PURPOSE: Benefits of early palliative referral in oncology are well documented. Palliative care referral "triggers" may help identify patients for referral. Many triggers have been proposed, but are not commonly used. This study reviewed the timing of palliative care involvement for patients in a tertiary referral oncology hospital, and whether the use of a trigger tool prior to admission would have facilitated earlier referral.
METHODS: This was a retrospective cohort study of cancer patients who died during an unplanned admission between November 2014 and October 2015. A literature review identified seven palliative care referral tools which were included in this analysis, and compared by identifying common themes. Each tool was applied to patients by reviewing electronic patient records. Timing of palliative referral and whether patients met any triggers within 6 months before their terminal admission were assessed.
RESULTS: A total of 159 patients were identified. Forty-six percent were referred to palliative care prior to terminal admission. Application of 6 out of 7 trigger tools would have resulted in the majority of patients (up to 91.2%) referred to palliative care prior to admission. Most patients (52.2%) were referred only during their terminal admission. Patients known to palliative care before admission (N = 73) were reviewed quicker than those who were not (N = 86) (median (range) 1 day (0-23 days) versus 5 days (0-59 days), p < 0.00001).
CONCLUSIONS: In this patient cohort, a palliative referral trigger tool may have proactively identified most patients prior to their terminal admission. Prospective testing of trigger tools in oncology populations is warranted.
CONTEXT: Terminally ill patients (TIP) frequently visit the emergency department (ED), but the prevalence of these visits is unclear.
OBJECTIVE: To determine the prevalence of TIP visiting the ED.
METHODS: Systematic review of observational studies published between 1998 and 2018 reporting adults TIP who used the hospital ED, searching in PubMed, CINAHL, SciELO, LILACS, and Cochrane. Three evaluators selected and extracted data (kappa concordance 0.63). The quality of the studies was evaluated with the Newcastle-Ottawa scale and global estimates were made, calculating combined prevalence (95% confidence interval [CI]) and heterogeneity of the studies (I2).
RESULTS: We identified 2429 publications, ultimately including 31 studies in 14 countries; 79% were from high-income countries, 21% from medium-income countries and none from low-income countries. Most were from 2015. We found that 45% of cancer patients visited the ED in the last month of life (95% CI 37-54%) and 75% in the last 6 months of life (95% CI 62-83%); I2 100%. Overall, 17% of patients who visited the ED had a terminal illness (95% CI 12-23%); I2 98%. Few studies reported terminal non-oncologic illness, specific age groups or diseases, hospital admission rates, use of palliative care or non-resuscitation, or other criteria that could be used for grouping.
CONCLUSIONS: Patients with terminal cancer frequently use the ED at the end of life, although use varies among patients and few studies have examined low-income countries or patients with non-oncologic terminal illness. The global prevalence of TIP in the ED cannot be calculated from limited reports.
BACKGROUND: COVID-19 pandemic could create a collateral damage to cancer care denoting disruptions in care due to a significant burden on healthcare and resource allocations. Herein, we evaluate the early changes in the inpatient and outpatient oncology clinics to take a snapshot of this collateral damage at Hacettepe University Cancer Institute.
METHODS: Patients applying the outpatient clinic and outpatient palliative care (OPC) clinic for the first time and patients admitted to inpatient wards in the first 30 days after the first case of COVID-19 in Turkey were evaluated. These data were compared with data from the same time frame in the previous 3 years.
RESULTS: The mean number of daily new patient applications to the outpatient clinic (9.87±3.87 vs 6.43±4.03, p<0.001) and OPC clinic (3.87±1.49 vs 1.13±1.46, p<0.001) was significantly reduced compared with the previous years. While the number of inpatient admissions was similar for a month frame, the median duration of hospitalisation was significantly reduced. The frequency of hospitalisations for chemotherapy was higher than in previous years (p<0.001). By comparison, the rate of hospitalisations for palliative care (p=0.028) or elective interventional procedures (p=0.001) was significantly reduced.
CONCLUSION: In our experience, almost all domains of care were affected during the pandemic other than patients' systemic treatments. There were significant drops in the numbers of newly diagnosed patients, patients having interventional procedures and palliative care services, and these problems should be the focus points for the risk mitigation efforts for prevention of care disruptions.
Background: Symptom assessment is essential in palliative care, but holds challenges concerning implementation and relevance. This study aims to evaluate patients’ main symptoms and problems at admission to a specialist inpatient palliative care (SIPC) ward using physician proxy- and patient self-assessment, and aims to identify their prognostic impact as well as the agreement between both assessments.
Methods: Within 12 h after admission, palliative care specialists completed the Symptom and Problem Checklist of the German Hospice and Palliative Care Evaluation (HOPE-SP-CL). Patients either used the new version of the minimal documentation system for patients in palliative care (MIDOS) or the Integrated Palliative Care Outcome Scale (IPOS) plus the Distress Thermometer (DT).
Results: Between 01.01.2016–30.09.2018, 1206 patients were included (HOPE-SP-CL 98%; MIDOS 21%, IPOS 34%, DT 27%) where of 59% died on the ward. Proxy-assessment showed a mean HOPE-SP-CL Total Score of 24.6 ± 5.9 of 45. Most frequent symptoms/problems of at least moderate intensity were weakness (95%), needs of assistance with activities of daily living (88%), overburdening of family caregivers (83%), and tiredness (75%). Factor analysis identified four symptom clusters (SCs): (1) Deteriorated Physical Condition/Decompensation of Home Care, (2) Emotional Problems, (3) Gastrointestinal Symptoms and (4) Other Symptoms. Self-assessment showed a mean MIDOS Total Score of 11.3 ± 5.3 of 30, a mean IPOS Total Score of 32.0 ± 9.0 of 68, and a mean distress of 6.6 ± 2.5 of 10. Agreement of self- and proxy-assessment was moderate for pain ( = 0.438) and dyspnea ( = 0.503), fair for other physical ( = 0.297 to 0.394) and poor for psychological symptoms ( = 0.101 to 0.202). Multivariate regression analyses for single symptoms and SCs revealed that predictors for dying on the SIPC ward included impaired ECOG performance status, moderate/severe dyspnea, appetite loss, tiredness, disorientation/confusion, and the SC Deteriorated Physical Condition/Decompensation of Home Care.
Conclusion: admissions to a SIPC ward are mainly caused by problems impairing mobility and autonomy. Results demonstrate that implementation of self- and reliability of proxy- and self-assessment is challenging, especially concerning non-physical symptoms/problems. We identified, specific symptoms and problems that might provide information needed for treatment discussions regarding the medical prognosis.
BACKGROUND: Acute hospitalization is a frequent reason for live discharge from hospice. Although risk factors for live discharge among hospice patients have been well documented, prior research has not examined the role of neighborhood socioeconomic characteristics, or how these characteristics relate to racial/ethnic disparities in hospice outcomes.
OBJECTIVE: To examine associations between neighborhood socioeconomic characteristics and risk for live discharge from hospice because of acute hospitalization. The authors also explore the moderating role of race/ethnicity in any observed relationship.
RESEARCH DESIGN: Retrospective cohort study using electronic medical records of hospice patients (N=17,290) linked with neighborhood-level socioeconomic data (N=55 neighborhoods). Multilevel models were used to identify the independent significance of patient and neighborhood-level characteristics for risk of live discharge because of acute hospitalization.
RESULTS: Compared with the patients in the most well-educated and affluent sections of New York City [quartile (Q)4], the odds of live discharge from hospice because of acute hospitalization were greater among patients who resided in neighborhoods where lower proportions of residents held college degrees [Q1 adjusted odds ratio (AOR), 1.36; 95% confidence interval (CI), 1.06-1.75; Q2 AOR, 1.41; 95% CI, 1.07-1.84] and median household incomes were lower (Q1 AOR, 1.42; 95% CI, 1.10-1.85; Q2 AOR, 1.43; 95% CI, 1.10-1.85; Q3 AOR, 1.39; 95% CI, 1.07-1.80). However, these observed relationships were not equally distributed by patient race/ethnicity; the association of neighborhood socioeconomic disadvantage and risk for live discharge was significantly lower among Hispanic compared with white patients.
CONCLUSIONS: Findings demonstrate neighborhood socioeconomic disadvantage poses a significant risk for live discharge from hospice. Additional research is needed to clarify the social mechanisms underlying this association, including greater attention to the experiences of hospice patients from under-represented racial/ethnic groups.
Background: Community transmission of coronavirus 2019 (Covid-19) was detected in the state of Washington in February 2020.
Methods: We identified patients from nine Seattle-area hospitals who were admitted to the intensive care unit (ICU) with confirmed infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Clinical data were obtained through review of medical records. The data reported here are those available through March 23, 2020. Each patient had at least 14 days of follow-up.
Results: We identified 24 patients with confirmed Covid-19. The mean (±SD) age of the patients was 64±18 years, 63% were men, and symptoms began 7±4 days before admission. The most common symptoms were cough and shortness of breath; 50% of patients had fever on admission, and 58% had diabetes mellitus. All the patients were admitted for hypoxemic respiratory failure; 75% (18 patients) needed mechanical ventilation. Most of the patients (17) also had hypotension and needed vasopressors. No patient tested positive for influenza A, influenza B, or other respiratory viruses. Half the patients (12) died between ICU day 1 and day 18, including 4 patients who had a do-not-resuscitate order on admission. Of the 12 surviving patients, 5 were discharged home, 4 were discharged from the ICU but remained in the hospital, and 3 continued to receive mechanical ventilation in the ICU.
Conclusions: During the first 3 weeks of the Covid-19 outbreak in the Seattle area, the most common reasons for admission to the ICU were hypoxemic respiratory failure leading to mechanical ventilation, hypotension requiring vasopressor treatment, or both. Mortality among these critically ill patients was high. (Funded by the National Institutes of Health.)
Background: Heart failure (HF) impacts 6.2 million American adults. With no cure, therapies aim to prevent progression and manage symptoms. Inclusion of palliative care (PC) helps improve symptoms and quality of life. Heart failure guidelines recommend the inclusion of PC in HF therapy, but referrals are often delayed.
Objective: Introduce PC to patients with HF and examine the impact on PC consults, readmission, mortality, and intensive care unit (ICU) transfers.
Methods: Patients (n = 60) admitted with HF to an academic hospital were asked to view a PC educational module. A number of PC consults, re-admissions, mortality, and transfers to the ICU were compared among participants and those who declined.
Results: Nine patients in the intervention group (n = 30) requested a PC consult ( P = .042) versus 2 in the usual care group (n = 30; P = .302). There was no statistically significant difference in readmissions, mortality, or ICU transfers between groups.
Conclusions: Palliative care education increases the likelihood of PC utilization but in this short-term project was not found to statistically impact mortality, re-admissions, or transfers to higher levels of care.
EXECUTIVE SUMMARY: Usage of hospice services for patients facing life-limiting illness has steadily increased. In these services, hospitals discharge patients to various hospice settings, including the inpatient model, where a patient may remain in the discharging hospital to receive hospice services. In this discharge practice, the patient is considered a hospital survivor and subsequent hospice death. The purpose of the study was to determine if the decline of in-hospital mortality for six common high-volume admission diagnoses could be attributed in part to an increase in discharges to a hospice setting for end-of-life care. In this retrospective study using the National Inpatient Sample database from 2007 to 2011, we identified patients = 18 years for six acute and chronic diagnoses: heart failure, chronic obstructive pulmonary disease, acute myocardial infarction, acute myocardial infarction with cardiogenic shock, septic shock, and lung neoplasm (cancer). We categorized patients according to their hospital discharge disposition as hospice or in-hospital mortality. A total of 10,458,728 patients met our criteria, of which 2.72% were discharged to hospice and 6.38% died. Compared to patients who died in the hospital, hospice patients were older, had a shorter length of stay, and experienced more comorbidities. Hospice use was more common in Medicare patients, in nonteaching hospitals, and in the South. White individuals were more likely to be discharged to hospice compared to nonwhites. Among the six selected diagnoses over the 5-year period, hospice use rose as observed mortality decreased. Our findings suggest that variability among hospitals in hospice use will affect benchmarked hospital mortality comparisons and could inappropriately reward or penalize hospitals in their public reporting.
Background: Large, nationally representative studies of the association between quality of life and survival time in cancer patients in specialized palliative care are missing.
Aim: The aim of this study was to investigate whether symptoms/problems at admission to specialized palliative care were associated with survival and if the symptoms/problems may improve prediction of death within 1 week and 1 month, respectively.
Setting/participants: All cancer patients who had filled in the EORTC QLQ-C15-PAL at admission to specialized palliative care in Denmark in 2010–2017 were included through the Danish Palliative Care Database. Cox regression was used to identify clinical variables (gender, age, type of contact (inpatient vs outpatient), and cancer site) and symptoms/problems significantly associated with survival. To test whether symptoms/problems improved survival predictions, the overall accuracy (area under the receiver operating characteristic curve) for different prediction models was compared. The validity of the prediction models was tested with data on 5,508 patients admitted to palliative care in 2018.
Results: The study included 30,969 patients with an average age of 68.9 years; 50% were women. Gender, age, type of contact, cancer site, and most symptoms/problems were significantly associated with survival time. The predictive value of symptoms/problems was trivial except for physical function, which clearly improved the overall accuracy for 1-week and 1-month predictions of death when added to models including only clinical variables.
Conclusion: Most symptoms/problems were significantly associated with survival and mainly physical function improved predictions of death. Interestingly, the predictive value of physical function was the same as all clinical variables combined (in hospice) or even higher (in palliative care teams).
BACKGROUND: Frailty and palliative performance scores are 2 markers used in the measurement of functional decline in oncology and hospice care.
OBJECTIVE: To evaluate the frailty and palliative performance scores of a long-term care resident community and determine whether frailty and palliative performance scores can predict hospital readmissions (HR) and survivability of the long-term care resident.
METHODS: One hundred seventy-one long-term care residents from 2 urban facilities were evaluated for functional decline using the Clinical Frailty Scale (CFS) and Palliative Performance Scale (PPS). Sociodemographic, HR, and survival data for 1 year from study initiation were recorded.
RESULTS: The 171 long-term care residents, of lower socioeconomic status, primarily Medicare/Medicaid or dual-eligible, evaluated for functional decline using the CFS and PPS, had mean age of 73.1 years, 52.6% female, 94.7% African American, with 18.1% having HR and 87.1% surviving more than a year. There was a negative association between age and HR (P = .384). Among functional evaluation scales, CFS was positively associated with age (P = .013) but not PPS (P = .673). The residents scored 6.0 ± 1.2 on CFS and 52.8 ± 13.2 on PPS (%) with those residents readmitted to hospital having poorer outcomes. Readmission to hospital and survivability of the long-term care resident were both strongly associated with CFS (P = .001) and PPS (P = .001).
CONCLUSION: There is a strong association between the 2 markers used in the measurement of functional decline-Frailty measured by CFS and Palliative Performance Score measured by PPS. Frailty and palliative performance scores can strongly predict HR and survivability of the long-term care resident.
BACKGROUND: Hospitalisation during the last weeks of life when there is no medical need or desire to be there is distressing and expensive. This study sought palliative care initiatives which may avoid or shorten hospital stay at the end of life and analysed their success in terms reducing bed days.
METHODS: Part 1 included a search of literature in PubMed and Google Scholar between 2013 and 2018, an examination of governmental and organisational publications plus discussions with external and co-author experts regarding other sources. This initial sweep sought to identify and categorise relevant palliative care initiatives. In Part 2, we looked for publications providing data on hospital admissions and bed days for each category.
RESULTS: A total of 1252 abstracts were reviewed, resulting in ten broad classes being identified. Further screening revealed 50 relevant publications describing a range of multi-component initiatives. Studies were generally small and retrospective. Most researchers claim their service delivered benefits. In descending frequency, benefits identified were support in the community, integrated care, out-of-hours telephone advice, care home education and telemedicine. Nurses and hospices were central to many initiatives. Barriers and factors underpinning success were rarely addressed.
CONCLUSIONS: A wide range of initiatives have been introduced to improve end-of-life experiences. Formal evidence supporting their effectiveness in reducing inappropriate/non-beneficial hospital bed days was generally limited or absent.
TRIAL REGISTRATION: N/A.
BACKGROUND: Admission to the emergency department (ED) of patients with advanced or end-of-life (EoL) cancer saturates the services that provide active medical attention to the complications of anticancer therapy, and the lack of specific protocol limits proper handling.
OBJECTIVE: The aim of this study was to describe the characteristics of patients with advanced cancer admitted to the ED at the EoL in a comprehensive cancer center in Mexico.
PATIENTS AND METHODS: We conducted a retrospective analysis of patients admitted to ED of the National Cancer Institute of Mexico City, with 3 or less days before they died, between January 2011 and December 2018. The data collected included clinical and demographic characteristics, reason for admission to the ED, number of admissions to ED in the last month of life, and cancer treatment received.
RESULTS: A total of 426 patients were included; 60.8% were female with a median age of 60 years; 71.6% patients were receiving some kind of disease-modifying treatment, although the oncologist had considered they could die within 6 months, and 16 of them were receiving concomitant PC. 8.9% of these patients had been admitted 3 or more times to the ED in the last month. The principal reasons for admission to ED were dyspnea, uncontrolled pain, 12 patients were admitted in active death and 94 died within hours of admission to ED.
CONCLUSIONS: Palliative care approach in oncological patients admitted to ED is important to avoid unnecesary suffering at the EoL.
AIMS: New Zealanders dying in public hospitals or hospices are increasingly being discharged and admitted-to-die in aged residential care (ARC) facilities as hospitals and hospices struggle to meet demand. This study sought to investigate how care is delivered to patients admitted-to-die in an ARC facility.
METHODS: A mixed-methods case study including a clinical notes review of seven patients who died in one ARC facility within three months of admission and a focus group with ARC facility staff and visiting professionals from other organisations.
RESULTS: The clinical notes review showed a high burden of palliative care symptoms that constituted specialist palliative care, provided by ARC staff plus professionals from other organisations. Focus group data showed those involved were willing, but expressed significant concern about lack of structure and funding.
CONCLUSIONS: As our increasing and aging population reaches end-of-life, New Zealand hospitals/hospices will not be able to provide ongoing specialist palliative care and admission-to-die in ARC facilities may be a viable alternative. However, ARC facilities are not set up or staffed to provide specialist palliative care of those admitted-to-die. A specific model of care that is funded appropriately is required.
Sense of control in end-of-life (EOL) care plays a critical role in the patient's well-being. However, little is known about the areas of control essential to patients and families at a specific time point in the illness trajectory: when patients stop curative treatments and are referred to hospice. This study qualitatively explored such areas. Sixteen admissions staff members from four hospice agencies were interviewed about their perceptions of areas in which patients and families worried about losing control by accepting hospice. The thematic analysis revealed four areas of control: changes to medical care, health care provider changes, use of life-sustaining treatments, and daily life. Participants of this study put a great emphasis on consistently communicating their willingness to honor patients' and families' control over their care decisions and lives. Future research should examine control in EOL care among diverse populations and effectiveness of hospice staff's strategies to address desire for control.
BACKGROUND: Predicting death in a cohort of clinically diverse, multi-condition hospitalized patients is difficult. This frequently hinders timely serious illness care conversations. Prognostic models that can determine 6-month death risk at the time of hospital admission can improve access to serious illness care conversations.
OBJECTIVE: The objective is to determine if the demographic, vital sign, and laboratory data from the first 48 h of a hospitalization can be used to accurately quantify 6-month mortality risk.
DESIGN: This is a retrospective study using electronic medical record data linked with the state death registry.
PARTICIPANTS: Participants were 158,323 hospitalized patients within a 6-hospital network over a 6-year period.
MAIN MEASURES: Main measures are the following: the first set of vital signs, complete blood count, basic and complete metabolic panel, serum lactate, pro-BNP, troponin-I, INR, aPTT, demographic information, and associated ICD codes. The outcome of interest was death within 6 months.
KEY RESULTS: Model performance was measured on the validation dataset. A random forest model-mini serious illness algorithm-used 8 variables from the initial 48 h of hospitalization and predicted death within 6 months with an AUC of 0.92 (0.91-0.93). Red cell distribution width was the most important prognostic variable. min-SIA (mini serious illness algorithm) was very well calibrated and estimated the probability of death to within 10% of the actual value. The discriminative ability of the min-SIA was significantly better than historical estimates of clinician performance.
CONCLUSION: min-SIA algorithm can identify patients at high risk of 6-month mortality at the time of hospital admission. It can be used to improved access to timely, serious illness care conversations in high-risk patients.
BACKGROUND: Care home residents are increasingly frail with complex health and social care needs. Their transfer to hospital at the end-of-life can be associated with unwanted interventions and distress. However, hospitals do enable provision of care that some residents wish to receive. We aimed to explore the factors that influence hospital admission of care home residents who then died in hospital.
METHODS: This study combined in-depth case note review of care home residents dying in two Scottish teaching hospitals during a 6-month period and semi-structured interviews with a purposive sample of 26 care home staff and two relatives.
RESULTS: During the 6-month period, 109 care home residents died in hospital. Most admissions occurred out-of-hours (69%) and most were due to a sudden event or acute change in clinical condition (72%). Length of stay in hospital before death was short, with 42% of deaths occurring within 3 days. Anticipatory Care Planning (ACP) regarding hospital admission was documented in 44%.Care home staff wanted to care for residents who were dying; however, uncertain trajectories of decline, acute events, challenges of ACP, relationship with family and lack of external support impeded this.
CONCLUSIONS: Managing acute changes on the background of uncertain trajectories is challenging in care homes. Enhanced support is required to improve and embed ACP in care homes and to provide rapid, 24 hours-a-day support to manage difficult symptoms and acute changes.
OBJECTIVE: To identify factors associated with referral to an exclusive palliative care unit (PCU) in patients with colorectal cancer (CRC).
METHODS: Retrospective cohort study with patients having CRC of both sexes treated at a hospital unit, aged = 20 years. Data were extracted from the medical records of pretreatment patients between January 2008 and August 2014. The outcome was referral to the PCU within 5 years. Logistic regression analyses were performed to assess whether sociodemographic, clinical, nutritional, and biochemistry data were associated to referral, generating odds ratios (OR), and 95% confidence intervals (CI).
RESULTS: Four hundred fifteen patients were evaluated. The Patient-Generated Subjective Global Assessment demonstrated a prevalence of malnutrition of 57.3%. One hundred one (24.3%) patients were referred to the PCU after 16.3 months (interquartile range: 7.2-33.5). These patients were more likely to be at an advanced stage of the disease and have malnutrition and exacerbated systemic inflammation. Tumor stage III and IV (OR: 2.05; 95% CI: 1.12-3.76) and neutrophil-to-lymphocyte ratio (NLR) =3 (OR: 1.89; 95% CI: 1.12-3.17) were predictors of an increased chance of referral to the PCU.
CONCLUSION: Advanced disease stage and NLR were associated with referral of patients with CCR to a PCU.
BACKGROUND: This study prospectively evaluated distress, depressive and anxiety symptoms as well as associated factors in family caregivers (FC) of advanced cancer patients at initiation of specialist inpatient palliative care.
METHODS: Within 72 h after the patient's first admission, FCs were asked to complete German versions of the Distress Thermometer, Generalized Anxiety Disorder 7-item scale (GAD-7), Patient Health Questionnaire depression module 9-item scale (PHQ-9) for outcome measure. Multivariate logistic regression analyses were used to identify associated factors.
RESULTS: In 232 FCs (62% spouses/partners), mean level of distress was 7.9 (SD 1.8; range, 2-10) with 95% presenting clinically relevant distress levels. Most frequent problems were sadness (91%), sorrows (90%), anxiety (78%), exhaustion (77%) and sleep disturbances (73%). Prevalence rates of moderate to severe anxiety and depressive symptoms were 47 and 39%, respectively. Only 25% of FCs had used at least one source of support previously. In multivariate regression analysis, being female (OR 2.525), spouse/partner (OR 2.714), exhaustion (OR 10.267), and worse palliative care outcome ratings (OR 1.084) increased the likelihood for moderate to severe anxiety symptom levels. Being female (OR 3.302), low socio-economic status (OR 6.772), prior patient care other than home-based care (OR 0.399), exhaustion (OR 3.068), sleep disturbances (OR 4.183), and worse palliative care outcome ratings (OR 1.100) were associated with moderate to severe depressive symptom levels.
CONCLUSIONS: FCs of patients presenting with indication for specialist palliative care suffer from high distress and relevant depressive and anxiety symptoms, indicating the high need of psychological support not only for patients, but also their FCs. Several socio-demographic and care-related risk-factors influence mental burden of FCs and should be in professional caregivers' focus in daily clinical practice.
Parkinson's disease and frailty are both common conditions affecting older people. Little is known regarding the association of the Clinical Frailty Scale with hospital outcomes in idiopathic Parkinson's disease patients admitted to the acute hospital. We aimed to test whether frailty status was an independent predictor of short-term mortality and other hospital outcomes in older inpatients with idiopathic Parkinson's disease.
METHOD: We conducted an observational retrospective study in a large tertiary university hospital between October 2014 and October 2016. Routinely measured patient characteristics included demographics (age and sex), Clinical Frailty Scale, acute illness severity (Emergency Department Modified Early Warning Score), the Charlson Comorbidity Index, discharge specialty, history of dementia, history of depression and the presence of a new cognitive impairment. Outcomes studied were inpatient mortality, death within 30 days of discharge, new institutionalisation, length of stay >= 7 days and readmission within 30 days to the same hospital.
RESULTS: There were 393 first admission episodes of idiopathic Parkinson's disease patients aged 75 years or more; 166 (42.2%) were female. The mean age (standard deviation) was 82.8 (5.0) years. The mean Clinical Frailty Scale was 5.9 (1.4) and the mean Charlson Comorbidity Index was 1.3 (1.5). After adjustment for covariates, frailty and acute illness severity were independent predictors of inpatient mortality; odds ratio for severely/very severely frail or terminally ill = 8.1, 95% confidence interval 1.0-63.5, p = 0.045 and odds ratio for acute illness severity: 1.3, 95% confidence interval 1.1-1.6, p = 0.005). The Clinical Frailty Scale did not significantly predict other hospital outcomes.
CONCLUSIONS: The Clinical Frailty Scale was a significant predictor of inpatient mortality in idiopathic Parkinson's disease patients admitted to the acute hospital and it may be useful as a marker of risk in this vulnerable population.
Only 2.3% of patients at a Midwest home healthcare (HH) agency had documented advance directives (ADs), compared with 28% nationally. Of concern, this HH agency lacked standardized procedures for advance care planning (ACP) leading to inadequate staff knowledge regarding end-of-life, avoidable hospital readmissions, and delayed transitions into hospice care. Lack of ADs is directly correlated to higher hospital readmission rates and lower hospice length of stay. The purpose of this initiative was to develop evidence-based procedures using the Respecting Choices ACP model to: 1) educate staff, 2) increase ACP conversations offered and completed among high-risk patients, 3) increase Practitioner Orders for Life-Sustaining Treatment (POLST) rates, 4) reduce 60-day hospital readmissions, and 5) support hospice care admissions. Staff received discipline-specific education on ACP/ADs. The Knowledge-Attitudinal-Experiential Survey on Advance Directives (KAESAD), assessed staff ACP/AD knowledge, confidence, and experiences. Standardized electronic medical record tools were created to track ACP conversations, POLST rates, 60-day hospital readmissions, and hospice admissions. Paired t-test and chi-square analyses compared changes pre- and post implementation. The KAESAD survey was analyzed for 75 staff (100%) and demonstrates improvement in knowledge, confidence, and experiences. Data also demonstrate increases in: ACP offered 6% to 80% (p < .001); ACP conversations completed 4% to 31% (p < .001); POLST rates 26% to 43.6% (p = .059); decreased 60-day hospital readmissions 40% to 20% (p = .025); whereas hospice care admissions was not impacted ranging from 10% to 5.5% (p = .381). Respecting Choices serves as an effective ACP framework to improve ACP conversations, POLST rates, and hospital readmissions.