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

Influence of prior knowledge and experience on willingness to pay for home hospice services: a contingent valuation study

Home hospice services contribute to dying in dignity by addressing medical and social needs at the end of life. The respective monetary valuation in a sense of willingness to pay is not available yet. We aim to quantify the benefits of home hospice services to society using society's monetary valuation and examine the influence of prior knowledge and experience on willingness to pay for home hospice services. A nationwide cross-sectional contingent valuation study was conducted in Austria. We analyzed the impact of the determinants of interest on having a positive willingness to pay for home hospice services via multivariate Probit regression. Stated willingness to pay was analyzed using interval regression. Variable selection of potential influence factors and confounders was based on the literature. The variables of interest, prior knowledge of and experience with home hospice services, were represented by twelve related variables. We included 1262 respondents in the analysis. The two-part regression analysis showed a statistically significant positive impact on the probability of having a positive willingness to pay by prior knowledge of home hospice services, prior donations, and the wish of not dying alone. Prior donations also increase the level of willingness to pay. The probability of a positive willingness to pay was statistically significantly lower for respondents that stated to have experienced the death of more than ten close persons and perceived spending time with dying persons as burden than their respective counterparts. Our study provides evidence that information campaigns to increase the recognition and awareness of existing home hospice services could increase their perceived value in society.

Changes in Place of Death of Older Adults during the COVID-19 Pandemic: A Retrospective Study from an Aging Country

In the COVID-19 pandemic, due to the difficulties in patients' applications to health centres, changes have occurred in the places of death of older adults. It is aimed to investigate the change in the places of death of older adults in Turkey, which is one of the countries most affected by the pandemic. Patients admitted to the geriatric outpatient clinic of a university hospital from 01.01.2013 to 29.02.2020 were included. Place and date of death were recorded as hospital or out-of-hospital death. According to results, while the median age of those who died during the pandemic was higher than before (p < 0.001) and during the pandemic, the hospital mortality ratio was higher than before. During the pandemic period, the hospital mortality ratio of older adults has increased in Turkey. This situation, which has occurred despite the increasing healthcare burden, can show the importance of the measures taken and robust health infrastructure.

Community-based palliative care in two primary care settings - nursing homes and home care: a national survey

AIMS

Based on selected themes from a national survey, the study aims to describe and analyse similarities and differences in community-based palliative care provided to people living at home in two different care settings - the nursing home setting and the home care setting.

METHODS

Responses from four palliative care themes covered by a national survey sent to 717 managers in municipality-based care units were used. The themes were: (a) target groups in palliative care; (b) wishes for end-of-life care; (c) tools/guidelines in palliative care; and (d) palliative care provided to relatives.

RESULTS

The response rates were 53% in the nursing home setting and 69% in the home care setting (69%). Both settings had target groups for palliative care, in which significantly more units in the home care settings cared for people with other cultural backgrounds or children. Wishes for end-of-life care were addressed by more than 90% of the units in both settings. There were significantly more nursing home units that addressed questions regarding resuscitation, decision making when you are incapable of making decisions for yourself, and the level of medication. In both settings, around half of the units did not use or did not know if they used tools/guidelines to identify palliative care needs. Half of home care and 65% of nursing home settings did not/were unaware of providing palliative care to relatives.

CONCLUSIONS

Both settings serve target populations for palliative care with few differences. Identifying palliative care needs seemed to be a low priority in both settings. A difference was found between the settings regarding end-of-life care questions and palliative care promotion to relatives.

Registry study of cardiovascular death in Sweden 2013-2019: Home as place of death and specialized palliative care are the preserve of a minority

Background

Palliative care needs in patients with cardiovascular diseases (CVD) are expected to increase. For the planning of equitable palliative care, it is important to understand where people with CVD die. The aim was to examine trends in place of death, associated factors including utilization of specialized palliative services, and to what extent longitudinal development is influenced by national policy.

Methods

A population-level registry study of place of death for adults deceased due to CVD (n = 209 671) in Sweden 2013-2019. Linear regression analysis was applied.

Results

The predominant place of death was nursing home (39.1 %) and hospital (37.6 %), followed by home (22.0 %). From 2013 to 2019 home deaths increased by 2.8 % and hospital deaths decreased by 3.0 %. An overall downward trend was found for dying in hospital compared to dying at home. With variations, this trend was seen in all healthcare regions and for all CVD types, except Stockholm and cerebrovascular disease, with no significant trend. Overall, but with cross-regional variations, 2.1 % utilized specialized palliative services, while 94.2 % had potential palliative care needs. Other variables significantly influencing the trend were age and having had an unplanned healthcare visit.

Conclusion

Despite a slight positive trend, only a minority of people with CVD die in their own home. Regional variations in place of death and the low and varied utilization of specialized palliative services indicate inequity in access to palliative care. Hence, the impact of current national policies is questionable and calls for strengthening through inclusion of early palliative care in specific CVD policies.

Factors for Consideration for Hematological Cancer Patients When Planning for Place of Death: A Constructive Grounded Theory Study

BACKGROUND

Planning for place of death is considered troublesome for patients with hematological cancer. Qualitative studies have focused on healthcare professionals and caregivers. To date, no study has been conducted from the patient's perspective of planning for place of death in the last year of life.

OBJECTIVE

To develop an understanding of how patients with hematological cancer experience planning for place of death in their last year of life.

METHODS

The study used constructivist grounded theory, semistructured interviews, a constant comparison technique, and memoing to collect and analyze data. The 21 participants were attending a cancer center, cancer unit, or hospice in the United Kingdom.

RESULTS

This article describes one core category, factors influencing planning for death, within the incurable hematology cancer illness trajectory through the following 2 subcategories: personal factors-driving away, developing a legacy, designing a death plan, and disease determining; and environmental factors-dependent determination, displacement of the home, and discernment of services.

CONCLUSION

This critical study illustrates that planning for place of death is complex and multifaceted in conjunction with an unpredictable incurable illness trajectory.

IMPLICATIONS FOR PRACTICE

Preferences for the place of death will change over time depending on the illness trajectory experienced by patients with hematological cancer and the level of physical and emotional energy and independence afforded to discuss and plan.

Barriers and facilitators for place of death: A scoping review

OBJECTIVES

Many factors influence where people die, but most people prefer to die at home. Investigating the factors affecting death at different locations can enhance end-of-life care and enable more people to die at their preferred place. The aim was to investigate barriers and facilitators affecting place of death and compare facilitators and barriers across different places of death.

METHODS

A scoping review registered on Open Science Framework was conducted in accordance with the guidelines for Scoping Reviews (PRISMA-ScR). An electronic search of literature was undertaken in MEDLINE, EMBASE, PUBMED, PsycINFO, and CINAHL covering the years January 2013-December 2023. Studies were included if they described barriers and/or facilitators for place of death among adults.

RESULTS

This review identified 517 studies, and 95 of these were included in the review. The review identified the following themes. Illness factors: disease type, dying trajectory, treatment, symptoms, and safe environment. Individual factors: sex, age, ethnicity, preferences, and for environmental factors the following were identified: healthcare inputs, education and employment, social support, economy, and place of residence.

SIGNIFICANCE OF RESULTS

The factors influencing place of death are complex and some have a cumulative impact affecting where people die. These factors are mostly rooted in structural aspects and make hospital death more likely for vulnerable groups, who are also less likely to receive palliative care and advanced care planning. Disease type and social support further impact the location of death. Future research is needed regarding vulnerable groups and their preferences for place of death.

Age- and gender-based social inequalities in palliative care for cancer patients: a systematic literature review

Objectives

Cancer is a major public health problem worldwide, given its magnitude and growing burden, in addition to the repercussions on health and quality of life. Palliative care can play an important role improving quality of life and it is cost-effective, but some population groups may not benefit from it or benefit less based on age and gender inequalities. The aim of this systematic review was to analyze the available evidence on age- and gender-based social inequalities in access to and use of palliative care in cancer patients.

Methods

A systematic review was conducted following the PRISMA guidelines. An exhaustive literature research was performed in Pubmed, CINHAL and Embase until November 2022 and were not restricted by language or date of publication. Eligible studies were observational studies analyzing the access and use of palliative care in cancer patients.

Results

Fifty-three studies were included in the review. Forty-five analyzed age and 44 analyzed gender inequalities in relation to use of and access to palliative care. Our results show that older people receive poorer quality of care, worst symptom control and less preferences for palliative care. In relation to gender, women have a greater preference for the use of palliative care and generally have more access to basic and specialized palliative care services and palliative care facilities.

Conclusion

This review reveals difficulties for older persons and men for access to key elements of palliative care and highlights the need to tackle access barriers for the most vulnerable population groups. Innovative collaborative services based around patient, family and wider community are needed to ensure optimal care.

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

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

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

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

The determinants of actual place of death among noncancer patients with end-stage chronic health conditions: a scoping review

A home is a preferred place of death by most people. Nurses play a key role in supporting end-of-life home care, yet less is known about the factors that determine home as a place of death. This scoping review describes the percentage of actual places of death and determines social factors related to home as the place of death among noncancer patients with end-stage chronic health conditions. Inclusion criteria included (1) noncancer chronic illness conditions, (2) outcomes of place of death, and (3) factors that determine home as a place of death. Sources of evidence included PubMed, CINAHL, and Web of Science databases, which were searched in May 2022, and additional searches from May 2022 to November 2023.The JBI scoping review guide (2020) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review extension were used. Twenty-eight studies were included in this analysis. The range of percentages is varied within the same place of death among the sample. Two major constructs that determine a home as a place of death were identified: preceding factors and social capital. The results suggest that the place of death among noncancer patients with end-stage chronic health conditions should be continued to be understood. Two constructs determined home as a place of death and are considered as a fundamental to increasing equal accessibility in the initiation of palliative care services to promote home death and meet end-of-life care goals.

Trends in the place of death in Sweden from 2013 to 2019 - disclosing prerequisites for palliative care

Background

The drive for home care has increasingly impacted the organization and allocation of resources within the Swedish healthcare system.

Objectives

With an interest in uncovering prerequisites for palliative care, this study aimed to investigate longitudinal trends in place of death within the adult Swedish population from 2013 to 2019 and examine potential associations between place of death and individual, geographic, and socioeconomic factors; hospital capacity; and healthcare utilization.

Methods

This population-level comprehensive register study included all deceased individuals ⩾18 years old with a registered place of death (n = 599,137). Data were retrieved from public and patient data registers and the national register for palliative care. Trends and associations between place of death and co-variables were investigated by logistic regression- and interaction analyses.

Results

From 2013 to 2019, the total number of home deaths increased by 1.9%, whereas the number of hospital deaths decreased by 2.6%. In the overall population of individuals living in their own homes, from 2013 to 2019, the likelihood of dying in hospital versus dying at home decreased (odds ratio: 0.98, 95% confidence interval: 0.97-0.99). Within the population with potential palliative needs living in their own home (78.4%), the likelihood of dying in hospitals equally decreased, except in Stockholm and the north region. For individuals residing in a nursing home, however, the likelihood of dying in hospital versus remaining in the nursing home until death only significantly decreased in the southern region.

Conclusion

The results show a trend towards a decrease in hospital deaths but with cross-regional variations. Still, in 2019, only about one-fifth of all individuals died in their own homes. Public health-oriented interventions aimed at strengthening palliative care resources in nursing homes and home care are suggested.

Place of Death for Young Adults With Chronic Illness

BACKGROUND

Little is known about where young adults with chronic illness die in the United States and factors associated with place of death.

OBJECTIVES

This study aimed to examine place of death and factors associated with place of death for young adults with chronic illness using the most recent national data.

METHODS

Our sample ( N = 405,535) from the National Center for Health Statistics Division of Vital Statistics death certificate data (2003-2018) included young adults (age 18-39 years) who died from chronic conditions common in childhood or young adulthood. Conditions were grouped by underlying pathophysiology (oncological, cardiovascular, neuromuscular, metabolic, hematological/immunological, renal, chromosomal/congenital, gastrointestinal, and respiratory). Place of death was dichotomized into acute care (inpatient, outpatient/emergency room, and dead on arrival) or nonacute care (home, hospice, nursing home/long-term care, other, and unknown). Examined factors were gender, year of death, age, race (White, Black, Asian/Pacific Islander, American Indian/Alaskan Native), cause of death, and city of residence population (100,000 or greater and under 100,000). Descriptive statistics and logistic regression were used to examine factors related to place of death.

RESULTS

Over half of young adults died in acute care settings. Young adults who were Asian/Pacific Islander or Black or who died from a respiratory or renal cause of death were most likely to die in an acute care setting. Rates of acute care death decreased over the studied years.

DISCUSSION

Many young adults died in an acute care setting. Race and cause of death were the most influential factors associated with place of death. Young adults with an oncological cause of death were less likely to die in an acute care setting than patients with other underlying causes. This may indicate that specific care needs or preferences at the end of life may differ in certain disease populations and may affect place of death. Previous research has shown similar results in other developmental populations; however, given the complex psychosocial concerns that often arise during young adulthood, further research is needed to describe how the young adult status may specifically affect place of death.

Factors associated with home death in South Korea: Using the exit data from the Korean Longitudinal Study of Aging, 2008-2018

BACKGROUND

Even though home deaths have been reported to improve quality of life, satisfy patients and families, and reduce healthcare expenditures, not enough is known about the factors that influence home deaths in Korea.

OBJECTIVES

This study aimed to examine the factors associated with home deaths among middle-aged and older adults in South Korea.

METHODS

This secondary data analysis used core interview and exit interview data of the Korean Longitudinal Study of Aging conducted between 2008 and 2018. The deceased included adults over the age of 45 years. The exit data were obtained from interviews with family members or other acquaintances known to the deceased every two years since 2008. Complex-sample logistic regression was conducted using 1,565 middle-aged and older deceased adults.

RESULTS

Among 1,565 decedents, the average age at the time of death was 80.67±10.69 in the home death group, and 78.72±9.83 in the non-home death group. The proportion of home-related deaths was 26.4%. Age over 81 years was associated with increased odds of home death, whereas having two or more living children, living in town/small city, paid medical expenses by children/grandchildren and their spouses, expected death, death from disease, and having three or more chronic diseases were associated with decreased odds of home death. An increase in activities of daily living during three months before death was associated with a decrease in home death.

CONCLUSION

The findings could help healthcare professionals develop tailored interventions to help people die at their preferred place of death based on family characteristics and healthcare accessibility. Age, residential area, number of children and children's financial support, and illness-related factors influenced home death by creating differences in access to healthcare resources and support. Policymakers should decrease healthcare disparities and improve health resource allocation and home-based care.

Cost consequences of unscheduled emergency admissions in cancer patients in the last year of life

OBJECTIVES

Cancer is a leading cause of death. This paper examines the utilisation of unscheduled emergency end-of-life healthcare and estimates expenditure in this domain. We explore care patterns and quantify the likely benefits from service reconfigurations which may influence rates of hospital admission and deaths.

METHODS

Using prevalence-based retrospective data from the Northern Ireland General Registrar's Office linked by cancer diagnosis to Patient Administration episode data for unscheduled emergency care (1st January 2014 to 31st December 2015), we estimate unscheduled-emergency-care costs in the last year of life. We model potential resources released by reductions in length-of-stay for cancer patients. Linear regression examined patient characteristics affecting length of stay.

RESULTS

A total of 3134 cancer patients used 60,746 days of unscheduled emergency care (average 19.5 days). Of these, 48.9% had ≥1 admission during their last 28 days of life. Total estimated cost was £28,684,261, averaging £9200 per person. Lung cancer patients had the highest proportion of admissions (23.2%, mean length of stay = 17.9 days, mean cost=£7224). The highest service use and total cost was in those diagnosed at stage IV (38.4%), who required 22,099 days of care, costing £9,629,014. Palliative care support, identified in 25.5% of patients, contributed £1,322,328. A 3-day reduction in the mean length of stay with a 10% reduction in admissions, could reduce costs by £7.37 million. Regression analyses explained 41% of length-of-stay variability.

CONCLUSIONS

The cost burden from unscheduled care use in the last year of life of cancer patients is significant. Opportunities to prioritise service reconfiguration for high-costing users emphasized lung and colorectal cancers as offering the greatest potential to influence outcomes.