PURPOSE: This study aimed to determine the impact of advanced care planning (ACP) on potentially avoidable hospital admissions at the end of life (EOL) among a sample of hospice-referred patients with cancer, in order to present actionable considerations for the practicing clinician.
METHODS: This study was designed as a retrospective cohort using electronic health record data that assessed likelihood of hospital admissions in the last 30 days of life for 1185 patients with a primary diagnosis of cancer, referred to hospice between January 1, 2014, and December 31, 2015, at a large academic medical center. Inverse probability treatment weighting based on calculated propensity scores balanced measured covariates between those with and without ACP at baseline. Odds ratios (ORs) were calculated from estimated potential outcome means for the impact of ACP on admissions in the last 30 days of life.
RESULTS: A verified do-not-resuscitate (DNR) order prior to the last 30 days of life was associated with reduced odds of admission compared to those without a DNR (OR = 0.30; P < .001). An ACP note in the problem list prior to the last 30 days of life was associated with reduced odds of admission compared to those without an ACP note (OR = 0.71, P = .042), and further reduced odds if done 6 months prior to death (OR = 0.35, P < .001).
CONCLUSIONS: This study shows that dedicated ACP documentation is associated with fewer admissions in the last 30 days of life for patients with advanced cancer referred to hospice. Improving ACP processes prior to hospice referral holds promise for reducing EOL admissions.
Background:: Palliative care services and life-sustaining treatments are provided to dying patients with lung cancer in the United States. However, data on the utilization trends of palliative care services and life-sustaining treatments of dying patients with lung cancer are not available.
Methods: This study was a retrospective analysis of the National Inpatient Sample data (2005-2014) and included patients with lung cancer, aged = 18 years, who died in the hospitals. Claims data of palliative care services and life-sustaining treatments that contained systemic procedures, local procedures, or surgeries were extracted. Compound annual growth rates (CAGRs) using Rao-Scott correction for 2 tests were used to determine the statistical significance of temporal utilization trends of palliative care services and life-sustaining treatments and their hospital costs. Multilevel multivariate regressions were performed to identify factors associated with hospital costs.
Results: A total of 120 144 weighted patients with lung cancer died in the hospitals and 41.9% of them received palliative care services. The CAGRs of systemic procedures, local procedures, surgeries, palliative care services, and hospital cost were 3.42%, 3.48%, 6.08%, 18.5%, and 5.0% (all P < .001), respectively. Increased hospital cost was attributed to systemic procedures (50.6%), local procedures (74.4%), and surgeries (68.5%; all P < .001), respectively. Palliative care services were related to decreasing hospital costs by 28.6% (P < .001).
Conclusion: The temporal trends of palliative care services indicate that their utilization has increased gradually. Palliative care services were associated with reduced hospital costs. However, life-sustaining treatments were associated with increased hospital costs.
BACKGROUND: Cancer is the second leading cause of death globally, causing a substantial economic burden on cancer suffers and their families. The aim of this study is to explore the prevalence, determinants and consequences of catastrophic health expenditure (CHE) among urban and rural end-of-life (EOF) cancer patients in China.
METHODS: Using respondent-driven sampling and face-to-face interviews, field research was conducted with a specialist questionnaire. Data were collected on 792 cancer patients who died between June 2013 and June 2016 in China. The determinants of household catastrophic expenditure were identified by multivariate logistic regression.
FINDINGS: It is found that more than 80% of cancer patients received life-extending treatment. Extremely high rates of CHE were identified among EOL cancer patients, at 94.3% for urban families and 96.1% for rural families. After spending for health, 84.1% of urban and 91.1% rural EOL cancer patient households were impoverished, falling below the poverty line. For both urban and rural households, income was the most significant factor associated with catastrophic health expenditure (CHE). Health insurance did not adequately compensate for CHE. Rural families experienced higher CHE, lower levels of health care utilization, a different mix of health care access and higher rates of borrowing for out-of-pocket (OOP) health care expenditures than urban families. Both urban and rural households suffered long-term economic disadvantage due to CHE and borrowing for OOP medical care expenses.
CONCLUSIONS: EOL cancer patients experienced severe CHE, with families forced into poverty. With only about 1% of EOL cancer patients receiving palliative care, developing palliative care services and expanding the acceptance of palliative care in China is both urgent and essential. To help address impoverishment due to CHE, China should also develop targeted programs to reduce income inequality, especially rural-urban inequalities; increase access to health care; and accelerate health reform. Increasing the retirement age would provide households with more savings and wealth to withstand CHE.
BACKGROUND: Palliative care can improve end-of-life care and reduce health care expenditures, but the optimal timing for initiation remains unclear. We sought to characterize the association between timing of palliative care, in-hospital deaths, and health care costs.
METHODS: This is a retrospective cohort study including all patients who were diagnosed and died of colorectal cancer between 2004 and 2012 in Manitoba, Canada. The primary exposure was timing of palliative care, defined as no involvement, late involvement (less than 14 d before death), early involvement (14 to 60 d before death), and very early involvement (>60 d before death). The primary outcome was in-hospital deaths and end-of-life health care costs.
RESULTS: A total of 1607 patients were included; 315 (20%) received palliative care and 162 (10%) died in hospital. Compared to those who did not receive palliative care, patients with early and very early involvement experienced significantly decreased odds of dying in hospital (OR 0.21 95% CI 0.06-0.69 P = 0.01 and OR 0.11 95% CI 0.01-0.78 P = 0.03, respectively) and significantly lower health care costs. There were no significant differences in in-hospital deaths and health care costs between patients without palliative care and those who received late palliative care.
CONCLUSIONS: Early palliative care involvement is associated with decreased odds of dying in hospital and lower health care utilization and costs in patients with colorectal cancer. These findings provide real-world evidence supporting early integration of palliative care, although the optimal timing (early versus very early) remains a matter of debate.
Background: The benefit of palliative chemotherapy (PC) in patients with advanced solid tumors and poor performance status (ECOG-PS) has not been prospectively validated, which makes treatment decision challenging. We aimed to evaluate the overall survival, factors associated with early mortality, and adoption of additional procedures in hospitalized patients with advanced cancer and poor ECOG-PS treated with PC.
Methods: We analyzed a retrospective cohort of patients with advanced cancer treated with PC during hospitalization at an academic cancer center in Brazil from 2014 to 2016. Eligibility criteria included: ECOG-PS 3–4 and start of first-line PC; or ECOG-PS = 2 and start of second or subsequent lines. Primary endpoint was 30-day survival from start of PC. Kaplan-Meier method was used for survival estimates and Cox regression for factors associated with 30-day mortality.
Results: Two hundred twenty-eight patients were eligible. 21.9, 66.7 and 11.4% of patients had ECOG-PS 2, 3 and 4, respectively. 49.6% had gastrointestinal tumors. Median follow-up was 49 days (range 1–507). 98.2% of patients had died, 32% during the index hospitalization. The 30-day and 60-day survival rates were 55.7 and 38.5%, respectively. 30% of patients were admitted to the intensive care unit. In a multivariable analysis, ECOG-PS 3/4 (HR 2.01; P = 0.016), hypercalcemia (HR 2.19; P = 0.005), and elevated bilirubin (HR 3.17; P < 0.001) were significantly associated with 30-day mortality.
Conclusions: Patients with advanced cancer and poor ECOG-PS had short survival after treatment with inpatient PC. Inpatient PC was associated with aggressive end-of-life care. Prognostic markers such as ECOG-PS, hypercalcemia and elevated bilirubin can contribute to the decision-making process for these patients.
BACKGROUND: Patients with serious mental disorders have poorer healthcare outcomes at the end of life and are at greater risk of dying from unnatural causes. Aims: To explore place of death and demographic and clinical correlates of unnatural causes of death in patients with serious mental disorders.
METHOD: Routinely collected patient data were used to explore bivariate and adjusted associations between covariates and natural/unnatural cause of death.
RESULTS: In multivariable analysis (n = 1029), dying at home (odds ratio (OR) = 1.87, 95% CI 1.03-3.40), 'other' locations (OR = 16.50, 95% CI 7.57-36.00), younger age (OR = 17.26, 95% CI 8.28-36.00) and a diagnosis other than schizophrenia spectrum disorder (OR = 1.69, 95% CI 1.04-2.73) were correlates of unnatural cause of death.
CONCLUSIONS: Deaths from unnatural causes were high and more likely to occur at home and non-healthcare settings. Unnatural causes of death were higher in younger patients with non-schizophrenia spectrum disorder diagnoses. Declaration of interest: F.G. has received support or honoraria for CME, advisory work and lectures from Bristol-Myers Squibb, Janssen, Lundbeck, Otsuka, Roche, and Sunovion, and has a family member with professional links to Lilly and GSK, including shares.
BACKGROUND: High rates of health care utilization at the end of life may be a marker of care that does not align with patient-stated preferences. We sought to describe trends in end-of-life care and factors associated with dying in hospital.
METHODS: We conducted a population-level retrospective cohort study of adult decedents in Ontario between Apr. 1, 2004, and Mar. 31, 2015, using linked administrative data sets, including the Office of the Registrar General for Deaths database, the hospital Discharge Abstract Database, the National Ambulatory Care Reporting System and physicians' billing claims (Ontario Health Insurance Plan). The primary outcome was place of death. To determine health care utilization and health care costs during the 6 months before death, we also identified admissions to hospital and to the intensive care unit, emergency department visits, and receipt of mechanical ventilation and palliative care.
RESULTS: In the last 6 months of life, 77.3% of 962 462 decedents presented to an emergency department, 68.4% were admitted to hospital, 19.4% were admitted to an intensive care unit, and 13.9% received mechanical ventilation. Forty-five percent of all deaths occurred in hospital, a proportion that declined marginally over time, whereas receipt of palliative care increased during terminal hospital admissions (from 14.0% in fiscal year 2004/05 to 29.3% in 2014/15, p < 0.001) and in the last 6 months of life (from 28.1% in 2004/05 to 57.7% in 2014/15, p < 0.001). The proportion of decedents who presented to the emergency department, were admitted to hospital or were admitted to the intensive care unit in the last 6 months of life did not change over 11 years. The mean total health care costs in the last 6 months of life were highest among those dying in hospital, with most costs attributable to inpatient medical care.
INTERPRETATION: Health care utilization in the last 6 months of life was substantial and did not decrease over time. It is possible that increased capacity for palliative, hospice and home care at the end of life may help to better align health system resources with the preferences of most patients, a topic that should be explored in future studies.
BACKGROUND AND OBJECTIVES: The development of advance care plans (Plans) in general practice can be time consuming. End-of-life care should reflect an individual’s documented preferences. The aim of this study was to examine the content and implementation of Plans in hospital during end-of-life care.
METHODS: A retrospective cohort study of the hospital medical records of decedents aged =75 years was performed to assess Plan content and implementation.
RESULTS: Of the 536 decedents, 52 had a Plan. There were 17 cases where life-prolonging treatment was given and contradicted preferences listed in the Plan. This included instances of intubation, surgery and curative medication.
DISCUSSION: General practice staff investment in advance care planning should be reflected in the utilisation of Plans and, where medically indicated, respect for patients’ preferences.
BACKGROUND: transitions between care settings near the end-of-life for people with dementia can be distressing, lead to physical and cognitive deterioration, and may be avoidable.
OBJECTIVE: to investigate determinants of end-of-life hospital transitions, and association with healthcare use, among people with dementia.
DESIGN: retrospective cohort study.
SETTING: electronic records from a mental health provider in London, linked to national mortality and hospital data.
SUBJECTS: people with dementia who died in 2007-2016.
METHODS: end-of-life hospital transitions were defined as: multiple admissions in the last 90 days (early), or any admission in the last three days of life (late). Determinants were assessed using logistic regression.
RESULTS: of 8,880 people, 1,421 (16.0%) had at least one end-of-life transition: 505 (5.7%) had early, 788 (8.9%) late, and 128 (1.5%) both types. Early transitions were associated with male gender (OR 1.33, 95% CI 1.11-1.59), age (>90 vs <75 years OR 0.69, 95% CI 0.49-0.97), physical illness (OR 1.52, 95% CI 1.20-1.94), depressed mood (OR 1.49, 95% CI 1.17-1.90), and deprivation (most vs least affluent quintile OR 0.58, 95% CI 0.37-0.90). Care home residence was associated with fewer early (OR 0.63, 95% CI 0.53 to 0.76) and late (OR 0.80, 95% CI 0.65 to 0.97) transitions. Early transitions were associated with more hospital admissions throughout the last year of life compared to those with late and no transitions (mean 4.56, 1.89, 1.60; P < 0.001).
CONCLUSIONS: in contrast to late transitions, early transitions are associated with higher healthcare use and characteristics that are predictable, indicating potential for prevention.
OBJECTIVE: A proportion of children die, making them potentially eligible to be organ/tissue donors. Not all are approached for donation, and experiences of those parents are not well understood. The objective was to investigate to what extent organ and tissue donation (OTD) is discussed as part of end-of-life care and to explore parents' and healthcare professionals' (HCPs) experiences.
DESIGN: A retrospective qualitative study.
SETTING: Multicentre study with participants recruited through two neonatal intensive care units (ICUs), two paediatric ICUs, a cardiac ICU and a children's hospice.
PATIENTS: Bereaved parents, parents of a child with a long-term condition (LTC) and HCPs.
MAIN OUTCOMES AND MEASURES: Parents' and HCPs' views and experiences of discussions about OTD.
RESULTS: 24 parents of 20 children were interviewed: 21 bereaved parents and 3 parents of a child with a LTC. Seven parents were asked about donation (13 not asked), four agreed and two donated. 41 HCPs were interviewed. Themes: complexity of donation process, OTD as a coping strategy, the importance of asking, difficulty of raising the topic,\ and parents' assumptions about health of organs (when donation is not discussed).
CONCLUSIONS: The findings add new knowledge about parents' assumptions about the value of their child's organs when discussions about OTD are not raised, and that HCPs do not routinely ask, are sometimes hesitant to ask in fear of damaging relationships, and the reality of the complexity of the donation process. Given the current levels of awareness around OTD, the topic should be raised.
OBJECTIVES: Out-of-hours (OOH) primary care services are contacted in the last 4 weeks of life by nearly 30% of all patients who die, but OOH palliative prescribing remains poorly understood. Our understanding of prescribing demand has previously been limited by difficulties identifying palliative patients seen OOH. This study examines the volume and type of prescriptions issued by OOH services at the end of life.
METHODS: A retrospective cohort study was performed by linking a database of Oxfordshire OOH service contacts over a year with national mortality data, identifying patients who died within 30 days of OOH contact. Demographic, service and prescribing data were analysed.
RESULTS: A prescription is issued at 14.2% of contacts in the 30 days prior to death, compared with 29.9% of other contacts. The most common prescriptions were antibiotics (22.2%) and strong opioids (19%). 41.8% of prescriptions are for subcutaneously administered medication. Patients who were prescribed a syringe driver medication made twice as many OOH contacts in the 30 days prior to death compared with those who were not.
CONCLUSION: Absolute and relative prescribing rates are low in the 30 days prior to death. Further research is required to understand what occurs at these non-prescribing end of life contacts to inform how OOH provision can best meet the needs of dying patients. Overall, relatively few patients are prescribed strong opioids or syringe drivers. When a syringe driver medication is prescribed this may help identify patients likely to be in need of further support from the service.
Introduction: Early integration of palliative interventions in patients with central airway obstruction (CAO) has shown to reduce patients' distress due to breathlessness and achieve better outcomes at lower cost. This retrospective review was performed to determine whether rigid bronchoscopic interventions alleviated the symptom burden and the requirement for continued mechanical ventilation in patients with CAO in a tertiary care hospital.
Materials and Methods: Detailed records of 105 patients with CAO were retrospectively studied. The Numerical Rating Scale (NRS) score for cough and dyspnea before and after the intervention was noted. A need for an escalation or reduction in level of care was also noted.
Results: The mean NRS score for dyspnea (n = 84) reduced from 7.5 (4-9) (before procedure) to 2.5 (2-6) after intervention (P < 0.01). The mean NRS score for cough (n = 68) also reduced from 6.5 (4-8) (before procedure) to 4 (3-7) after intervention (P < 0.01). Of these patients, bronchoscopic intervention allowed transfer out of the ICU in 14 patients (42%) and immediate withdrawal of mechanical ventilation in 8 patients (42%).
Conclusion: There is an instantaneous valuable palliation of symptoms and improved health-care utilization with airway tumor debulking and stenting. Multidisciplinary interventions with emphasis delivery of palliative care provide better care of patients with CAO.
Aims: There is a lack of data on physical functional status near death of patients with different types of dementia that can contribute to decisions about what kind of care is needed. The aim of this study was to investigate the course of functional status along with the documented reasons for death in participants with dementia who had regularly been followed at a geriatric outpatient unit.
Setting and Design: A retrospective observational cohort study was done using the database of a geriatric outpatient clinic.
Subjects and Methods: Sociodemographic and medical records of patients with Alzheimer's disease (AD), vascular dementia, mixed dementia, and dementia with Lewy bodies (DLB)/Parkinson's disease dementia (PDD) who had received routine care in a geriatrics outpatient setting for a minimum of 12 months before death were analyzed. Scores for activities of daily living and documented probable causes of death were recorded.
Results: Of the 258 participants, 111 (42 female and 69 male) were included in this study. AD was the leading cause of dementia (51.8%). The median duration of survival with dementia was 4 years. The leading causes of death were cardiovascular disease (CVD) (27.0%) and dementia (27.0%) followed by infections (21.6%) and stroke (10.8%). Disability was the highest in patients with DLB/PDD.
Conclusions: This study found relatively shorter survival after the diagnosis of dementia when compared to other populations. CVD still appeared as a major cause of that in this particular disease. Most debilitating type of dementia was DLB/PDD.
PURPOSE: It is imperative to provide quality end-of-life (EOL) care for patients with cancer. Although rates of hospice use within the Veterans Health Administration have improved, antineoplastic administration and intensive care unit (ICU) admission at the EOL, indicators of aggressive care, have not clearly declined over recent years.
METHODS: We identified 32,665 veterans diagnosed with stage IV lung, colorectal, or pancreatic cancer who died between 2009 and 2016 using a novel EOL Dashboard Tool created from Veterans Administration Cancer Registry data. This EOL tool reports the incidence of antineoplastic drug use in the last 14 days of life, ICU admission in the last 30 days of life, and hospice admission or consult. Change from 2009 to 2016 was assessed using a repeated measures one-way analysis of variance with post hoc test for linear trend of time for individual cancers and two-way analysis of variance for all cancers combined.
RESULTS: Antineoplastic use in the last 14 days of life declined from 6.8% in 2009 to 4.4% in 2016 (P = .03). ICU admission in the last 30 days did not change significantly, from 13.3% in 2009 to 14.7% in 2016. The exception was patients with stage IV lung cancer, in whom ICU admissions increased from 12.9% to 16.2% (P = .01). Patients using hospice services increased from 32.4% to 52.6% (P < .01).
CONCLUSION: Although antineoplastic administration at the EOL is declining for veterans with stage IV cancer, ICU admissions are unchanged and becoming more common in stage IV lung cancer despite increasing hospice use.
CONTEXT: The end-of-life period is characterized by increased hospital utilization despite patients' preferences to receive care and die at home.
OBJECTIVES: To evaluate the impact of interventions aimed at planning for a home death (Yellow Folder) and managing symptoms in the home (Symptom Response Kit) on place of death and hospital utilization among palliative home care patients.
METHODS: This was an ecologic and retrospective cohort study of palliative home care patients in southeastern Ontario from April 2009 to March 2014. Linked health administrative and clinical databases were used to identify palliative home care patients and their receipt of the interventions, hospitalizations, emergency department visits, and place of death. Bivariable and multivariable regression was used to evaluate outcomes according to patients' receipt of intervention(s).
RESULTS: The proportion of patients who died in the community increased after implementation of the interventions, from 42.8% to 48.5% (p < 0.0001). Compared to patients who received neither intervention, patients who received the Yellow Folder or Symptom Response Kit had an increased likelihood of dying in the community, with the largest relative risk observed in patients who received both interventions (relative risk=2.20, 95% confidence interval 2.05-2.36). Receipt of these interventions was only associated with reductions in hospitalizations or emergency department visits in the six months prior to death.
CONCLUSION: Patients who received the Yellow Folder or Symptom Response Kit were more likely remain at home at the end-of-life. This association was stronger when these interventions were used together.
CONTEXT: Palliative care in oncology provides multiple benefits, however access to specialty palliative clinicians is limited in community cancer centers. Individual support services are more often available, but little is known on the utilization and impact of these services.
OBJECTIVES: To describe the utilization of outpatient support services in the advanced cancer population and the association with ED and hospital use in a community setting.
METHODS: A retrospective chart review of 314 patients with advanced cancer of lung, gastrointestinal, genitourinary, and gynecologic origin was conducted. Data collected included demographics, descriptive data, type and number of support services (symptom management, nurse navigator, social worker, nutrition, financial counselor, chaplain, and oncology clinical counselor) within 90 days of diagnosis and descriptions of ED visits/hospitalizations within 12 months of diagnosis. Support services were available to patients by referral.
RESULTS: 29.6% of patients were deceased within 6 months and were considered to have severe disease. Patients with severe disease had a significantly greater mean number of support services than patients with non-severe disease (8.9 vs 6.0, p=0.001) and had a greater mean number of visits per year to the ED (6.4 vs 1.8, p<0.001). A greater proportion of patients with severe disease had palliative consultations (48.9% vs 21.7%, p<0.001), but 65.5% of palliative consultations occurred after an ED or hospital visit.
CONCLUSION: Our data demonstrated that advanced cancer patients with severe disease had increased healthcare utilization in all areas measured. Despite high utilization, outpatient support services used in a reactive manner were not effective in reducing ED or hospital visits.
CONTEXT: Malignant bowel obstruction (MBO) is a frequent complication for patients with advanced cancer. Symptom management for patients with end-stage MBO can be challenging especially when venting gastrostomy is contraindicated. Percutaneous transesophageal gastrostomy (PTEG) is an alternative option allowing safe and effective symptom management in palliative care patients.
OBJECTIVES: We describe our experience with an initial series of 10 patients with MBOs refractory to medical management who received PTEG for gastrointestinal decompression, with a focus on palliative outcomes and safety.
METHODS: We retrospectively reviewed the charts of 10 patients with advanced malignancy and associated gastrointestinal obstruction who received PTEG for symptom management between March 2018 to November 2018. We report on patient diagnosis, indications for PTEG, outcomes following insertion, and any associated morbidity and mortality.
RESULTS: PTEGs were successfully inserted in all 10 patients with contraindications to a venting gastrostomy. There were no acute post-procedure complications. Median time from PTEG insertion to death was 15 days. Symptoms of MBO improved in all ten patients and all were able to resume some degree of oral intake. Importantly, unlike with venting gastrostomies, all patients required suction to maintain resolution of MBO symptoms.
CONCLUSION: PTEG should be considered for gastrointestinal decompression in patients with malignant bowel obstruction who are not candidates for surgical decompression or standard venting gastrostomy. This safe and effective procedure improves symptom management and quality of life for patients with MBO who are approaching end of life.
Background: Delivery of health services in the province of Ontario is organized into 14 Local Health Integration Networks (LHINs), and further into 76 LHIN subregions, making these a natural unit of comparing the regional differences in palliative care receipt among decedents who were identified as having palliative care needs.
Objective: To assess the presence and magnitude of the remaining regional variation in palliative care receipt in Ontario after accounting for demographic and socioeconomic differences between the LHIN subregions, and therefore to assess whether the standardized proportion of palliative care receipt as a performance indicator can capture potential performance-related issues.
Design: A retrospective cohort study based on Ontario administrative data sources.
Setting/Subjects: Ontario residents who died between April 1, 2015 and March 31, 2016 and were identified as having palliative care needs.
Measurements: Date of death, diagnostic codes used for determining palliative care needs, and services receipt in last year of life were identified from multiple administrative databases. Demographic and socioeconomic information were derived from linking decedents' postal codes to Statistics Canada Census data and Ontario Marginalization Index.
Results: Statistically significant variation ranging from 63% to 75% in palliative care receipt exists between Ontario subregions even after accounting for demographic and socioeconomic differences, including age, sex, rurality, income quintile, and the four dimensions of the Ontario Marginalization Index.
Conclusions: Annual directly standardized proportion of palliative care receipt can be used as a performance indicator to detect regional differences in service receipt while adjusting for regional differences in the characteristics of the decedent populations. The factors to be adjusted for can be chosen based on the comparison of interest.
Background: In recent years, there has been a rising demand for home hospice care in Singapore and globally. Studies have shown that polypharmacy and the use of potentially inappropriate medications (PIMs) remain prevalent in palliative care patients. This is commonly associated with increased adverse drug reactions and hospitalization. However, research on medication use in hospice care and its appropriateness is lacking in Asian settings.
Objective: (1) To describe the medication use among cancer and non-cancer patients in home hospice care settings in Singapore at two time points, on the day of referral and at death. (2) To describe the discontinuation patterns of medications and assess their appropriateness.
Design: This retrospective study analyzed 6158 cancer and 780 non-cancer cases referred to HCA Hospice Care (HCA), Singapore. Sociodemographic, clinical, and medication data were extracted from electronic medical records. The OncPal Deprescribing Guideline (OncPal) was utilized to assess the appropriateness of discontinuation of medications.
Results: Non-cancer patients had a higher mean number of medications at admission and death, with 7.84 and 7.07 medications, respectively (p < 0.05), compared with cancer patients, with 5.65 and 5.69 medications, respectively (p = 0.372). The top medications for all patients were laxatives, opioids, and proton pump inhibitors (PPIs). These were mainly used for symptom control. PPI was the main PIM identified by OncPal.
Conclusion: Despite being close to end of life and on hospice care, majority of patients still experienced significant medication burden. Continuous assessment of PIMs for their appropriateness based on clinical indications is imperative to reduce polypharmacy.
BACKGROUND: Published reports of continuous palliative sedation therapy (CPST) suggest heterogeneity in practice. There is a paucity of reports that compare practice with clinical guidelines.
OBJECTIVES: To assess adherence of continuous palliative sedation practices with criteria set forth in local clinical guidelines, and to describe other features including prevalence, medication dosing, duration, multidisciplinary team involvement, and concurrent therapies.
DESIGN: Retrospective chart review. Settings/Subjects: We included cases in which a midazolam infusion was ordered at the end of life. Study sites included four adult hospitals in the Calgary health region, two hospices, and a tertiary palliative care unit.
MEASUREMENTS: Descriptive data, including proportion of deaths involving palliative sedation therapy, number of criteria documented, midazolam dose/duration, concurrent symptom management therapies, and referrals to spiritual care, psychology, or social work.
RESULTS: CPST occurred in 602 out of 14,360 deaths (4.2%). Full adherence to criteria occurred in 7% of cases. The most commonly missed criteria were: a "C2" goals-of-care designation order (comfort care focus in the imminently dying) (84%) and documentation of imminent death in the chart (55%). Concurrent medical therapies included opioids in 98% of cases and intravenous hydration in 85% of cases. Few referrals were made to multidisciplinary care teams.
CONCLUSIONS: We found low adherence to palliative sedation guidelines. This may reflect the perception that some criteria are redundant or clinically unimportant. Future work could include a study of barriers to guideline uptake, and guideline modification to provide direction on concurrent therapies and multidisciplinary team involvement.