Patterns of dying: palliative care for non-malignant disease

Prognostic models and factors identifying end-of-life in non-cancer chronic diseases: a systematic review

BACKGROUND

Precise prognostic information, if available, is very helpful for guiding treatment decisions and resource allocation in patients with non-cancer non-communicable chronic diseases (NCDs). This study aimed to systematically review the existing evidence, examining prognostic models and factors for identifying end-of-life non-cancer NCD patients.

METHODS

Electronic databases, including Medline, Embase, CINAHL, Cochrane Library, PsychINFO and other sources, were searched from the inception of these databases up until June 2023. Studies published in English with findings mentioning prognostic models or factors related to identifying end-of-life in non-cancer NCD patients were included. The quality of studies was assessed using the Quality in Prognosis Studies tool.

RESULTS

The analysis included data from 41 studies, with 16 focusing on chronic obstructive pulmonary diseases (COPD), 10 on dementia, 6 on heart failure and 9 on mixed NCDs. Traditional statistical modelling was predominantly used for the identified prognostic models. Common predictors in COPD models included dyspnoea, forced expiratory volume in 1 s, functional status, exacerbation history and body mass index. Models for dementia and heart failure frequently included comorbidity, age, gender, blood tests and nutritional status. Similarly, mixed NCD models commonly included functional status, age, dyspnoea, the presence of skin pressure ulcers, oral intake and level of consciousness. The identified prognostic models exhibited varying predictive accuracy, with the majority demonstrating weak to moderate discriminatory performance (area under the curve: 0.5-0.8). Additionally, most of these models lacked independent external validation, and only a few underwent internal validation.

CONCLUSION

Our review summarised the most relevant predictors for identifying end-of-life in non-cancer NCDs. However, the predictive accuracy of identified models was generally inconsistent and low, and lacked external validation. Although efforts to improve these prognostic models should continue, clinicians should recognise the possibility that disease heterogeneity may limit the utility of these models for individual prognostication; they may be more useful for population level health planning.

Quality of death in patients in advanced chronic liver disease and cancer patients managed by gastroenterologists in Portugal: are we doing it right?

INTRODUCTION

The incidence of chronic progressive diseases is rising and investment on quality of death and dying is of utmost importance to minimize physical and emotional suffering. There is still a gap in palliative care (PC) between patients with cancer and those with advanced chronic liver disease (ACLD). Our objectives were to characterize clinical attitudes and therapeutic interventions and to evaluate the differences in end-of-life care between inpatients with cancer and ACLD under gastroenterology care.

METHODS

Retrospective cohort study, including patients with cancer or ACLD who died in a Gastroenterology department between 2012 and 2021. Demographic characteristics, clinical and endoscopic procedures and symptom control were compared between the groups.

RESULTS

From 150 patients, 118 (78.7%) died with cancer and 32 (21.3%) died from ACLD without concomitant hepatocellular carcinoma. ACLD patients were more frequently male ( P  = 0.001) and younger ( P  = 0.001) than patients with cancer. Median time of hospitalization in the last month of life was 16 days for both groups. Discussion of prognosis with the patient was more frequent for cancer patients (35.6% versus 3.2%, P  < 0.001). Referral to PC occurred in 18.8% and 61% of the patients with ACLD and cancer respectively ( P  < 0.001). Endoscopic procedures were performed in half of the patients and were more likely to be unsuccessful in those with cancer.

CONCLUSION

Clinical decisions were different between groups in terms of PC access and discussion of prognostic with the patient. It is urgent to define and implement metrics of quality of death and dying to prevent potentially inappropriate treatment.

Palliative medicine trainees be should learn about frailty: meta-synthesis and Delphi study to establish curriculum content

OBJECTIVES

Frailty is common and highly associated with morbidity and mortality, a fact that has been highlighted by COVID-19. Understanding how to provide palliative care for frail individuals is an international priority, despite receiving limited mention in Palliative Medicine curricula or examinations worldwide. This study aimed to synthesise evidence and establish expert consensus on what should be included in a Palliative-Medicine Specialist Training Curriculum for frailty.

METHODS

Literature Meta-synthesis conducted by palliative medicine, frailty and education experts produced a draft curriculum with Bologna based Learning-Outcomes. A Delphi study asked experts to rate the importance of Learning-Outcomes for specialist-training completion and propose additional Learning-Outcomes. This process was repeated until 70% consensus was achieved for over 90% of Learning-Outcomes. Experts divided Learning-Outcomes into specific (for inclusion in a frailty subsection) or generic (applicable to other palliative conditions). The Delphi panel was Subject Matter Experts: Palliative-Medicine Consultants (n=14) and Trainees (n=10), representing hospital, community, hospice and care home services and including committee members of key national training organisations. A final reviewing panel of Geriatric Medicine Specialists including experts in research methodology, national training requirements and frailty were selected.

RESULTS

The meta-synthesis produced 114 Learning-Outcomes. The Delphi Study and Review by Geriatric Medicine experts resulted in 46 essential and 33 desirable Learning-Outcomes.

CONCLUSIONS

This frailty curriculum is applicable internationally and highlights the complex and unique palliative needs of frail patients. Future research is required to inform implementation, educational delivery and service provision.

Palliative Care and Multi-Agent Systems: A Necessary Paradigm Shift

Palliative care is intended to relieve caregivers of physical, psychological, and even spiritual elements of care. One of the most prevalent issues facing this form of care is a lack of healthcare resources and structures to deal with an aging population. This aging population is placing a strain on the healthcare system, prompting a need for a shift in system management. A potential answer to this issue may be the Multi-Agent System (MAS). This category of computerized networking system was created by programmers to gather relevant health information on a patient and allow for the system to act with other agents to decide the best course for disease management. It can also allow for a multidisciplinary healthcare team to make more informed plans of actions for their patients by providing accurate and up-to-date information resulting from a greater synergetic mesh. MASs could fulfill the demands of a rising chronic illness population and deliver high-quality care, indicating a major paradigm shift within the US. In this review, we will evaluate the aging population and contributing factors, palliative care and the need for the multi-agent system, and clinical considerations involving examples from healthcare systems both on and beyond US shores.

Clinical frailty and performance scale translation in palliative care: scoping review

BACKGROUND

Frailty is associated with advancing age and increases the risk of adverse outcomes and death. Routine assessment of frailty is becoming more common in a number of healthcare settings, but not in palliative care, where performance scales (eg, the Australia-modified Karnofsky Performance Status Scale (AKPS)) are more commonly employed. A shared understanding of performance and frailty measures could aid interspecialty collaboration in both end-of-life care research and clinical practice.

AIMS

To identify and synthesise evidence comparing measures of performance routinely collected in palliative care with the Clinical Frailty Scale (CFS), and create a conversion chart to support interspecialty communication.

METHODS

A scoping literature review with comprehensive searches of PubMed, Web of Science, Ovid SP, the Cochrane Library and reference lists. Eligible articles compared the CFS with the AKPS, Palliative Performance Scale (PPS), Karnofsky Performance Scale or Eastern Cooperative Oncology Group Performance Status or compared these performance scales, in patients aged >18 in any setting.

RESULTS

Searches retrieved 3124 articles. Two articles directly compared CFS to the PPS. Thirteen studies translated between different performance scores, facilitating subsequent conversion to CFS, specifically: AKPS/PPS 10/20=very severe frailty, AKPS/PPS 30=severe frailty, AKPS/PPS 40/50=moderate frailty, AKPS/PPS60=mild frailty.

CONCLUSION

We present a tool for converting between the CFS and performance measures commonly used in palliative care. A small number of studies provided evidence for the direct translation between CFS and the PPS. Therefore, more primary evidence is needed from a wider range of population settings, and performance measures to support this conversion.

Prognostic value of the Surprise Question for one-year mortality in older patients: a prospective multicenter study in acute geriatric and cardiology units

OBJECTIVES

To determine the prognostic value of the Surprise Question (SQ) in older persons.

METHODS

A multicenter prospective study, including patients aged 75 years or older admitted to acute geriatric (AGU) or cardiology unit (CU). The SQ was answered by the treating physician. Patients or relatives were contacted after 1 year to determine 1-year survival. Logistic regression was used to explore parameters associated with SQ. Summary ROC curves were constructed to obtain the pooled values of sensitivity and specificity based on a bivariate model.

RESULTS

The SQ was positive (death within 1 year is no surprise) in 34.7% AGU and 33.3% CU patients (p = 0.773). Parameters associated with a positive SQ were more severe comorbidity, worse functionality, significant weight loss, refractory symptoms and the request for palliative care by patient or family. One-year mortality was, respectively, 24.9% and 20.2% for patients hospitalized on AGU and CU (p = 0.319). There was no difference in sensitivity or specificity, respectively, 64% and 77% (AUC 0.635) for AGU versus 63% and 76% (AUC 0.758) for CU (p = 0.870). A positive SQ is associated with a significant shorter time until death (HR 5.425 (95% CI 3.332-8.834), p < 0.001) independently from the ward.

CONCLUSION

The Surprise Question is moderately accurate to predict 1-year mortality in older persons hospitalized on acute geriatric and cardiologic units.

Availability as key determinant in the palliative home care setting from the patients' and family caregivers' perspectives: A quantitative-qualitative-content analysis approach

OBJECTIVE

A sense of security is important in palliative home care. Yet, knowledge about which components contribute most to feeling secure from the patients' and family caregivers' perspectives, especially since the introduction of specialist palliative home care, is sparse. The goal of the current study was to determine the key components contributing to a sense of security and how they relate to each other as experienced by patients and family caregivers in specialist and generalist palliative home care.

METHODS

The current sub-study, as part of a larger study, was performed in different regions in Germany. Palliative care patients and family caregivers of at least 18 years of age, being cared for at home were interviewed using semi-structured interview guides following a three-factor model and analyzed by using a combined quantitative-qualitative-content approach.

RESULTS

One hundred and ninty-seven patients and 10 carers completed interviews between December 2017 and April 2019. The majority of patients were diagnosed with an oncological disease. Sense of security was mentioned particularly often suggesting its high relevance. We identified nine subcategories that were all mentioned more frequently by specialist than generalist palliative home care recipients in the following order of priority and relation: (i) patient-centeredness: availability, provision of information/education, professional competence, patient empowerment, and trust (ii) organizational work: comprehensive responsibility, external collaboration, and internal cooperation, and (iii) direct communication.

SIGNIFICANCE OF RESULTS

The work of specialist palliative home care services in particular was perceived as very effective and beneficial. Our findings confirm a previously developed three-factor model allowing for generalizability and revealed that availability was most important for improving the sense of security for effective palliative home care.

Optimal timing for hospice-shared care initiation in terminal cancer patients

PURPOSE

The existing concept suggests early palliative and hospice therapy for a better quality of care (QOC) and less medical expense in terminal cancer patients, but the time points of "early" initiation were defined by pre-set study protocol rather than the real-world data. The study aimed to determine the optimal timing of initiating palliative care for patients with terminal cancer.

METHODS

This retrospective population-based study was conducted using a nationwide database. We extracted patients with cancer who were in their last year of lives in the period from 1 January 2010 to 31 December 2013 and categorized them into two groups ("hospice-shared care" (HSC) group and "usual care" (UC) group) after a matching process. Subsequently, we used a generalized linear mixed-effects model to compare the QOC and medical expenses between groups.

RESULTS

After the selection and matching process, we enrolled 1714 patients (67.7 ± 13.2 years, 62.7% male) categorized into the HSC and UC groups (n = 857 in each group). The HSC groups showed generally better QOC in the four indices (with emergency room visit, hospitalization, intensive care unit admission, and receiving chemotherapy) than the UC group in those who initiated HSC 8-60 days before death. The HSC group also had significantly lower medical expenses than the UC group in those who initiated HSC 15-90 days before death.

CONCLUSIONS

Among patients with terminal cancer, HSC initiation before the last 8 days and 15 days of lives can effectively improve QOC and save medical expenses, respectively.

Neuropalliative care: An integrative review of the nursing literature

BACKGROUND

In the last few decades, research and clinical care have attempted to identify and meet the palliative care needs, concerns and challenges of patients of all ages with neurologic disease, under the newly defined subspecialty of neuropalliative care. However, the role of nurses in care organization and provision, as well as nursing priorities with regards to the needs and concerns of patients and families, have not been well articulated. The purpose of this review is to outline priorities in neuropalliative care nursing and examine what questions have been investigated to date.

METHODS

The integrative review approach was used to produce an analysis of existing nursing literature on neuropalliative care. As the broadest of research review methods, integrative review includes experimental and non-experimental research, as well as theoretical work, allowing us to engage with concepts and evidence from multiple perspectives.

RESULTS AND DISCUSSION

Six themes of concern for nursing care and research were identified: (1) managing a heavy symptom burden, (2) unmet care needs, (3) the need for care pathways and protocols, (4) caregiver burden, (5) poor recognition of the dying, and (6) the impact of communication and cognition changes. An analysis and critique of the literature yielded the following recommendations for clinical and research priorities: (1) a paradigm shift in how neurologic disorders is perceived and managed, (2) redefining the scope of neuropalliative care and services, (3) understanding and addressing the needs of family members and caregivers and including them in assessments, care planning and provision; (4) having the difficult conversations and asking the right questions.

CONCLUSIONS

Nurses and nursing studies pay attention to things that matter to patients and their families. As the health professionals who spend the most time with patients and families at the bedside and in the community, nurses are well placed to build strong relationships, recognize needs and concerns, and recommend strategies and interventions to enhance comfort and alleviate suffering. In neuropalliative care nursing, this relational engagement becomes critical since patients experience changes to their cognition and communication as a result of disease progression. To enhance patient agency during a vulnerable time, methodologies to include patients who think and communicate differently in clinical care and research are urgently needed. Tweetable abstract: Neuropalliative nursing researchers call for better prognostication, recognition of the dying process, including patients in care decisions.

GPs' perspective on End-of-Life Care - an evaluation based on the German version of the General Practice End of Life Care Index

Objective: General practitioners (GPs) play a key role in the provision of general outpatient palliative care (AAPV) for the majority of patients at the end of life. The aim of this study was to evaluate the quality of End-of-Life Care (EoLC) from a GPs’ perspective using the German version of the General Practice End of Life Care Index (GP-EoLC-I).

Methods: Between autumn 2018 and spring 2019, all registered and eligible GPs in two counties in Lower Saxony (n=190) were asked to participate in a survey on EoLC using the German version of the self-assessment questionnaire GP-EoLC-I. The index comprises two subscales: clinical care (13 items) and practice organisation (12 items). The summated index of both subscales measures the quality of EoLC by GPs (25 items; range 14–40). The questionnaire was supplemented by questions on sociodemographic data, indicators for good palliative care (PC) and requirements to improve PC. Quantitative data were analysed by descriptive statistics and free text answers by conventional content analysis according to Hsieh and Shannon.

Results: 52 GPs (females: n=16) of 34 practices (single practices: n=26) participated in the study. The mean GP-EoLC-I was 27.5 (SD 4.5). The items revealed potential for improvement: systematic identification of patients with potential PC needs, multidisciplinary case conferences to discuss PC patients, application of care protocols and symptom assessment tools, documentation of patients’ wishes and beliefs as well as inclusion of family and carers. Regarding the indicators for good PC, the most relevant indicators from the GPs’ perspective were collaboration and coordination, integration of relatives, advance care planning and documentation. As requirements to improve PC, GPs highlighted further training and the use of standardised tools such as instruments to support the systematic identification of PC patients.

Conclusions: To our knowledge for the first time in Germany, an internationally tested self-assessment questionnaire measuring the quality of EoLC by GPs was applied. The GP-EoLC-I in this study was slightly lower than the index of GPs in the United Kingdom. Including relatives and family carers, implementing tools to support early identification of PC patients and strengthening cooperation between GPs and other stakeholders in PC may be promising approaches to improve general PC and EoLC in Germany.

Healthcare utilisation in the last year of life in internal medicine, young-old versus old-old

Background

With increasing cost of healthcare in our aging society, a consistent pain point is that of end-of-life care. It is particularly difficult to prognosticate in non-cancer patients, leading to more healthcare utilisation without improving quality of life. Additionally, older adults do not age homogenously. Hence, we seek to characterise healthcare utilisation in young-old and old-old at the end-of-life.

Methods

We conducted a single-site retrospective review of decedents under department of Advanced Internal Medicine (AIM) over a year. Young-old is defined as 65–79 years; old-old as 80 years and above. Data collected was demographic characteristics; clinical data including Charlson Comorbidity Index (CCI), FRAIL-NH and advance care planning (ACP); healthcare utilisation including days spent in hospital, hospital admissions, length of stay of terminal admission and clinic visits; and quality of end-of-life care including investigations and symptomatic control. Documentation was individually reviewed for quality of communication.

Results

One hundred eighty-nine older adult decedents. Old-old decedents were mostly females (63% vs. 42%, p = 0.004), higher CCI scores (7.7 vs 6.6, p = 0.007), similarly frail with lower polypharmacy (62.9% vs 71.9%, p = 0.01). ACP uptake was low in both, old-old 15.9% vs. young-old 17.5%. Poor prognosis was conveyed to family, though conversation did not result in moderating extent of care.

Old-old had less healthcare utilisation. Adjusting for sex, multimorbidity and frailty, old-old decedents had 7.3 ± 3.5 less hospital days in their final year. Further adjusting for cognition and residence, old-old had 0.5 ± 0.3 less hospital admissions. When accounted for home care services, old-old spent 2.7 ± 0.8 less hospital days in their last admission.

Conclusion

There was high healthcare utilisation in older adults, but especially young-old. Enhanced education and goal-setting are needed in the acute care setting. ACP needs to be reinforced in acute care with further research to evaluate if it reduces unnecessary utilisation at end-of-life.

Palliative and End-of-Life Care: Vital Aspects of Holistic Diabetes Care of Older People With Diabetes

Palliative and end-of-life care and advance care planning are important components of holistic diabetes management, especially for older people with a long duration of diabetes and comorbidities who experience unpleasant symptoms and remediable suffering. Many diabetes clinicians do not have conversations about advance care planning with people with diabetes, often because they are reluctant to discuss these issues and are not familiar with palliative care. This article outlines palliative, terminal, and end-of-life care for older people with type 1 or type 2 diabetes and suggests when to consider changing the focus on tight blood glucose control to a focus on safety and comfort. It proposes strategies to incorporate palliative and end-of-life care into personalized holistic diabetes care, determined with older people with diabetes and their families through shared decision-making.

Hospitalisation at the end of life among cancer and non-cancer patients in Denmark: a nationwide register-based cohort study

OBJECTIVES

End-of-life hospitalisations may not be associated with improved quality of life. Studies indicate differences in end-of-life care for cancer and non-cancer patients; however, data on hospital utilisation are sparse. This study aimed to compare end-of-life hospitalisation and place of death among patients dying from cancer, heart failure or chronic obstructive pulmonary disease (COPD).

DESIGN

A nationwide register-based cohort study.

SETTING

Data on all in-hospital admissions obtained from nationwide Danish medical registries.

PARTICIPANTS

All decedents dying from cancer, heart failure or COPD disease in Denmark between 2006 and 2015.

OUTCOME MEASURES

Data on all in-hospital admissions within 6 months and 30 days before death as well as place of death. Comparisons were made according to cause of death while adjusting for age, sex, comorbidity, partner status and residential region.

RESULTS

Among 154 235 decedents, the median total bed days in hospital within 6 months before death was 19 days for cancer patients, 10 days for patients with heart failure and 11 days for patients with COPD. Within 30 days before death, this was 9 days for cancer patients, and 6 days for patients with heart failure and COPD. Compared with cancer patients, the adjusted relative bed day use was 0.65 (95% CI, 0.63 to 0.68) for heart failure patients and 0.68 (95% CI, 0.66 to 0.69) for patients with COPD within 6 months before death. Correspondingly, this was 0.65 (95% CI, 0.63 to 0.68) and 0.70 (95% CI, 0.68 to 0.71) within 30 days before death.Patients had almost the same risk of dying in hospital independently of death cause (46.2% to 56.0%).

CONCLUSION

Patients with cancer, heart failure and COPD all spent considerable part of their end of life in hospital. Hospital use was highest among cancer patients; however, absolute differences were small.

End-of-Life Care in Cystic Fibrosis: Comparing Provider Practices Based on Lung Transplant Candidacy

Background: The optimal timing to introduce palliative care (PC) and end-of-life (EOL) conversations into the lives of people with cystic fibrosis (CF) has not been established. Objective: Compare EOL care practices for people with CF who died without a lung transplant (LT), are living without an LT, and those who received an LT. Design: Retrospective chart review. Setting/Subjects: People with CF who received care from 2012 to 2017 at the University of Texas Southwestern Medical Center. Measurements: Primary outcomes were (1) EOL discussion with a pulmonologist, (2) time of EOL discussion before death or LT, (3) evaluation by PC, and (4) documentation of advanced directive or medical power of attorney. Results: Twenty-three patients died without LT, 40 patients received an LT, and 222 were living without an LT. Among LT recipients, 10% had EOL conversations compared with 74% of deceased patients and 5% of living patients without LT (p = 0.001). Among deceased patients, 39% had EOL conversations more than six months before death, while 5% of transplanted patients had EOL conversation more than six months before LT (p < 0.001). Deceased patients were more likely to have seen PC (57%) than either patients who received LT (2%) or those living without LT (3%, p = 0.0001). Conclusions: Patients who died without LT were more likely to have seen PC and had an EOL conversation than patients who received LT or who are living without LT. Further research should explore the optimal timing to discuss EOL care and the best timing to involve PC.

Differences in medical costs for end-of-life patients receiving traditional care and those receiving hospice care: A retrospective study

Background

Hospice care has a positive effect on medical costs. The correlation between survival time after receiving hospice care and medical costs has not been previously investigated in the literature on Taiwan. This study aimed to compare the differences in medical costs between traditional care and hospice care among end-of-life patients with cancer.

Methods

Data from Taiwan’s National Health Insurance program on all patients who had passed away between 2010 and 2013 were used. Those whose year of death was between 2010 and 2013 were defined as end-of-life patients. The patients were divided into two groups: traditional care and hospice care. We then analyzed the differences in end-of-life medical cost between the two groups.

Results

From 2010 to 2013, the proportion of patients receiving hospice care significantly increased from 22.2% to 41.30%. In the hospice group, compared with the traditional group, the proportions of hospital stays over 14 days and deaths in a hospital were significantly higher, but the proportions of outpatient clinic visits; emergency room admissions; intensive care unit admissions; use of ventilator; use of cardiopulmonary resuscitation; and use of hemodialysis, surgery, and chemotherapy were significantly lower. Total medical costs were significantly lower. A greater number of days of survival for end-of-life patients when receiving hospice care results in higher saved medical costs.

Conclusion

Hospice care can effectively save a large amount of end-of-life medical costs, and more medical costs are saved when patients are referred to hospice care earlier.

Pharmacovigilance in Hospice/Palliative Care: De-Prescribing Combination Controlled Release Oxycodone-Naloxone

Background: Pharmacovigilance studies in hospice/palliative care provide extra information to improve medication safety. Combination controlled release oxycodone-naloxone offers an alternative opioid with less risk of opioid-induced constipation. Objective: To examine why palliative care clinicians chose to cease oxycodone-naloxone and to explore immediate and short-term benefits and harms of this medication change. Design: A consecutive cohort study. Setting: 112 adults from 13 palliative care centers. Measurements: Reasons for ceasing medication and the harms and benefits that followed this 24 and 72 hours later. Symptom burdens were summarised by the National Cancer Institute Common Terminology Criteria for Adverse Events Toxicity Gradings. Results: Combination medication was most commonly ceased because of poor pain control or impaired hepatic function. The last median oral morphine equivalent oxycodone dose before the switch was 45 mg (range 7.5-240 mg) with 76 switched to an alternative long-acting opioid (initial median oral morphine equivalent dose being 45 mg [range 5-210 mg]). Subgroup analysis of those switched because of clinicians' concerns about hepatic dysfunction demonstrated this group were receiving significantly lower opioid doses pre-cessation compared to those switched because of other reasons( p = 0.007). Regardless of why the medication was changed, improvements in pain and constipation scores were seen, the latter associated with an attendant increase in laxatives. Conclusions: This preliminary work suggests that despite theoretical concerns regarding the effect of the naloxone on opioid doses, most people were switched safely to very similar opioid doses with attendant improvements in pain control.

Acute Care Utilization and Place of Death among Patients Discharged from an Inpatient Palliative Care Unit

Background: Discharging patients from inpatient palliative care units to the community is aligned with patients' desires to be cared for and die at home. However, there is little research examining patient outcomes after discharge. Objective: To describe the outcomes of patients discharged from an inpatient palliative care unit. Design: A single-institution retrospective cohort study using medical record data linked to regional acute care hospital and home care data. Setting/Participants: Patients (n = 75) discharged to the community over a one-year period from a 31-bed inpatient palliative care unit in an academic continuing care facility. Measurements: Survival, postdischarge hospitalizations and emergency department visits, and place of death. Results: Patients discharged to the community had poor prognosis. Over one-third had a discharge Palliative Performance Score <50. The median survival after discharge was 96 days, and 36% of decedent patients died in an acute care hospital. Thirteen percent of patients were hospitalized, and 23% visited an emergency department within 30 days of discharge, often for reasons that could have been managed in the community. Certain groups of patients were at greater risk of acute care use and in-hospital deaths, including younger patients, patients with nonmalignant diseases, and patients discharged home or retirement home, compared to long-term care settings. Conclusions: Patients discharged from an inpatient palliative care setting are at risk of postdischarge hospitalizations, emergency department visits, and in-hospital deaths, despite having community supports in place. Variations in outcomes can point to groups of patients who may require greater intensity of supports postdischarge.

What do young doctors know of palliative care; how do they expect the concept to work? : A 'palliative care' knowledge and opinion survey among young doctors

Objectives

Discipline of palliative care is still evolving in developed parts of the world while it remains at an infantile stage in Sri Lanka which has not been formally assessed as of today. We aimed at evaluating the level of palliative care knowledge and opinions among young medical graduates. A descriptive cross-sectional study was carried out among pre-residency medical graduates of Sri Lanka through a social media based online survey. The pre-tested questionnaire assessed the level of knowledge on general principles, service organization, clinical management and ethical considerations while it also evaluated their opinions.

Results

Response rate was 35.8% (n = 351). The average score among the respondents was 37.25% [standard deviation (SD) = 11.975]. Specific knowledge on “general principles” was adequate (score ≥ 50%) with an average of 62.61%, SD = 24.5 while “ethics” was observed to be the area with the poorest knowledge (average score = 19.55%, SD = 22). Average scores for “service organization” and “managerial aspects” were 34.54%, SD = 17.6 and 32.26%, SD = 22.3, respectively. The majority (> 90%) believed that de-novo establishment of hospice, hospital and community-based palliative services would sustainably improve holistic patient care. Measures must be taken to optimize basic palliative care knowledge among the undergraduates in view of achieving Universal Health Coverage in the long term.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4462-2) contains supplementary material, which is available to authorized users.

Does comprehensive geriatric assessment (CGA) in an outpatient care setting affect the causes of death and the quality of palliative care? A subanalysis of the age-FIT study

PURPOSE

The purposes of this study were to retrospectively study whether comprehensive geriatric assessment (CGA) given to community-dwelling old patients with high health care usage has effects regarding: (1) the cause of death and (2) the quality of the provided palliative care when compared to patients without CGA-based care.

METHOD

This study includes secondary data from a randomised controlled trial (RCT) with 382 participants that took place in the periods 2011-2013. The present study examines all electronical medical records (EMR) from the deceased patients in the original study regarding cause of death [intervention group (IG) N = 51/control group (CG) N = 66] and quality of palliative care (IG N = 33/CG N = 41). Descriptive and comparative statistics were produced and the significance level was set at p < 0.05.

RESULTS

The causes of death in both groups were dominated by cardiovascular and cerebrovascular diseases with no statistical difference between the groups. Patients in the intervention group had a higher degree of support from specialised palliative care teams than had the control group (p = 0.01).

CONCLUSION

The present study in an outpatient context cannot prove any effects of CGA on causes of death. The study shows that CGA in outpatient care means a higher rate of specialised palliative care, but the study cannot show any effects on the palliative quality parameters measured. Further studies with statistical power are needed.

Who finds the road to palliative home care support? A nationwide analysis on the use of supportive measures for palliative home care using linked administrative databases

Background

Many countries developed supportive measures for palliative home care, such as financial incentives or multidisciplinary palliative home care teams. For policy makers, it is important to evaluate the use of these national palliative home care supportive measures on a population level.

Methods and findings

Using routinely-collected data on all deaths in Belgium in 2012 (n = 107,847) we measured the use of four statutory supportive measures, specifically intended for patients who have obtained the legal palliative status, and three non-statutory supportive measures. Factors associated with uptake were analysed using multivariable logistic regression. Of all deaths of adult home-dwelling persons in Belgium (n = 87,007), 17.9 percent used at least one statutory supportive measure and 51.5 percent used at least one non-statutory supportive measure. In those who died of an illness indicative of palliative care needs 33.1 percent used at least one statutory supportive measure and 62.2 percent used at least one non-statutory supportive measure. Younger people and persons dying from cancer were more likely to use a statutory policy measure. Older people and persons dying from COPD were most likely to use a non-statutory policy measure. Women, non-single people, and those living in less urbanised areas were most likely to use any supportive measure.

Conclusions

Statutory supportive measures for palliative home care are underused, even in a subpopulation of persons with potential palliative care needs. Policy makers should stimulate an equitable uptake, and reducing the observed inequalities is an important focus for health care policy.

Lower Extremity Amputation and Health Care Utilization in the Last Year of Life among Medicare Beneficiaries with ESRD

BACKGROUND

Lower extremity amputation is common among patients with ESRD, and often portends a poor prognosis. However, little is known about end-of-life care among patients with ESRD who undergo amputation.

METHODS

We conducted a mortality follow-back study of Medicare beneficiaries with ESRD who died in 2002 through 2014 to analyze patterns of lower extremity amputation in the last year of life compared with a parallel cohort of beneficiaries without ESRD. We also examined the relationship between amputation and end-of-life care among the patients with ESRD.

RESULTS

Overall, 8% of 754,777 beneficiaries with ESRD underwent at least one lower extremity amputation in their last year of life compared with 1% of 958,412 beneficiaries without ESRD. Adjusted analyses of patients with ESRD showed that those who had undergone lower extremity amputation were substantially more likely than those who had not to have been admitted to-and to have had prolonged stays in-acute and subacute care settings during their final year of life. Amputation was also associated with a greater likelihood of dying in the hospital, dialysis discontinuation before death, and less time receiving hospice services.

CONCLUSIONS

Nearly one in ten patients with ESRD undergoes lower extremity amputation in their last year of life. These patients have prolonged stays in acute and subacute health care settings and appear to have limited access to hospice services. These findings likely signal unmet palliative care needs among seriously ill patients with ESRD who undergo amputation as well as opportunities to improve their care.

Referrals of Cancer versus Non-Cancer Patients to A Palliative Care Consult Team: Do They Differ?

This retrospective study compared 100 consecutive non-cancer (NC) patients referred to a palliative care consult team (PCT) in a Swiss university hospital to 506 cancer (C) patients referred during the same period. The frequencies of reported symptoms were similar in both groups. The main reasons for referral in the NC group were symptom control, global evaluation, and assistance with discharge. Requests for symptom control predominated in the C group. Prior to the first visit, 50% of NC patients were on opioids, compared to 58% of C patients. After the first visit, the proportion of NC patients on opioids increased to 64% and the proportion of C patients to 73%. The median daily oral morphine equivalent dose for NC patients taking opioids prior to the first PCT visit was higher than that for C patients (60 mg versus 45 mg). At the time of death or discharge, the percentage of NC patients on opioids was 64%, while that of C patients was 76%. Moreover, NC patients were on significantly lower median doses of opioids than C patients (31 mg versus 60 mg). Over half the NC patients died during hospitalization, as compared to 33% of C patients. Only 6% of NC patients were discharged to palliative care units, as compared to 22% of C patients.

Comparing End-Of-Life Care for Hospitalized Patients with Chronic Obstructive Pulmonary Disease and Lung Cancer in Taiwan

When it comes to end-of-life care, chronic obstructive pulmonary disease (COPD) patients are often treated differently from lung cancer patients. However, few reports have compared end-of-life care between these two groups. We investigated the differences between patients with end-stage COPD and end-stage lung cancer based on end-of-life symptoms and clinical practice patterns using a retrospective study of COPD and lung cancer patients who died in an acute care hospital in Taiwan. End-stage COPD patients had more comorbidities and spent more days in the intensive care unit (ICU) than end-stage lung cancer patients. They were more likely to die in the ICU and less likely to receive hospice care. COPD patients also had more invasive procedures, were less likely to use narcotic and sedative drugs, and were less likely to have given do-not-resuscitate consent. Symptoms were similar between these two groups. Differences in treatment management suggest that COPD patients receive more care aimed at prolonging life than care aimed at relieving symptoms and providing end-of-life support. It may be more difficult to determine when COPD patients are at the end-of-life stage than it is to identify when lung cancer patients are at that stage. Our findings indicate that in Taiwan, more effort should be made to give end-stage COPD patients the same access to hospice care as end-stage lung cancer patients.

One-Year Linear Trajectories of Symptoms, Physical Functioning, Cognitive Functioning, Emotional Well-being, and Spiritual Well-being Among Patients Receiving Dialysis

BACKGROUND

This study evaluated 1-year linear trajectories of patient-reported dimensions of quality of life among patients receiving dialysis.

STUDY DESIGN

Longitudinal observational study.

SETTING & PARTICIPANTS

227 patients recruited from 12 dialysis centers.

FACTORS

Sociodemographic and clinical characteristics.

MEASUREMENTS/OUTCOMES

Participants completed an hour-long interview monthly for 12 months. Each interview included patient-reported outcome measures of overall symptoms (Edmonton Symptom Assessment System), physical functioning (Activities of Daily Living/Instrumental Activities of Daily Living), cognitive functioning (Patient's Assessment of Own Functioning Inventory), emotional well-being (Center for Epidemiologic Studies Depression Scale, State Anxiety Inventory, and Positive and Negative Affect Schedule), and spiritual well-being (Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale). For each dimension, linear and generalized linear mixed-effects models were used. Linear trajectories of the 5 dimensions were jointly modeled as a multivariate outcome over time.

RESULTS

Although dimension scores fluctuated greatly from month to month, overall symptoms, cognitive functioning, emotional well-being, and spiritual well-being improved over time. Older compared with younger participants reported higher scores across all dimensions (all P<0.05). Higher comorbidity scores were associated with worse scores in most dimensions (all P<0.01). Nonwhite participants reported better spiritual well-being compared with their white counterparts (P<0.01). Clustering analysis of dimension scores revealed 2 distinctive clusters. Cluster 1 was characterized by better scores than those of cluster 2 in nearly all dimensions at baseline and by gradual improvement over time.

LIMITATIONS

Study was conducted in a single region of the United States and included mostly patients with high levels of function across the dimensions of quality of life studied.

CONCLUSIONS

Multidimensional patient-reported quality of life varies widely from month to month regardless of whether overall trajectories improve or worsen over time. Additional research is needed to identify the best approaches to incorporate patient-reported outcome measures into dialysis care.

End-of-life care in UK care homes: a systematic review of the literature

BACKGROUND

The number of people requiring end-of-life care provision in care homes has grown significantly. There is a need for a systematic examination of individual studies to provide more comprehensive information about contemporary care provision.

AIM

The aim of this study was to systematically review studies that describe end-of-life care in UK care homes.

METHOD

A systematic PRISMA review of the literature published between 2008 and April 2017 was carried out. A total of 14 studies were included in the review.

RESULTS

A number of areas of concern were identified in the literature in relation to the phases of dying during end-of-life care: end-of-life pre-planning processes; understandings of end-of-life care; and interprofessional end-of-life care provision.

CONCLUSIONS

Given that the problems identified in the literature concerning end-of-life care of residents in care homes are similar to those encountered in other healthcare environments, there is logic in considering how generalised solutions that have been proposed could be applied to the specifics of care homes. Further research is necessary to explore how barriers to good end-of-life care can be mitigated, and facilitators strengthened.

Access to palliative care by disease trajectory: a population-based cohort of Ontario decedents

OBJECTIVES

To examine access to palliative care between different disease trajectories and compare to other geographic areas.

DESIGN

A retrospective population-based decedent cohort study using linked administrative data.

SETTING

Ontario, Canada.

PARTICIPANTS

Ontario decedents between 1 April 2010 and 31 December 2012. Patients were categorised into disease trajectories: terminal illness (eg, cancer), organ failure (eg, chronic heart failure), frailty (eg, dementia), sudden death or other.

INTERVENTIONS

Receipt of palliative care services from institutional and community settings, derived from a validated list of palliative care codes from multiple administrate databases.

OUTCOME MEASURES

Receiving any palliative care services in the last year of life (yes/no), intensity (total days) and time of initiation of palliative care, in hospital and community sectors. Multivariable analysis examined the association between disease trajectory and the receipt of palliative care in the last year of life.

RESULTS

We identified 235 159 decedents in Ontario. In the last year of life, 88% of terminal illness, 44% of organ failure and 32% of frailty decedents accessed at least one palliative care service. Most care was provided during an inpatient hospitalisation. Terminal illness decedents received twice as many palliative care days (mean of 49 days) compared with organ failure and frailty decedents. Patients with terminal illness initiated palliative care median of 107 days before death compared with median of 19 days among those using the US Medicare hospice benefit.

CONCLUSIONS

Terminal illness decedents are more likely to receive any palliative care, with increased intensity and earlier before death than organ failure or frailty decedents. These data serve as a useful comparison for other countries with similar and different healthcare systems and eligibility criteria.

Patients' and carers' perspectives of palliative care in general practice: A systematic review with narrative synthesis

BACKGROUND

General practitioners have overall responsibility for community care, including towards end of life. Current policy places generalists at the centre of palliative care provision. However, little is known about how patients and carers understand the general practitioner's role.

AIMS

To explore patient and carer perspectives of (1) the role of the general practitioner in providing palliative care to adult patients and (2) the facilitators and barriers to the general practitioner's capacity to fulfil this perceived role.

DESIGN

Systematic literature review and narrative synthesis.

DATA SOURCES

Seven electronic databases (MEDLINE, Embase, PsycINFO, BNI, CINAHL, Cochrane and HMIC) were searched from inception to May 2017. Two reviewers independently screened papers at title, abstract and full-text stages. Grey literature, guideline, hand searches of five journals and reference list/citation searches of included papers were undertaken. Data were extracted, tabulated and synthesised using narrative, thematic analysis.

RESULTS

A total of 25 studies were included: 14 employed qualitative methods, 8 quantitative survey methods and 3 mixed-methods. Five key themes were identified: continuity of care, communication between primary and secondary care, contact and accessibility, communication between general practitioner and patient, and knowledge and competence.

CONCLUSION

Although the terminology and context of general practice vary internationally, themes relating to the perceived role of general practitioners were consistent. General practitioners are considered well placed to provide palliative care due to their breadth of clinical responsibility, ongoing relationships with patients and families, and duty to visit patients at home and coordinate healthcare resources. These factors, valued by service users, should influence future practice and policy development.

'I'm only dealing with the acute issues': How medical ward 'busyness' constrains care of the dying

Acute hospital units are a common location of death. Curative characteristics of the acute medical setting make it difficult to provide adequate palliative care; these characteristics include an orientation to life-prolonging treatment, an emphasis on routine or task-oriented care and a lack of priority on emotional engagement with patients. Indeed, research shows that dying patients in acute medical units often experience unmet needs at the end of life, including uncontrolled symptoms (e.g. pain, breathlessness), inadequate emotional support and poor communication. A focused ethnography was conducted on an acute medical ward in Canada to better understand how this curative/life-prolonging care environment shapes the care of dying patients. Fieldwork was conducted over a period of 10 months and included participant-observation and interviews with patients, family members and staff. On the acute medical ward, a 'logic of care' driven by discourses of limited resources and the demanding medical unit created a context of busyness. Staff experienced an overwhelming workload and felt compelled to create priorities, which reflected taken-for-granted values regarding the importance of curative/life-prolonging care over palliative care. This could be seen through the way staff prioritized life-prolonging practices and rationalized inconsistent and less attentive care for dying patients. These values influenced care of the dying through delaying a palliative approach to care, limiting palliative care to those with cancer and providing highly interventive end-of-life care. Awareness of these taken-for-granted values compels a reflective and critical approach to current practice and how to stimulate change.

Implementing a novel model for hospice and palliative care in the emergency department: An experience from a tertiary medical center in Taiwan

Hospice and palliative care has been recognized as an essential part of emergency medicine; however, there is no consensus on the optimal model for the delivery of hospice and palliative care in the emergency department (ED). Therefore, we conducted a novel implementation in a tertiary medical center in Taiwan. In the preintervention period, we recruited a specialist for hospice and palliative medicine in the ED to lead our intervention. In the early stage of the intervention, starting on July 1, 2014, we encouraged and funded ED physicians and nurses to receive training for hospice and palliative medicine and residents of emergency medicine to rotate to the hospice ward. In the late stage of the intervention, we initiated educational programs in the ED, an interdisciplinary meeting with the hospice team every month, sharing information and experience via a cell phone communication app, and setting aside an emergency hospice room for end-of-life patients. We compared the outcomes among pre-, during, and postintervention periods. Compared with 4 in the preintervention period, the cases of do not resuscitate (DNR) per month increased significantly to 30.1 in the early stage of intervention, 23.9 in late stage of intervention, and 34.6 in the postintervention period (all P < .001 compared with the preintervention period). Compared with 10.8% in the preintervention period, the ratio of DNR orders signed in the ED/total DNR orders signed in the study hospital was increased to 17.1% in early stage of intervention, 12.5% in late stage of intervention, and 22.8% in postintervention. Compared with zero in preintervention and early intervention, the cases of consultation with the hospice team increased significantly to 19 cases per month in the late stage of intervention and postintervention. The ability of nurses in hospice and palliative care, including knowledge and the timing and method of consultation with the hospice team, was also significantly improved. We successfully implemented a novel model of hospice and palliative care in the ED via a champion, education, and close collaboration with the hospice team, which could be an important reference for other EDs and intensive care unit in the future.

Patient reported outcome measures of quality of end-of-life care: A systematic review

End-of-life (EoL) care¹ is increasingly used as a generic term in preference to palliative care or terminal care, particularly with reference to individuals with chronic disease, who are resident in community and long-term care (LTC) settings. This review evaluates studies based on patient reported outcome measures (PROMS) of quality of EoL care across all health-care settings. From 1041 citations, 12 studies were extracted by searches conducted in EBSCO, Scopus, Web of Science, PubMed, Cochrane, Open Grey and Google Scholar databases. At present, the evidence base for EoL care is founded on cancer care. This review highlights the paucity of studies that evaluate quality of EoL care for patients with chronic disease outside the established cancer-acute care paradigm, particularly in LTC. This review highlights the absence of any PROMs for the estimated 60% of patients in LTC with cognitive impairment. Patient-reported outcomes (PROs) are critical to understanding how EoL care services and practices affect patients' health and EoL experience. PROMs describe the quality of care from the patient's perspective and add balance to existing clinical or proxy-derived knowledge on the quality of care and services provided.

Reducing inequalities in care for patients with non-malignant diseases: Insights from a realist evaluation of an integrated palliative care pathway

BACKGROUND

The need for palliative care is growing internationally with an increasing prevalence of non-malignant diseases. The integrated care pathway was implemented in primary care by multidisciplinary teams from 2009 in a locality in the North East of England. Fourteen general practitioner practices provided data for the study.

AIM

To find whether, how, and under what circumstances palliative care registrations are made for patients with non-malignant diseases in primary care.

DESIGN

General practitioner practice data were analysed statistically and qualitative data were collected from health care professionals and members of relevant organisations.

FINDINGS

A mixed-effects logistic model indicated a significant difference beyond the 0.1% level (p < 0.001) in registrations between the malignant and non-malignant groups in 2011, with an odds ratio of 0.09 (=exp(-2.4266)), indicating that patients in the non-malignant group are around 11 times (1/0.09) less likely to be registered than patients in the malignant group. However, patients with non-malignant diseases were significantly more likely to be registered in 2012 than in 2011 with an odds ratio of 1.46, significant beyond the 1% level. Qualitative analyses indicate that health care professionals find registering patients with non-malignant diseases stressful, yet feel that their confidence in treating this population is increasing.

CONCLUSION

The integrated care pathway began to enable the reduction in inequalities in care by identifying, registering and managing an increasing number of palliative patients with non-malignant diseases. Consensual and inclusive definitions of palliative care were developed in order to legitimise the registration of such patients.

Towards integration of palliative care in patients with chronic heart failure and chronic obstructive pulmonary disease: a systematic literature review of European guidelines and pathways

Background

Despite the positive impact of Palliative Care (PC) on the quality of life for patients and their relatives, the implementation of PC in non-cancer health-care delivery in the EU seems scarcely addressed. The aim of this study is to assess guidelines/pathways for integrated PC in patients with advanced Chronic Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD) in Europe via a systematic literature review.

Methods

Search results were screened by two reviewers. Eligible studies of adult patients with CHF or COPD published between 01/01/1995 and 31/12/2013 in Europe in 6 languages were included. Nine electronic databases were searched, 6 journals were hand-searched and citation tracking was also performed. For the analysis, a narrative synthesis was employed.

Results

The search strategy revealed 26,256 studies without duplicates. From these, 19 studies were included in the review; 17 guidelines and 2 pathways. 18 out of 19 focused on suffering reduction interventions, 13/19 on a holistic approach and 15/19 on discussions of illness prognosis and limitations. The involvement of a PC team was mentioned in 13/19 studies, the assessment of the patients’ goals of care in 12/19 and the advance care planning in 11/19. Only 4/19 studies elaborated on aspects such as grief and bereavement care, 7/19 on treatment in the last hours of life and 8/19 on the continuation of goal adjustment.

Conclusion

The results illustrate that there is a growing awareness for the importance of integrated PC in patients with advanced CHF or COPD. At the same time, however, they signal the need for the development of standardized strategies so that existing barriers are alleviated.

Hospice care in the Netherlands: who applies and who is admitted to inpatient care?

Background

Ten percent of non-sudden deaths in the Netherlands occur in inpatient hospice facilities. To investigate differences between patients who are admitted to inpatient hospice care or not following application, how diagnoses compare to the national population, characteristics of application, and associations with being admitted to inpatient hospice care or not.

Methods

Data from a database representing over 25 % of inpatient hospice facilities in the Netherlands were analysed. The study period spanned the years 2007–2012. Multivariate regression analyses were performed to study associations between demographic and application characteristics, and admittance.

Results

Ten thousand two hundred fifty-four patients were included. 84.1 % of patients applying for inpatient hospice care had cancer compared to 37.0 % of deaths nationally. 52.4 % of applicants resided in hospital at the time of admission. Most frequent reasons for application were the wish to die in an inpatient hospice facility (70.5 %), needing intensive care or support (52.2 %), relieving caregivers (41.4 %) and needing pain/symptom control (39.9 %). Living alone (OR 1.68, 95 % CI 1.46–1.94), having cancer (OR 1.40, 95 % CI 1.11–1.76), relieving caregivers (OR 1.18, 95 % CI 1.01–1.38), needing pain/symptom control (OR1.72, 95 % CI 1.46–2.03) wanting inpatient hospice care until death (vs respite care) (OR 3.59, 95 % CI 2.11–6.10), wanting to be admitted as soon as possible (OR 1.64, 95 % CI 1.42–1.88), and being referred by a primary care professional (OR 1.36, 95 % CI 1.17–1.59) were positively associated with being admitted. Wishing to die in an inpatient hospice facility was negatively associated with being admitted (OR 0.85, 95 % CI 0.72–1.00).

Conclusions

This study suggests that when applying for inpatient hospice care, patients who seem most urgently in need of inpatient hospice care are more frequently admitted. However, non-cancer patients seem to be an under-represented population. Staff should consider application based on need for palliation, irrespective of diagnosis.

Managing uncertainty in advanced liver disease: a qualitative, multiperspective, serial interview study

OBJECTIVE

To understand the experiences and support needs of people with advanced liver disease and those of their lay and professional carers to inform improvements in the supportive and palliative care of this rapidly growing but currently neglected patient group.

DESIGN

Multiperspective, serial interviews. We conducted up to three qualitative in-depth interviews with each patient and lay carer over 12 months and single interviews with case-linked healthcare professionals. Data were analysed using grounded theory techniques.

PARTICIPANTS

Patients with advanced liver disease of diverse aetiologies recruited from an inpatient hepatology ward, and their lay carers and case-linked healthcare professionals nominated by the patients.

SETTING

Primary and secondary care in South-East Scotland.

RESULTS

37 participants (15 patients, 11 lay and 11 professional carers) completed 51 individual and 13 joint patient-carer interviews. Nine patients died during the study. Uncertainty dominated experiences throughout the course of the illness, across patients' considerable physical, psychological, social and existential needs and affected patients, lay carers and professionals. This related to the nature of the condition, the unpredictability of physical deterioration and prognosis, poor communication and information-sharing, and complexities of care. The pervasive uncertainty also shaped patients' and lay carers' strategies for coping and impeded care planning. While patients' acute medical care was usually well coordinated, their ongoing care lacked structure and focus.

CONCLUSIONS

Living, dying and caring in advanced liver disease is dominated by pervasive, enduring and universally shared uncertainty. In the face of high levels of multidimensional patient distress, professionals must acknowledge this uncertainty in constructive ways that value its contribution to the person's coping approach. Pervasive uncertainty makes anticipatory care planning in advanced liver disease challenging, but planning 'just in case' is vital to ensure that patients receive timely and appropriate supportive and palliative care alongside effective management of this unpredictable illness.

Living with and dying from advanced heart failure: understanding the needs of older patients at the end of life

Background

Heart failure (HF) is a life-limiting illness and patients with advanced heart failure often suffer from severe physical and psychosocial symptoms. Particularly in older patients, HF often occurs in conjunction with other chronic diseases, resulting in complex co-morbidity. This study aims to understand how old and very old patients with advanced HF perceive their disease and to identify their medical, psychosocial and information needs, focusing on the last phase of life.

Methods

Qualitative longitudinal interview study with old and very old patients (≥70 years) with severe HF (NYHA III-IV). Interviews were conducted at three-month intervals over a period of up to 18 months and were analysed using qualitative methods in relation to Grounded Theory.

Results

A total of 95 qualitative interviews with 25 patients were conducted and analysed. The following key categories were developed: (1a) dealing with advanced heart failure and ageing, (1b) dealing with end of life; (2a) perceptions regarding care, and (2b) interpersonal relations. Overall, our data show that older patients do not experience HF as a life-limiting disease. Functional restrictions and changed conditions leading to problems in daily life activities were often their prime concerns. The needs and priorities of older HF patients vary depending on their disease status and individual preferences. Pain resulting in reduced quality of life is an example of a major symptom requiring treatment. Many older HF patients lack sufficient knowledge about their condition and its prognosis, particularly concerning emergency situations and end of life issues, and many expressed a wish for open discussions. From the patients’ perspective, there is a need for improvement in interaction with health care professionals, and limits in treatment and medical care are not openly discussed.

Conclusion

Old and very old patients with advanced HF often do not acknowledge the seriousness and severity of the disease. Their communication with physicians predominantly focuses on curative treatment. Therefore, aspects such as self-management of the disease, dealing with emergency situations and end-of-life issues should be addressed more prominently. An advanced care planning (ACP) programme for heart disease in older people could be an option to improve patient-centred care.

Knowledge of Dementia: Do family members understand dementia as a terminal condition?

Current research identifies advanced dementia to be the terminal phase of this progressive and incurable condition. However, there has been relatively little investigation into how family members of people with advanced dementia understand their relative's condition. In this article, we report on semi-structured interviews with 10 family members of people with advanced dementia, in a residential aged care facility. Using a qualitative, descriptive design, we explored family members' understandings of dementia, whether they were aware that it was a terminal condition, and the ways they developed their understandings. Findings revealed that the majority of family members could not recognize the terminal nature of dementia. Relying on predominantly lay understandings, they had little access to formal information and most failed to conceptualize a connection between dementia and death. Moreover, family members engaged in limited dialogue with aged care staff about such issues, despite their relatives being in an advanced stage of the disease. Findings from our study suggest that how family members understand their relative's condition requires greater attention. The development of staff/family partnerships that promote shared communication about dementia and dying may enhance family members' understandings of the dementia trajectory and the types of decisions they may be faced with during the more advanced stages of the disease.

International study of the place of death of people with cancer: a population-level comparison of 14 countries across 4 continents using death certificate data

Background:

Where people die can influence a number of indicators of the quality of dying. We aimed to describe the place of death of people with cancer and its associations with clinical, socio-demographic and healthcare supply characteristics in 14 countries.

Methods:

Cross-sectional study using death certificate data for all deaths from cancer (ICD-10 codes C00-C97) in 2008 in Belgium, Canada, Czech Republic, England, France, Hungary, Italy, Mexico, the Netherlands, New Zealand, South Korea, Spain (2010), USA (2007) and Wales (N=1 355 910). Multivariable logistic regression analyses evaluated factors associated with home death within countries and differences across countries.

Results:

Between 12% (South Korea) and 57% (Mexico) of cancer deaths occurred at home; between 26% (Netherlands, New Zealand) and 87% (South Korea) occurred in hospital. The large between-country differences in home or hospital deaths were partly explained by differences in availability of hospital- and long-term care beds and general practitioners. Haematologic rather than solid cancer (odds ratios (ORs) 1.29–3.17) and being married rather than divorced (ORs 1.17–2.54) were most consistently associated with home death across countries.

Conclusions:

A large country variation in the place of death can partly be explained by countries' healthcare resources. Country-specific choices regarding the organisation of end-of-life cancer care likely explain an additional part. These findings indicate the further challenge to evaluate how different specific policies can influence place of death patterns.

Comparison of terminally ill cancer- vs. non-cancer patients in specialized palliative home care in Germany - a single service analysis

Background

Palliative care (PC) is no longer offered with preference to cancer patients (CA), but also to patients with non-malignant, progressive diseases. Taking current death statistics into account, PC in Europe will face a growing number of patients dying from non-cancer diseases (NCA). More insights into specialized palliative home care (SPHC) in NCAs are needed.

Methods

Retrospective analysis and group comparisons between CAs and NCAs of anonymous data of all patients cared for between December 2009 and June 2012 by one SPHC team in Germany. Patient-, disease- and care-related data are documented in clinical routine by specialized PC physicians and nurses in the Information System Palliative Care 3.0 ® (ISPC®).

Results

Overall, 502 patients were cared for by the SPHC team; from 387 patients comprehensive data sets were documented. These 387 data sets (CA: N = 300, 77.5 % and NCA: N = 87, 22.5 %) are used for further analysis here. NCAs were significantly older (81 vs. 73 years; p < .001), than CAs and most often suffered from diseases of the nervous system (40 %). They needed significantly more assistance with defecation (87 vs. 74 %; p < .001) and urination (47 vs. 29 %; p < .001) and were more often affected from impaired vigilance (30 vs. 11 %; p < .001) than CAs. A by trend higher proportion of NCAs died within one day after admission to palliative home care (12 vs. 5 %; p < .05) and a smaller proportion was re-admitted to hospital during home care (6 vs. 20 %; p < .001). NCAs died predominantly in nursing homes (50 vs. 20 %; p < .001).

Conclusions

Although the proportion of NCAs was relatively high in this study, the access to PC services seems to takes place late in the disease trajectory, as demonstrated by the lower survival rate for NCAs. Nevertheless, the results show, that NCAs PC needs are as complex and intense as in CAs.

What's in a mechanism? Development of a key concept in realist evaluation

Background

The idea that underlying, generative mechanisms give rise to causal regularities has become a guiding principle across many social and natural science disciplines. A specific form of this enquiry, realist evaluation is gaining momentum in the evaluation of complex social interventions. It focuses on ‘what works, how, in which conditions and for whom’ using context, mechanism and outcome configurations as opposed to asking whether an intervention ‘works’. Realist evaluation can be difficult to codify and requires considerable researcher reflection and creativity. As such there is often confusion when operationalising the method in practice. This article aims to clarify and further develop the concept of mechanism in realist evaluation and in doing so aid the learning of those operationalising the methodology.

Discussion

Using a social science illustration, we argue that disaggregating the concept of mechanism into its constituent parts helps to understand the difference between the resources offered by the intervention and the ways in which this changes the reasoning of participants. This in turn helps to distinguish between a context and mechanism. The notion of mechanisms ‘firing’ in social science research is explored, with discussions surrounding how this may stifle researchers’ realist thinking. We underline the importance of conceptualising mechanisms as operating on a continuum, rather than as an ‘on/off’ switch.

Summary

The discussions in this article will hopefully progress and operationalise realist methods. This development is likely to occur due to the infancy of the methodology and its recent increased profile and use in social science research. The arguments we present have been tested and are explained throughout the article using a social science illustration, evidencing their usability and value.

Enteral nutrition in dementia: a systematic review

The aim of this systematic review is to evaluate the role of enteral nutrition in dementia. The prevalence of dementia is predicted to rise worldwide partly due to an aging population. People with dementia may experience both cognitive and physical complications that impact on their nutritional intake. Malnutrition and weight loss in dementia correlates with cognitive decline and the progress of the disease. An intervention for long term eating difficulties is the provision of enteral nutrition through a Percutaneous Endoscopic Gastrostomy tube to improve both nutritional parameters and quality of life. Enteral nutrition in dementia has traditionally been discouraged, although further understanding of physical, nutritional and quality of life outcomes are required. The following electronic databases were searched: EBSCO Host, MEDLINE, PubMed, Cochrane Database of Systematic Reviews and Google Scholar for publications from 1st January 2008 and up to and including 1st January 2014. Inclusion criteria included the following outcomes: mortality, aspiration pneumonia, pressure sores, nutritional parameters and quality of life. Each study included separate analysis for patients with a diagnosis of dementia and/or neurological disease. Retrospective and prospective observational studies were included. No differences in mortality were found for patients with dementia, without dementia or other neurological disorders. Risk factors for poor survival included decreased or decreasing serum albumin levels, increasing age or over 80 years and male gender. Evidence regarding pneumonia was limited, although did not impact on mortality. No studies explored pressure sores or quality of life.

Improving End-of-Life Care Prognostic Discussions

Research has validated the desire of patients and families for ongoing prognostic information; however, few conversations occur before patients reach the advanced stages of their disease trajectory. Physician hesitance and delay in discussing unfavorable prognoses deny patients and families optimal time to prepare for critical decision making. Advanced practice registered nurses can play a crucial, complementary role with the critical care interdisciplinary team to implement strategies to improve communication about prognosis and end of life with patients and families. Clinicians should discuss deterioration in disease-specific characteristics and changes (decline) in functional status. Functional status can serve as an accurate guide for forecasting prognosis, particularly in patients with heart failure, stroke, chronic lung disease, and end-stage renal disease. This article provides an overview of effective intensive care unit prognostic systems and discusses barriers and opportunities for nurses to use evidence-based knowledge related to disease trajectory and prognosis to improve communication and the quality of palliative and end-of-life care for patients.