient’s functional mobility and independence declined throughout hospitalization. The patient was able to achieve one of two personal goals; he was able to tolerate sitting in an upright position for his daughter’s wedding but unfortunately did not return home prior to expiration. Although the patient suffered eventual mortality, consistent physical therapy allowed him to achieve a major life goal, serving as an important motivator and improved quality of life (QoL) even in end-of-life conditions. Unfortunately, physical therapy services are often overlooked and under-utilized in patients with terminal conditions receiving palliative care, despite the growing body of literature supporting the benefits. By utilizing rehabilitation in reverse as well as skilled maintenance, physical therapy assists in maintaining mobility and achieving personal goals of individuals with terminal cancer, thus improving QoL even with a poor prognosis.

Home-care nurses' community involvement activities and preference regarding the place for end-of-life period among single older adults: A cross-sectional study in Japan

Older adults' preference regarding where they want to spend their end-of-life (EOL) has been reported to be a significant predictor of the actual EOL location. Home-care nurses have often been reported to try involving single older adults' neighbours in the support network of the older adults (community involvement activities) to allow them to stay at home. Hence, nurses' community involvement activities may be among the significant factors of older adults' preference to stay at home during EOL. Therefore, this study explored home-care nurses' community involvement activities and its association with single older adults' EOL preference. A cross-sectional questionnaire survey was conducted with older adults (aged 65 years or older) who lived alone and used home-care nursing services for more than 6 months, their home-care nurses, and managers of their home-care nursing agencies. Questions included participants' characteristics, nurses' community involvement activities and older adults' preference to remain at home during EOL. We conducted multiple logistic regression analyses to explore the relationship between nurses' community involvement activities and older adults' preference to remain at home during EOL while controlling for their demographic variables. In total, 103 pairs of home-care nurses and single older adults from 27 home-care nursing agencies participated. Approximately 70% of older adults preferred to remain at home during EOL, and 50% of nurses implemented community involvement activities. Older adults' preference to remain at home during EOL was associated with implementation of community involvement activities (Odds Ratio [OR]: 3.4; 95% Confidence Interval [95%CI]:1.1-9.8), home-care nurses' higher practical clinical ability (OR: 1.4, 95%CI:1.0-1.8), and older adult's longer use of home-care nursing service (OR: 2.2, 95%CI:1.2-4.1). Community involvement activities may be essential in helping single older adults to stay at home as per their preference for EOL.

"I want to go home": How location at death influences caregiver well-being in bereavement

OBJECTIVES

Goal concordant or congruent care involves having expressed wishes upheld. Yet, the preferred location for end-of-life care may be unaddressed. Caregiver-patient congruence between preferred and actual locations of care may influence the quality of life in bereavement. The study aimed to explore how the congruence between caregiver-patient preferred and actual locations of death influenced well-being in bereavement.

METHODS

Mixed methods were employed. In-depth in-person interviews were conducted with 108 bereaved caregivers of a hospice patient about 4 months after the death. An interview guide was used to collect quantitative and qualitative data: demographics, decision-making, Core Bereavement Items (CBI), Health Related Quality of Life, and perspectives on the end-of-life experiences. Data were analyzed with a convergent mixed methods one-phase process.

RESULTS

Patient preference-actual location congruence occurred for 53%; caregiver preference-actual location congruence occurred for 74%; caregiver-patient preference and location of death occurred for 48%. Participants who reported some type of incongruence demonstrated higher levels of distress, including more days of being physically and emotionally unwell and more intense bereavement symptoms. The Acute Separation subscale and CBI total scores demonstrated significant differences for participants who experienced incongruence compared with those who did not. Preference location congruence themes emerged: (1) caregiver-patient location congruence, (2) caregiver-patient location incongruence, and (3) location informed bereavement.

CONCLUSIONS

Congruence between a dying person's preferred and actual locations at death has been considered good care. There has been little focus on the reciprocity between caregiver-patient wishes. Discussing preferences about the place of end-stage care may not make location congruence possible, but it can foster shared understanding and support for caregivers' sense of coherence and well-being in bereavement.

Healthy days at home: A population-based quality measure for cancer patients at the end of life

BACKGROUND

Healthy Days at Home (HDAH) is a novel population-based outcome measure. In this study, its use as a potential measure for cancer patients at the end of life (EOL) was explored.

METHODS

Patient demographics and health care use among Medicare beneficiaries with cancer who died over the years 2014 to 2017 were identified. The HDAH was calculated by subtracting the following components from 180 days: number of days spent in inpatient and outpatient hospital observation, the emergency room, skilled nursing facilities (SNF), inpatient psychiatry, inpatient rehabilitation, long-term hospitals, and inpatient hospice. How HDAH and its components varied by beneficiary demographics and health care market were evaluated. A patient-level linear regression model with HDAH as the outcome, hospital referral region (HRR) random effects, and market fixed effects were specified, as well as beneficiary age, sex, and comorbidities as covariates.

RESULTS

The 294,751 beneficiaries at the EOL showed a mean number of 154.0 HDAH (out of 180 days). Inpatient (10.7 days) and SNF (9.7 days) resulted in the most substantial reductions in HDAH. Males had fewer adjusted HDAH (153.1 vs 155.7, P < .001) than females; Medicaid-eligible patients had fewer HDAH compared with non-Medicaid-eligible patients (152.0 vs 154.9; P < .001). Those with hematologic malignancies had the fewest number of HDAH (148.9). Across HRRs, HDAH ranged from 10.8 fewer to 10.9 more days than the national mean. At the HRR-level, home hospice was associated with greater HDAH, whereas home health was associated with fewer HDAH.

CONCLUSIONS

HDAH may be a useful measure to understand, quantify, and improve patient-centered outcomes for cancer patients at EOL.

Deaths from hepatocellular carcinoma are more likely to occur in medical facilities than deaths from other cancers: 2003-2018

Place of death is a key indicator of quality of end-of-life care, and most people with a terminal diagnosis prefer to die at home. Home has surpassed the hospital as the most common location of all-cause and total cancer-related deaths in the United States. However, trends in place of death due to hepatocellular carcinoma (HCC), which is uniquely comanaged by hepatologists and oncologists, have not been described. We analysed US death certificate data from 2003 to 2018 for the proportion of deaths over time at medical facilities, nursing facilities, hospice facilities and home, for HCC and non-HCC cancer. The proportion of deaths increased from 0.6% to 15.2% in hospice facilities (P trend < 0.0001) but did not change at home. In multivariable analysis, persons with HCC were more likely than persons with non-HCC cancer to die in medical facilities, while persons with HCC were less likely to die at home.

The Quality of Dying and Death of Advanced Cancer Patients in Palliative Care and Its Association With Place of Death and Quality of Care

The quality of dying and death is currently considered an objective to achieve at the end of life. The aim of this study is to analyze the quality of dying and death of advanced cancer patients in palliative care and its association with place of death and quality of care from the perspective of family caregivers. This is a cross-sectional study. The study sample included 72 family caregivers of advanced cancer patients in palliative care. For the evaluation of the quality of dying and death, the Spanish version of the Quality of Dying and Death Questionnaire was used. Quality of care was evaluated with the Palliative Care Outcome Scale. The mean (SD) total score on the Spanish version of the Quality of Dying and Death Questionnaire was 64.56 (20.97). The quality of dying and death was higher when the patients died at home, 70.45 (19.70), and it was positively correlated with quality of care (r = 0.61). Palliative care contributes to achieving a satisfactory quality of dying and death in Spanish advanced cancer patients. Further studies that evaluate interventions for improving the quality of dying and death in the advanced cancer population are needed.

Are cancer patients living alone more or less likely to achieve a good death? Two cross-sectional surveys of bereaved families

This study examined differences in sociodemographic characteristics and the achievement of a good death between cancer patients who live alone and those who do not live alone prior to death in different settings. Secondary analysis of data collected across two cross-sectional self-reported questionnaire surveys was undertaken. The participants were bereaved family members of cancer patients who had died in palliative care units (PCUs), acute hospitals or homes. We stratified the data by the place of death and examined the differences in sociodemographic characteristics to determine the relationship between cancer patients achieving a "good death" and whether they were living alone. The data were collected through 15,949 surveys. On the Good Death Inventory, significantly higher total scores emerged for cancer patients who were living alone than for those who not living alone in PCUs (effect size [ES] = 0.11, Student's t-test: p < .0001), but not in acute hospitals (ES = -0.03, p = 0.74) or home care services (ES = 0.02, p = 0.86). Cancer patients who were living alone were more likely to have been female, been older and have earned a lower annual income than those who were not living alone. Thus, among those who had received specialized palliative care, there was no difference in the quality of palliative care between cancer patients who were or were not living alone.

Factors associated with the accomplishment of home death among patients receiving physician-led home healthcare

AIM

To evaluate unique factors associated with home death in older Asian individuals who received physician-led home healthcare.

METHODS

We carried out a case-control study at a single hospital in Japan from February 2018 to December 2019. We included patients who had started receiving physician-led home healthcare and died at home as cases, and those receiving the same type of care but died in the hospital as controls. Multivariable logistic regression was used to evaluate factors associated with home death.

RESULTS

A total of 152 patients (mean age 70.3 years [SD 11.2 years]; 86 [56.6%] men) were included, of whom 89 (58.6%) died at home and 63 (41.4%) died in the hospital. Comparing the two groups, the presence of family psychological problems related to care was significantly more common in the hospital death group (home death 49.4%; hospital death 32.3%, P = 0.036). Home death was related to patients aged >85 years compared with patients aged <75 years (adjusted odds ratio 6.47, 95% CI 1.52-27.48) and patients who were in the highest quartile of the number of symptoms (adjusted odds ratio 5.45, 95% CI 1.15-25.95) compared with the lowest. Family members' willingness for the patient to die at home was associated with home death (adjusted odds ratio 7.47, 95% CI 2.13-26.19).

CONCLUSIONS

Older age and multiple symptoms were related to accomplishing home death. Patient preference was not associated with the place of death, but family member preference was. These results might reflect family concepts particular to Asia. Geriatr Gerontol Int 2021; 21: 525-531.

Place of Death and Density of Homecare Resources: A Nationwide Study in Japan

Background

Although more than half of the population of Japan wants to spend their last days at home, approximately only 10% are able to do so. This study examined the associations between death at home and healthcare facility density by municipality based on the analysis of nationwide observed data in Japan.

Methods

We used data on deaths at home and healthcare resources in municipalities across Japan for the fiscal years 2014 and 2017. The proportions of deaths at home by municipality were used as the dependent variable, while healthcare resources (e.g., hospital density) divided by the population of older people in each municipality and municipality-level income were used as independent variables. We applied a fixed-effects regression analysis to examine the association of healthcare resources and municipality-level income with death at home.

Results

Clinics providing home medical care and facilities providing visiting nursing services were positively associated with death at home, with coefficients (95% confidence intervals) of 2.14 (1.12 to 3.15) and 2.19 (0.99 to 3.39), respectively. Stratified analysis showed that these associations were observed in higher income-level municipalities but not in lower income-level municipalities.

Conclusion

Municipalities with a higher density of home care services had higher rates of death at home, whereas municipalities with a higher density of hospitals had lower rates. We recommend the development of policy that allows hospitals to be converted into home care providers so that more people can spend time in peace at home at the end of their lives.

Enhanced home palliative care could reduce emergency department visits due to non-organic dyspnea among cancer patients: a retrospective cohort study

Background

Dyspnea is a common trigger of emergency department visits among terminally ill and cancer patients. Frequent emergency department (ED) visits at the end of life are an indicator of poor-quality care. We examined emergency department visit rates due to dyspnea symptoms among palliative patients under enhanced home palliative care.

Methods

Our home palliative care team is responsible for patient management by palliative care specialists, residents, home care nurses, social workers, and chaplains. We enhanced home palliative care visits from 5 days a week to 7 days a week, corresponding to one to two extra visits per week based on patient needs, to develop team-based medical services and formulate standard operating procedures for dyspnea care.

Results

Our team cared for a total of 762 patients who exhibited 512 ED visits, 178 of which were due to dyspnea (mean ± SD age, 70.4 ± 13.0 years; 49.4% male). Dyspnea (27.8%) was the most common reason recorded for ED visits, followed by pain (19.0%), GI symptoms (15.7%), and fever (15.3%). The analysis of Group A versus Group B revealed that the proportion of nonfamily workers (42.9% vs. 19.4%) and family members (57.1% vs. 80.6%) acting as caregivers differed significantly (P < 0.05). Compared to the ED visits of the Group A, the risk was decreased by 30.7% in the Group B (P < 0.05).

Conclusions

This study proves that enhanced home palliative care with two additional days per week and formulated standard operating procedures for dyspnea could significantly reduce the rate of ED visits due to non-organic dyspnea during the last 6 months of life.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00713-6.

Renal supportive care programs: An observational study assessing impact on hospitalization and survival outcomes

AIM

Renal supportive care (RSC) programs are used to manage non-dialysis end-stage kidney disease (ESKD) patients. The aim of this study was to analyse the impact of RSC programs on hospitalization and survival outcomes in these patients.

METHODS

A retrospective, single-centre observational cohort study of non-dialysis ESKD patients was undertaken. Hospitalizations and survival from eGFR≤15 ml/min was compared between patients managed in an RSC program (RSC group) and patients receiving standard conservative therapy (non-RSC group). Local databases, physician letters and electronic medical records were used for data collection. Prevalent patients from 2013 to 2017 with eGFR ≤15 ml/min were included. Cox proportion hazard testing and generalized linear modelling was undertaken to adjust for confounders.

RESULTS

A total of 172 patients were included (95 RSC; 75 non-RSC). The median age was 82 years [IQR 78-85], 46% were male, the median Charlson-comorbidity Index was 5 [IQR 4-7]. The RSC group had significantly lowered haemoglobin level (102 g/L vs. 111 g/L) and fewer English-speakers (34% vs. 44%). RSC was associated with the decreased number of days in hospital per year (estimated means 46.6 days [95% CI 21-67] vs. 83.2 days [95%CI 60.5-105.8]; p = .01) and decreased number of hospital admissions per year (estimated means 5.4 [95%CI 2.1-8.8] vs. 12.3 [95%CI 8.2-16.4]; p = .01) compared with non-RSC. Median overall survival from eGFR≤15 in the entire cohort was 735 days, with no significant difference between RSC and non-RSC groups (p = .9), both unadjusted and adjusted for confounders.

CONCLUSION

RSC programs can significantly decrease the number and length of hospitalizations in conservatively managed ESKD patients.

Caregiving Experience and Other Factors Associated With Having End-Of-Life Discussions: A Cross-Sectional Study of a General Japanese Population

CONTEXT

The factors associated with end-of-life discussion (EOLD) are not well elucidated; an understanding of these factors may help facilitate EOLD.

OBJECTIVES

To investigate the associations between EOLD and experiences of the death of and/or care for a loved one and other factors.

METHODS

Data from a nationwide anonymous questionnaire survey of public attitudes toward end-of-life medical care, conducted in December 2017 in Japan, were used. Participants were randomly selected from the general population (age ≥ 20 years), and respondents who completed the questionnaire were analyzed (respondents: n = 836; effective response rate: 13.9%). Respondents were divided into two groups based on their experience of EOLD: those who had engaged in EOLD and those who had not. The main predictors were the experiences of the death of and care for a loved one. Multivariable logistic regression analyses were performed.

RESULTS

Of the 836 respondents (male: 55.6%, aged 65 and over: 43.5%), 43.7% reported their engagement in EOLD. In the analyses, "having experience of caring for a loved one" was associated with EOLD compared with never having experience (odds ratio 1.88, 95% confidence interval 1.35-2.64). However, having experience of the death of a loved one had no association.

CONCLUSION

For health-care providers, it may be worth recognizing that the care experience of their patient's caregiver might affect the caregiver's own EOLD in the future.

Caregiver support and place of death among older adults

BACKGROUND/OBJECTIVES

As home becomes the most common place of death in the United States, information about caregiver support and place of death is critical to improve patient and caregiver experiences at end of life. We seek to examine (1) the association between family care availability and place of death; and (2) caregiving intensity associated with place of death.

DESIGN

2017 National Health and Aging Trends Study and National Study of Caregiving; nationally representative cross-sectional study of deceased older adults and last-month-of-life (LML) caregivers.

SETTING

United States; all places of deaths.

PARTICIPANTS

Three-hundred and seventy-five decedents and 267 LML caregivers.

MEASUREMENTS

Place of death (home, hospital, and nursing or hospice facility), family care availability (spouse/partner, household size, number of daughters and sons), caregiving intensity (hours of help provided at LML and a binary indicator for high care-related emotional difficulty).

RESULTS

38.9% of older adults died at home, followed by hospital (33.1%), and nursing or hospice facility (28.0%). In an adjusted multinomial logistic regression, decedents with larger household size (odds ratio [OR]: 0.441; 95% confidence interval [CI]: 0.269-0.724) and more daughters (OR: 0.743 [95% CI: 0.575-0.958]) had lower odds of dying in nursing or hospice facility relative to dying at home. For older adults who died at home, caregivers provided 209.8 h of help at LML. In contrast, when death occurred in nursing or hospice facility, caregivers provided 91.6 fewer hours of help, adjusted for decedent and caregiver characteristics. Dying in hospital was associated with higher odds of caregiver emotional difficulty relative to home deaths (OR: 4.093 [95% CI: 1.623-10.323]).

CONCLUSIONS

Household size and number of daughters are important determinants of place of death. Despite dying at home being associated with more hours of direct caregiving; caregiver emotional strain was experienced as higher for hospital deaths. Better support services for end-of-life caregivers might improve patient and caregiver experiences for home and hospital deaths.

A descriptive analysis of end-of-life discussions for high-grade glioma patients

Background

End-of-life discussions (EOLDs) in patients with high-grade glioma (HGG) have not been well described. Therefore, this study examined the appropriateness of timing and the extent of patient involvement in EOLDs and their impact on HGG patients.

Methods

A cross-sectional survey was conducted among 105 bereaved families of HGG patients at a university hospital in Japan between July and August 2019. Fisher's exact test and the Wilcoxon rank-sum test were used to assess the association between patient participation in EOLDs and their outcomes.

Results

In total, 77 questionnaires were returned (response rate 73%), of which 20 respondents replied with refusal documents. Overall, 31/57 (54%) participated in EOLDs at least once in acute hospital settings, and a significant difference was observed between participating and nonparticipating groups in communicating the patient's wishes for EOL care to the family (48% vs 8%, P = .001). Moreover, >80% of respondents indicated that the initiation of EOLDs during the early diagnosis period with patients and families was appropriate. Most EOLDs were provided by neurosurgeons (96%), and other health care providers rarely participated. Additionally, patient goals and priorities were discussed in only 28% of the EOLDs. Patient participation in EOLDs was not associated with the quality of EOL care and a good death.

Conclusions

Although participation in EOLDs is relatively challenging for HGG patients, this study showed that participation in EOLDs may enable patients to express their wishes regarding EOL care. It is important to initiate EOLDs early on through an interdisciplinary team approach while respecting patient goals and priorities.

A Population-Based Mortality Follow-Back Survey Evaluating Good Death for Cancer and Noncancer Patients: A Randomized Feasibility Study

CONTEXT

Evaluation of end-of-life care is a key element in quality improvement, and population-based mortality follow-back designs have been used in several countries. This design was adapted to evaluate a good death in Japan.

OBJECTIVES

This study aimed to explain the scientific background and rationale for assessing the feasibility of a mortality follow-back survey using a randomized design.

DESIGN

We used a cross-sectional questionnaire survey to assess feasibility using response rate, sample representativeness, effect on response rate with two methods, and survey acceptability.

SETTING/PARTICIPANTS

The subjects were 4812 bereaved family members of patients who died from the major five causes of death: cancer, heart disease, cerebrovascular disease, pneumonia, or kidney failure, using mortality data.

RESULTS

Overall, 682 (14.2%) questionnaires could not be delivered, and 2294 (55.5%) family members agreed to participate in the survey. There was little difference in the distribution of characteristics between the study subjects and the full population, and sample representativeness was acceptable. Sending the questionnaire with a pen achieved a higher response rate than without (weighted: 48.2% vs. 40.8%; P < 0.001). In follow-up contact, there was no difference in response rate between resending the questionnaire and a reminder letter alone (weighted: 32.9% vs. 32.4%; P = 0.803). In total, 84.8% (weighted) of the participants agreed with improving quality of care through this kind of survey.

CONCLUSION

This study demonstrated the feasibility of conducting a population-based mortality follow-back survey using a randomized design. An attached pen with the questionnaire was effective in improving the response rate.

Barriers to end-of-life discussion with advanced cancer patient as perceived by oncologists, certified/specialized nurses in cancer nursing and medical social workers

OBJECTIVE

The objectives of this study were to identify barriers to end-of-life discussion with advanced cancer patients and their families as perceived by oncologists, certified/specialized nurses in cancer nursing (hereafter, collectively referred to as 'nurses') and medical social workers, as well as to clarify their opinions about effective strategies to facilitate end-of-life discussion.

METHODS

A questionnaire survey was distributed to 4354 medical professionals working at 402 designated regional cancer hospitals in Japan. Responses were obtained from 494 oncologists (valid response rate 30.7%), 993 nurses (46.7%) and 387 medical social workers (48.1%).

RESULTS

Among the barriers to end-of-life discussion with advanced cancer patients, factors related to patients and families, such as 'Family members' difficulty accepting loved one's poor prognosis', were recognized as the most important issues, which was the common view shared across the three types of medical professionals who participated in this study. Nurses and medical social workers were significantly more likely than oncologists to recognize as important issues 'Health care team disagreement about goals of care' and 'Lack of training to have conversations for end-of-life discussion'. To facilitate end-of-life discussion, 'providing mental and emotional support for the patients and their families after end-of-life discussion' was needed most as perceived by the respondents regardless of their profession.

CONCLUSIONS

Barriers impeding end-of-life discussion were factors related to patients and their families, and oncologists' close cooperation with nurses and medical social workers is important in providing emotional support for patients and families. To facilitate end-of-life discussion, it is important to share information on patients' prognosis and goals for treatment among oncologists and other medical professionals, as well as strengthen communication skill of these medical professions.