Background: Studies on the appropriate use of urinary catheters for cancer patients at the end of life are limited.
Aim: To clarify the differences among institutions in the prevalence of and indications for urinary catheterization of advanced cancer patients at palliative care units.
Design: Pre-planned secondary analysis of a multicenter, prospective cohort study; East-Asian collaborative cross-cultural Study to Elucidate the Dying process (EASED).
Setting/participants: This study enrolled consecutive advanced cancer patients admitted to palliative care units between January and December 2017. The final study group comprised 1212 patients from 21 institutions throughout Japan.
Results: Out of the 1212 patients, 380 (31.4%; 95% confidence interval, 28.7%–34.0%) underwent urinary catheterization during their palliative care unit stay, and the prevalence of urinary catheterization in patients who died at palliative care units by institution ranged from 0.0% to 55.4%. When the 21 participating institutions were equally divided into three groups according to the institutional prevalence of catheterization, patients with difficulty in moving safely, exhaustion on movement, and restlessness or agitation were more likely to be catheterized in institutions with a high prevalence of catheterization than in those with a low or moderate prevalence (p < 0.008, p = 0.008, and p < 0.008, respectively).
Conclusion: This study revealed that the institutional prevalence of urinary catheterization in advanced cancer patients at palliative care units widely varied. Further studies are needed to establish the appropriate use of urinary catheters, especially in patients with difficulty in moving safely, exhaustion on movement, and restlessness or agitation.
OBJECTIVE: To describe the characteristics and outcomes of patients undergoing mechanical ventilation withdrawal and to compare them to mechanically ventilated patients with limitations (withhold or withdrawal) of life-sustaining therapies but who did not undergo mechanical ventilation withdrawal.
METHODS: This was a retrospective cohort study from January 2014 to December 2018 of mechanically ventilated patients with any organ support limitation admitted to a single intensive care unit. We compared patients who underwent mechanical ventilation withdrawal and those who did not regarding intensive care unit and hospital mortality and length of stay in both an unadjusted analysis and a propensity score matched subsample. We also analyzed the time from mechanical ventilation withdrawal to death.
RESULTS: Out of 282 patients with life-sustaining therapy limitations, 31 (11%) underwent mechanical ventilation withdrawal. There was no baseline difference between groups. Intensive care unit and hospital mortality rates were 71% versus 57% and 93% versus 80%, respectively, among patients who underwent mechanical ventilation withdrawal and those who did not. The median intensive care unit length of stay was 7 versus 8 days (p = 0.6), and the hospital length of stay was 9 versus 15 days (p = 0.015). Hospital mortality was not significantly different (25/31; 81% versus 29/31; 93%; p = 0.26) after matching. The median time from mechanical ventilation withdrawal until death was 2 days [0 - 5], and 10/31 (32%) patients died within 24 hours after mechanical ventilation withdrawal.
CONCLUSION: In this Brazilian report, mechanical ventilation withdrawal represented 11% of all patients with treatment limitations and was not associated with increased hospital mortality after propensity score matching on relevant covariates.
BACKGROUND: Advanced cancer patients are part of a group likely to be more susceptible to COVID-19.
AIMS: To describe the profile of advanced cancer inpatients to an exclusive Palliative Care Unit (PCU) with the diagnosis of COVID-19, and to evaluate the factors associated with death in these cases.
DESIGN: Retrospective cohort study with data from advanced cancer inpatients to an exclusive PCU, from March to July 2020, with severe acute respiratory syndrome. Diagnostic of COVID-19 and death were the dependent variables. Logistic regression analyses were performed, with the odds ratio (OR) and 95% confidence interval (CI).
RESULTS: One hundred fifty-five patients were selected. The mean age was 60.9 (±13.4) years old and the most prevalent tumor type was breast (30.3%). Eighty-three (53.5%) patients had a diagnostic confirmation of COVID-19. Having diabetes mellitus (OR: 2.2; 95% CI: 1.1-6.6) and having received chemotherapy in less than 30 days before admission (OR: 3.8; 95% CI: 1.2-12.2) were associated factors to diagnosis of COVID-19. Among those infected, 81.9% died and, patients with Karnofsky Performance Status (KPS) < 30% (OR: 14.8; 95% CI 2.7-21.6) and C-reactive protein (CRP) >21.6mg/L (OR: 9.3; 95% CI 1.1-27.8), had a greater chance of achieving this outcome.
CONCLUSION: Advanced cancer patients who underwent chemotherapy in less than 30 days before admission and who had diabetes mellitus were more likely to develop Coronavirus 2019 disease. Among the confirmed cases, those hospitalized with worse KPS and bigger CRP were more likely to die.
Background: The concept of cost-effectiveness is necessary for optimal utilization of limited health care resources. However, few studies have assessed the cost-effectiveness of palliative care using quality-adjusted life years (QALYs), considered common outcomes in health economics.
Objective: We aimed to perform a cost-effectiveness analysis of palliative care for terminal cancer patients by using QALYs.
Design: A retrospective cohort study was performed.
Setting/Patients: We included 401 patients with stage IV cancer, who were hospitalized and died at a Japanese general hospital during the period April 2014 to March 2019.
Methods: Using the hospital database, we compared the total admission costs and QALYs based on pain levels of patients admitted to the palliative care (PC) department with those of patients admitted to other usual care (UC) departments. Patients in each group were matched through propensity scores to reduce bias. Bootstrapping estimated the 95% confidence intervals (95% CIs) and the probability that PC was more cost-effective than UC.
Results: After matching, 128 patients in each group were selected. Converting 1 U.S. dollar (USD) to 100 Japanese yen, PC reduced mean total admission costs by 1732 USD (95% CI: 1584-1879) and improved mean health benefits by 0.0028 QALYs (95% CI: 0.0025-0.0032) compared with UC. Based on the Japanese cost-effectiveness threshold, there was an 82% probability that PC was more cost-effective than UC.
Conclusions: Our results indicated that admission of terminal cancer patients to the PC department was associated with improvement in cost-effectiveness. This finding could support the introduction of palliative care for terminal cancer patients. Our study was approved at St. Luke's International University (receipt number 18-R061 and at the Graduate School of Pharmaceutical Sciences, The Univesity of Tokyo (receipt number 31-29).
BACKGROUND: Dementia is a leading cause of death among US older adults. Little is known about end-of-life care intensity and do-not-resuscitate orders (DNRs) among patients with dementia who die in hospital.
AIM: Examine the relationship between dementia, DNR timing, and end-of-life care intensity.
DESIGN: Observational cohort study.
SETTING/PARTICIPANTS: Inpatient electronic health record extraction for 2,566 persons age 65 and older who died in 2 New York City hospitals in the United States from 2015 to 2017.
RESULTS: Multivariable logistic regression analyses modeled associations between dementia diagnosis, DNR timing, and 6 end-of-life care outcomes. 31% of subjects had a dementia diagnosis; 23% had a DNR on day of hospital admission. Patients with dementia were 18%-40% less likely to have received 4 of 6 types of intensive care (mechanical ventilation AOR: 0.82, 95%CI: 0.67 -1.00; intensive care unit admission AOR: 0.60, 95%CI: 0.49-0.83). Having a DNR on file was inversely associated with staying in the intensive care unit (AOR: 0.57, 95%CI: 0.47-0.70) and avoiding other intensive care measures. DNR placement later during the hospitalization and not having a DNR were associated with more intensive care compared to having a DNR upon admission.
CONCLUSIONS: Having dementia and a do-not resuscitate order upon hospital admission are associated with less intensive end-of-life care. Additional research is needed to understand why persons with dementia receive less intensive care. In clinical practice, encouraging advance care planning prior to and at hospital admission may be particularly important for patients wishing to avoid intensive end-of-life care, including patients with dementia.
PURPOSE: Clinical trials have shown that palliative chemotherapy (PC) improves survival in patients with incurable esophageal and gastric cancer; however, outcomes achieved in routine practice are unknown. We describe treatment patterns and outcomes among patients treated in the general population of Ontario, Canada.
METHODS: The Ontario Cancer Registry was used to identify patients with esophageal or gastric cancer from 2007 to 2016, and data were linked to other health administrative databases. Patients who received curative-intent surgery or radiotherapy were excluded. Factors associated with the receipt of PC were determined using logistic regression. First-line PC regimens were categorized, and trends over time were reported. Survival was determined using the Kaplan-Meier method.
RESULTS: The cohort included 9,848 patients; 22% (2,207 of 9,848) received PC. Patients receiving PC were younger (mean age, 63 v 74 years; P < .0001) and more likely male (71% v 65%; P < .0001). Thirty-seven percent of non-PC patients saw a medical oncologist in consultation. Over the study period, utilization of PC increased (from 11% in 2007 to 19% in 2016; P < .0001), whereas the proportion of patients receiving triplet regimens decreased (65% in 2007 to 56% in 2016; P = .04). In the PC group, the median overall and cancer-specific survival from treatment initiation was 7.2 months.
CONCLUSION: One fifth of patients with incurable esophageal and gastric cancer in the general population receive PC. Median survival of patients treated in routine practice is inferior to that in clinical trials. Only one third of patients not treated with PC had consultation with a medical oncologist. Further work is necessary to understand low utilization of PC and medical oncology consultation in this patient population.
Background: Head and neck cancer was the fourth-most common cause of cancer death among Taiwanese men in 2018. Hospice care has been proven to reduce the use of invasive medical interventions and expenditures in caring for cancer patients.
Aim: This study examined the effects of hospice care for terminal head and neck cancer patients.
Design: A matched cohort study was used to compare the use of invasive interventions and expenditures among hospice care and nonhospice care patients.
Setting/Participants: The investigated patients consisted of patients who died of head and neck cancer in Taiwan from 2004 to 2013 and were included in the Registry for Catastrophic Illness Patients in Taiwan and the Taiwan National Health Research Insurance Database.
Results: A total of 45,948 terminal head and neck cancer patients were identified, and 9883 patients remained in each group after matching for comorbidities. After that matching, the rates of intensive care unit admission (23.9% vs. 38.94%, p < 0.0001), endotracheal intubation (10.05% vs. 31.32%, p < 0.0001), cardiopulmonary resuscitation (2.93% vs. 20.18%, p < 0.0001), defibrillation (0.51% vs. 4.36%. p < 0.0001), ventilator use (21.92% vs. 46.47%, p < 0.0001), blood transfusion (71.25% vs. 73.45%, p = 0.006), and hemodialysis (1.06% vs. 3.26%. p < 0.0001) were significantly lower in the hospice group than the nonhospice group, although the rates of parenteral nutrition for the two groups were similar (7.74% vs. 7.97%, p = 0.5432). The mean medical expenditure per person in the six months before death was 460,531 New Taiwan Dollar (NTD) for the nonhospice group and 389,079 NTD for those provided hospice care for more than three months, which was the lowest amount among various hospice enrollment durations.
Conclusions: Hospice care can effectively reduce the use of invasive medical interventions in caring for terminal head and neck cancer patients and may improve their quality of death. Moreover, hospice care enrollment for more than three months can save on unnecessary medical expenditures for terminal head and neck cancer patients.
BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) often receive burdensome care at end-of-life (EOL) and infrequently complete advance care planning (ACP). The surprise question (SQ) is a prognostic tool that may facilitate ACP.
OBJECTIVE: To assess how well the SQ predicts mortality and prompts ACP for COPD patients.
DESIGN: Retrospective cohort study.
SUBJECTS: Patients admitted to the hospital for an acute exacerbation of COPD between July 2015 and September 2018.
MAIN MEASURES: Emergency department (ED) and inpatient clinicians answered, "Would you be surprised if this patient died in the next 30 days (ED)/one year (inpatient)?" The primary outcome measure was the accuracy of the SQ in predicting 30-day and 1-year mortality. The secondary outcome was the correlation between SQ and ACP (palliative care consultation, documented goals-of-care conversation, change in code status, or completion of ACP document).
KEY RESULTS: The 30-day SQ had a high specificity but low sensitivity for predicting 30-day mortality: sensitivity 12%, specificity 95%, PPV 11%, and NPV 96%. The 1-year SQ demonstrated better accuracy for predicting 1-year mortality: sensitivity 47%, specificity 75%, PPV 35%, and NPV 83%. After multivariable adjustment for age, sex, and prior 6-month admissions, 1-year SQ+ responses were associated with greater odds of 1-year mortality (OR 2.38, 95% CI 1.39-4.08) versus SQ-. One-year SQ+ patients were more likely to have a goals-of-care conversation (25% vs. 11%, p < 0.01) and complete an advance directive or POLST (46% vs. 23%, p < 0.01). After multivariable adjustment, SQ+ responses to the 1-year SQ were associated with greater odds of ACP receipt (OR 2.67, 95% CI 1.64-4.36).
CONCLUSIONS: The 1-year surprise question may be an effective component of prognostication and advance care planning for COPD patients in the inpatient setting.
Background:There is inconsistent evidence that palliative care intervention decreases total healthcare expenditure at end-of-life for oncology patients. This inconsistent evidence may result from small sample sizes at single institution studies and disparate characterization of costs across studies. Comprehensive studies in population-based datasets are needed to fully understand the impact of palliative care on total healthcare costs. This study analyzed the impact of palliative care on total healthcare costs in a nationally representative sample of advanced cancer patients.
Methods:We conducted a matched cohort study among Medicare patients with metastatic lung, colorectal, breast and prostate cancers. We matched patients who received a palliative care consultation to similar patients who did not receive a palliative care consultation on factors related to both the receipt of palliative care and end of life costs. We compared direct costs between matched patients to determine the per-patient economic impact of a palliative care consultation.
Results:Patients who received a palliative care consultation experienced an average per patient cost of $5,834 compared to $7,784 for usual care patients (25% decrease; p < 0.0001). Palliative care consultation within 7 days of death decreased healthcare costs by $451, while palliative care consultation more than 4 weeks from death decreased costs by $4,643.
Conclusion:This study demonstrates that palliative care has the capacity to substantially reduce healthcare expenditure among advanced cancer patients. Earlier palliative care consultation results in greater cost reductions than consultation in the last week of life.
PURPOSE: This study aimed to determine the palliative care difficulties experienced by nursing students during their clinical practice.
DESIGN AND METHODS: This descriptive and cross-sectional study was conducted with 305 nursing students at a university in Turkey. Data were collected using a student identification form and the palliative care difficulties scale.
FINDINGS: Nursing students experience a moderate level of difficulty in providing care for palliative care patients and receiving expert support facilitates their care initiatives.
PRACTICE IMPLICATIONS: It is important to support nursing students during their nursing education courses and clinical training, along with psychiatric nursing skills.
BACKGROUND: Palliative care improves the quality of lives of patients and families affected by advanced illnesses through the prevention and relief of suffering. While palliative care is well established in developed countries, it is inadequate or non-existent in most developing countries. Palliative care is an emerging concept in Bhutan, a tiny Himalayan Kingdom. A small community palliative care service is available in the national referral hospital with three dedicated inpatient palliative care beds. This study explored the needs for palliative care among patients diagnosed with advanced illnesses and is a component of a larger project aimed to inform a suitable palliative care model for the country.
METHODS: This is a cross-sectional descriptive study. A survey, using a structured questionnaire including the EORTC QLQ-C30, was carried out among patients with advanced illness in hospitals, primary care units and communities across the country. Purposeful and snowball sampling strategies were used to recruit study participants.
RESULTS: Seventy (76%), out of 93 eligible patients, agreed to participate in the survey. Participants reported low to moderate scores on physical, role, emotional, cognitive and social functioning, a moderate score for the global health/ quality of life scale and moderately high (worse) scores in symptoms including fatigue, pain, insomnia, loss of appetite and the financial impact from the disease.
CONCLUSIONS: The symptom burden experienced by patients affected by advanced illnesses demonstrates the need for palliative care in Bhutan. These findings will help inform the development of a public health-focused palliative care model, modified to the Bhutanese context, as recommended by the World Health Organization.
Objective: To assess trends in place of death for children with a life-limiting condition and the factors associated with death at home or hospice rather than hospital.
Design: Observational cohort study using linked routinely collected data.
Patients: Children aged 0-25 years who died between 2003 and 2017.
Main outcome measures: Place of death: hospital, hospice, home. Multivariable multinomial logistic regression models.
Results: 39 349 children died: 73% occurred in hospital, 6% in hospice and 16% at home. In the multivariable models compared with dying in a hospital: neonates were less likely, and those aged 1-10 years more likely, than those aged 28 days to <1 year to die in hospice. Children from all ethnic minority groups were significantly less likely to die in hospice, as were those in the most deprived group (RR 0.8, 95% CI 0.7 to 0.9). Those who died from 2008 were more likely than those who died earlier to die in a hospice.Children with cancer (RR 4.4, 95% CI 3.8 to 5.1), neurological (RR 2.0, 95% CI 1.7 to 2.3) or metabolic (RR 3.7, 95% CI 3.0 to 4.6) diagnoses were more likely than those with a congenital diagnosis to die in a hospice.Similar patterns were seen for clinical/demographic factors associated with home versus hospital deaths.
Conclusions: Most children with a life-limiting condition continue to die in the hospital setting. Further research on preferences for place of death is needed especially in children with conditions other than cancer. Paediatric palliative care services should be funded adequately to enable equal access across all settings, diagnostic groups and geographical regions.
PURPOSE: The purpose of this study was to evaluate end-of-life resource utilization and costs for prostate cancer patients during the last year of life in Korea.
MATERIALS AND METHODS: The study used the National Health Information Database (NHIS-2017-4-031) of the Korean National Health Insurance Service. Healthcare claim data for the years 2002 through 2015 were collected from the Korean National Health Insurance System. Among 83,173 prostate cancer patients, we enrolled 18,419 after excluding 1,082 who never claimed for the last year of life.
RESULTS: From 2006 to 2015, there was a 3.2-fold increase the total number of prostate cancer decedents. The average cost of care during the last year of life increased over the 10-year period, from 14,420,000 Korean won to 20,300,000 Korean won, regardless of survival time. The cost of major treatments and medications, other than analgesics, was relatively high. Radiologic tests, opioids, pain control, and rehabilitation costs were relatively low. Multiple regression analysis identified age and living in rural area as negatively associated with prostate cancer care costs, whereas income level and a higher number of comorbidities were positively associated.
CONCLUSIONS: Expenditure of prostate cancer care during the last year of life varied according to patient characteristics. Average costs increased every year. However, the results suggest underutilization of support services, likely due to lack of alternative accommodation for terminal prostate cancer patients. Further examination of patterns of utilization of healthcare resources will allow policymakers to take a better approach to reducing the burden of prostate cancer care.
Health care utilization of women with breast cancer (BC) during the last year of life, together with the causes and place of death and associated expenditure have been poorly described. Women treated for BC (2014-2015) with BC as a cause of death in 2015 and covered by the national health insurance general scheme (77% of the population) were identified in the French health data system (n = 6,696, mean age: 68.7 years, SD ± 15). Almost 70% died in short-stay hospitals (SSH), 4% in hospital-at-home (HaH), 9% in Rehab, 5% in skilled nursing homes (SNH) and 12% at home. One-third presented cardiovascular comorbidity. During the last year, 90% were hospitalized at least once in SSH, 25% in Rehab, 13% in HaH and 71% received hospital palliative care (HPC), but only 5% prior to their end-of-life stay. During the last month, 85% of women were admitted at least once to a SSH, 42% via the emergency department, 10% to an ICU, 24% received inpatient chemotherapy and 18% received outpatient chemotherapy. Among the 83% of women who died in hospital, independent factors for HPC use were cardiovascular comorbidity (adjusted odds ratio, aOR: 0.83; 95%CI: 0.72-0.95) and, in the 30 days before death, at least one SNH stay (aOR: 0.52; 95%CI: 0.36-0.76), ICU stay (aOR: 0.36; 95%CI: 0.30-0.43), inpatient chemotherapy (aOR: 0.55; 95%CI: 0.48-0.63), outpatient chemotherapy (aOR: 0.60; 95%CI: 0.51-0.70), death in Rehab (aOR: 1.4; 95%CI: 1.05-1.86) or HAH (aOR: 4.5; 95%CI: 2.47-8.1) vs SSH. Overall mean expenditure reimbursed per woman was €38,734 and €42,209 for those with PC. Women with inpatient or outpatient chemotherapy during the last month had lower rates of HPC, suggesting declining use of HPC before death. This study also indicates SSH-centered management with increased use of HPC in HaH and Rehab units and decreased access to HPC in SNH.
CONTEXT: Palliative care triggers have been used in the ICU setting, usually in high income countries, to identify patients who may benefit from palliative care consults. The utility and benefits of palliative care triggers in the ICU has not been previously studied in sub-Saharan Africa.
OBJECTIVES: Our objectives were to determine the prevalence of ICU admissions who met at least one palliative care trigger and whether a palliative care consult influenced the length of ICU stay and time to change of goals order.
METHODS: We conducted a prospective observational cohort study within our ICU at The Aga Khan University Hospital, Nairobi between December 2019 and August 2020. Data including initiation of a palliative care consult, length of ICU stay, mortality and time to change of goals order was collected.
RESULTS: During our study period, 72 of 159 (45.9%) patients met at least one palliative care trigger point. Of the patients who met the palliative care triggers, only 29.2% received a palliative care consult. Patients who received palliative care consults had higher rates of change of goals orders signed (52.3%) versus those who did not (P=0.009). There was no statistically significant difference between the consult and non-consult groups in regards to length of ICU stay, time to change of goals order and mortality.
CONCLUSION: A trigger-based model, geared to the needs of the specific ICU, may be one way of improving integration of palliative care into the ICU, especially in sub-Saharan Africa.
CONTEXT: In spring 2020, New York experienced as surge of patients hospitalized with severe acute respiratory syndrome coronavirus 2 (COVID-19) disease, as part of a global pandemic. There is limited data on populations of COVID-19 infected patients seen by palliative care services.
OBJECTIVE: To describe a palliative care population at one New York hospital system during the initial pandemic surge.
METHODS: This repeated cross sectional, observational study collected data on palliative care patients in a large health system seen during the COVID-19 outbreak and compared it to pre-COVID data.
RESULTS: Palliative service volume surged from 678 (4% of total admissions) pre-COVID-19 to 1,071 (10% of total admissions) during the COVID-19 outbreak. During the outbreak, 695 (64.9%) of palliative patients tested positive for the virus. Compared with a pre-outbreak group, this COVID-19 positive group had higher rates of male (60.7% vs 48.6%, p < 0.01) and Latino (21.3% vs 13.3%; p < 0.01) patients and less white patients (21.3% vs 13.3%; p < 0.01). Our patient's with COVID-19 also had greater prevalence of obesity and diabetes and lower rates of end-stage organ disease and cancers. The COVID-19 positive group had a higher rate of intensive care unit admissions (58.9% vs 33.9%; p < 0.01) and in-hospital mortality rate (57.4% vs 13.1%; p < 0.01) compared to the pre-outbreak group. There was increased odds of mortality in palliative care patients who were COVID-19 positive (OR = 3.21; 95% CI = 2.43 - 4.24) and those admitted to the ICU (OR = 1.45; 95% CI = 1.11 - 1.9).
CONCLUSION: During the initial surge of the COVID-19 pandemic in New York, palliative care services experienced a large surge of patients who tended to be healthier at baseline and more acutely ill at time of admission than pre-COVID palliative patients.
Context: Few studies have described the characteristics and palliative care needs in hospitalized patients with coronavirus disease 2019 (COVID-19).
Objectives: Describing characteristics, consultation demands, patients' needs, and outcomes of hospitalized patients with COVID-19 who received a palliative care evaluation.
Methods: Retrospective chart review of patients (aged 18+ years) with COVID-19 admitted to an academic quaternary center and seen by the geriatrics and palliative medicine team from March 1st to May 11th, 2020. Socio-demographics, operational metrics, severity of illness, goals of care-advanced care planning documentation, and outcomes were analyzed.
Results: Three hundred seventy-six (17.6%) out of 2138 COVID-19 admissions were seen by the consultation team. Compared with prepandemic situation (September 1st, 2019, to February 29th, 2020), overall new consults (205 vs. 371, P < 0.001) significantly increased, particularly in the intensive care unit (ICU; 9.5% vs. 36.9%, P < 0.001). For the COVID-19 population, median age was 78 years (interquartile range, 70-87; range, 36-102); 56% were male. LACE score, D-dimer, and C-reactive protein suggested severe disease and increased risk of mortality. Seventy-five percent of consults were for goals of care-advanced care planning, and 9.6% for symptoms. During the index admission, 7.1% had documented advanced directives, and 69.7% became do not resuscitate. Of all deaths, 55.5% were in the ICU, and 87.2% were aged =65 years. Underserved minority patients had a disproportionate mortality. Overall consultation mortality (38.3% vs. 70.4%, P < 0.001) and ICU mortality (55.2% vs. 78.1%, P < 0.001) significantly increased compared with those before COVID-19.
Conclusion: During this pandemic, understanding inpatient specialized palliative care needs and the vulnerable populations driving these causes may encourage health-care agencies and local, state, and federal governments to support the dedicated palliative care workforce.
Objectives: This study investigated whether and to what extent widowhood status is related to engagement in advance care planning (ACP), and further whether race/ethnicity moderated the relation.
Methods: We analyzed a total of 11,257 older Americans from the Health and Retirement Study using random-effect regression models after controlling for covariates and year-fixed effects.
Results: We found that both being a widow/widower ever and having been widowed for a longer period of time were associated with a higher probability of engagement in ACP. Specifically, we found that a one-year increase in the number of years since spousal death was associated with 1.02 (p < 0.05, 95% CI = 1.00, 1.03) changes in the odds ratios of informal ACP; however, inclusion of a quadratic term indicated that this association reversed after the peak. Moreover, our findings suggested a moderating effect of race/ethnicity on the relations of the length of time since spousal loss with engagement in ACP. Specifically, the odds of widowed non-Hispanic Blacks discussing with someone the care or medical treatment (informal ACP) and having a living will (formal ACP) were 0.96 (p < 0.05, 95% CI = 0.93, 1.00) and 0.88 (p < 0.05, 95% CI = 0.79, 0.97) times that of non-widowed non-Hispanic Whites. Compared with their non-Hispanic White counterparts, widowed non-Hispanic Blacks were less likely to engage in ACP, and the negative relations were exacerbated when they became widows/widowers.
Conclusion: We elaborated on these findings and discussed their implications for understanding the moderating effect of race/ethnicity on the relation between late life widowhood and engagement in ACP. In order to develop programs that enhance engagement in ACP and reduce racial/ethnic disparities, research must incorporate intersectionality theory with attention to motivations and decision-making style among diverse widows/widowers. The findings from this study could help inform policy makers when developing public health programs and health care reimbursement programs that enhance engagement in ACP among widows/widowers.
Background: Primary care clinicians care for most persons with Alzheimer's disease and related dementias (ADRDs), yet lack dementia-specific skills in advance care planning (ACP).
Objectives: To develop and evaluate a training toolkit for primary care clinicians to improve ACP communication for people with ADRD and their families.
Design: Clinical practice outcomes assessment and pre-post-training evaluation. Intervention training toolkit addressed ACP skills by dementia stage: (1) advance directives in early dementia, (2) decision-making capacity in moderate dementia, (3) Physician Orders for Life-Sustaining Treatment (POLST) in late-stage dementia, and (4) hospice and hospitalization in advanced dementia.
Setting/Subjects: Nonhospitalized clinical care sites, 51 clinicians in North Carolina, USA.
Measurements: Data collection utilized structured chart abstractions and pre- and post-training surveys.
Results: Of 51 participants trained, 33 had encounters with patients with ADRD in study period. Most participants were women (n = 42), white (n = 37), and physicians (n = 31). Participants increased documentation of surrogates (22.7% vs. 35.5%, p = 0.03), decision-making capacity (13.5% vs.23.2%, p = 0.04), and POLST completion (9.2% vs. 18.8%, p = 0.03). Training increased ACP documentation (6.4% vs. 14.5%, p = 0.031) and goals of care (GOC) decision-making discussions (17.0% vs. 31.9%, p = 0.005). In pre-post-comparisons, participant confidence increased in determining capacity, exploring dementia prognosis, GOC, eliciting surrogates, and leading family meetings (all p < 0.001). Most participants strongly agreed that the training addressed skills used in practice (n = 34), contained clear language (n = 40), took an appropriate amount of time (n = 32), and was designed effectively (n = 35).
Conclusion: This video-based training resource increased the use of dementia-specific ACP communication skills and clinician confidence.
Background: Paramedics commonly face acute crises of patients in palliative care, but their involvement in end-of-life care is not planned systematically.
Aim: To evaluate a protocol for end-of-life care at home including pre-planned integration of paramedics and end-of-life care wards.
Design: Paramedic visits to patients in end-of-life care protocol were retrospectively studied.
Setting/Participants: All of the patients who had registered for the protocol between 1 March 2015 and 28 February 2017 in North Karelia, Finland, were included in this study.
Results: A total of 256 patients were registered for the protocol and 306 visits by paramedic were needed. A need for symptom control (38%) and transportation (29%) were the most common reasons for a visit. Paramedics visited 43% and 70% of the patients in areas with and without 24/7 palliative home care services, respectively (p < 0.001); while 58% of all the visits were done outside of office hours. Problems were resolved at home in 31% of the visits. The patient was transferred to a pre-planned end-of-life care ward and to an emergency department in 48% and 16% of the cases, respectively. More patients died in end-of-life care wards in areas without (54%) than with (33%) 24/7 home care services (p = 0.001).
Conclusions: integration of paramedics into end-of-life care at home is reasonable especially in rural areas without 24/7 palliative care services and outside of office hours. The majority of patients can be managed at home or with the help of an end-of-life care ward without an emergency visit.