Abstract
Swagerty D: Integrating quality palliative and end-of-life care into the geriatric assessment. Opportunities and challenges. Clin Geriatr Med 2017;33:415–429.
This article provides a nice overview of how integrating quality palliative and end-of-life care into geriatric assessment can be a tremendous benefit to older adult patients and their families. Although the quality of palliative and end-of-life care for older adults has improved greatly, there are still many opportunities to improve the quality of life and function for older adult patients in the last few years of their life. The author suggests that more clinical expertise in comprehensive palliative and end-of-life care must be developed and maintained, and there must also be greater focus and more direct reimbursement developed for physicians and health system providers.
Sadler E, Hales B, Henry B, et al.: Factors affecting family satisfaction with inpatient end-of-life care. PLoS One 9:e110860. [E-pub ahead of print]. https://doi.org/10.1371/journal.pone.0110860.
The authors of this Canadian study suggest little data exist addressing satisfaction with end-of-life care among hospitalized patients, as they and their family members are systematically excluded from routine satisfaction surveys. They note it is imperative that society closely examine patient and institution factors associated with quality end-of-life care and determine high-priority target areas for quality improvement. The authors, between September 1, 2010 and January 1, 2012, mailed the Canadian Healthcare Evaluation Project (CANHELP) Bereavement Questionnaire to the next of kin of recently deceased inpatients to seek factors associated with satisfaction with end-of-life care. The primary outcome was the global rating of satisfaction; secondary outcomes included rates of actual versus preferred location of death, associations between demographic factors and global satisfaction, and identification of targets for quality improvement. Results demonstrated that the response rate was 33% among 275 valid addresses. Overall, 67.4% of respondents were very or completely satisfied with the overall quality of care their relative received. However, 71.4% of respondents who thought their relative did not die in their preferred location favored an out-of-hospital location of death. A common location of death was the intensive care unit (45.7%); however, this was not the preferred location of death for 47.6% of such patients. Multivariate Poisson regression analysis showed respondents who believed their relative died in their preferred location were 1.7 times more likely to be satisfied with the end-of-life care that was provided (p = 0.001). Items identified as high-priority targets for improvement included: relationships with, and characteristics of healthcare professionals; illness management; communication; and end-of-life decision making. The authors conclude that nearly three-quarters of recently deceased inpatients would have preferred an out-of-hospital death. Intensive care units were a common, but not preferred, location of in-hospital deaths. Family satisfaction with end-of-life care was strongly associated with their relative dying in their preferred location. The authors suggest that improved communication regarding end-of-life care preferences should be a high-priority quality improvement target.
De Vlemick A, Morrison RS, Meier DE, et al.: Hospice care for patients with dementia in the United States: A longitudinal cohort study. J Am Med Dir Assoc 2017. [E-pub ahead of print]. DOI: https://dx-doi-org.web.bisu.edu.cn/10.1016/j.jamda.2017.10.003.
Patients with dementia form an increasing proportion of those entering hospice care; however, little is known about the types of hospices serving patients with dementia and the patterns of hospice use, including timing of hospice disenrollment between patients with and without dementia. The objectives of this study were to characterize the hospices that serve patients with dementia, to compare patterns of hospice disenrollment for patients with dementia and without dementia, and to evaluate patient-level and hospice-level characteristics associated with hospice disenrollment. The authors used data from a longitudinal cohort study (2008–2011) of Medicare beneficiaries (n = 149,814) newly enrolled in a national random sample of hospices (n = 577) from the National Hospice Survey and followed until death (84% response rate). Results demonstrated that a total of 7328 patients (4.9%) had a primary diagnosis of dementia. Hospices caring for patients with dementia were more likely to be for-profit, larger sized, provide care for more than 5 years, and serve a large (>30%) percentage of nursing home patients. Patients with dementia were less likely to disenroll from hospice in conjunction with an acute hospitalization or emergency department visit and more likely to disenroll from hospice after long enrollment periods (more than 165 days) as compared with patients without dementia. No significant difference was found between patients with and without dementia for disenrollment after shorter enrollment periods (less than 165 days). In the multivariable analyses, patients were more likely to be disenrolled after 165 days if they were served by smaller hospices and hospices that served a small percentage of nursing home patients. The authors conclude that patients with dementia are significantly more likely to be disenrolled from hospice following a long enrollment period compared with patients without dementia. The authors also suggest that as the number of individuals with dementia choosing hospice care continues to grow, it is critical to address potential barriers to the provision of quality palliative care for this population near the end of life.
Bannon F, Cairnduff V, Fitzpatrick D, et al.: Insights into the factors associated with achieving the preference of home death in terminal cancer: A national population-based study. Palliat Support Care 2017. [E-pub ahead of print]. https://doi.org/10.1017/S1478951517000876.
Most terminally ill cancer patients prefer to die at home, yet only a minority achieves this. The author's aim was to investigate the factors associated with cancer patients achieving their preference to die at home. Their study took the form of a mortality follow back, population-based, observational survey of the relatives of deceased cancer patients in Northern Ireland. Individuals who registered the death of a friend or relative (aged ≥18 years) between December 1, 2011 and May 31, 2012, where the primary cause of death was cancer, were invited to take part. Preferred and actual place of death, and patient, service, and clinical data were collected. Multivariable logistic regression was employed to investigate the factors associated with achieving a home death when preferred. Results demonstrated that 467 of 1493 invited informants completed the survey. The 362 (77.5%) who expressed a preference for dying at home and spent time at home in their final 3 months were included in the analysis. Of these, 53.4% achieved their preference of a home death. Factors positively associated with achieving a home death were: living in an affluent area, receipt of good and satisfactory district nurse care, discussing place of death with health professionals, and the caregiver's preference for a home death. Being older than 80 years of age, being a Presbyterian, and being unconscious most of the time during their final week were negatively associated with achieving a home death. The authors conclude that their findings will help inform the design of future interventions aimed at increasing the proportion of patients achieving their preferred place of death at home, for example, by targeting interventions toward older patients and those from the most deprived communities.
Lindley LC: Children with intellectual disability and hospice utilization: The moderating effect of residential care. Am J Hosp Palliat Med 2017. [E-pub ahead of print]. https://doi.org/10.1177/1049909117743181.
Children with intellectual disability commonly lack access to pediatric hospice care services. Residential care may be a critical component in providing access to hospice care for children with intellectual disability. This study tested whether residential care intensifies the relationship between intellectual disability and hospice utilization (i.e., hospice enrollment, hospice length of stay), while controlling for demographic characteristics. Multivariate regression analyses were conducted using 2008 to 2010 California Medicaid claims data. Results demonstrated that the odds of children with intellectual disability in residential care enrolling in hospice care were three times higher than their counterparts in their last year of life, when controlling for demographics. Residential care promoted hospice enrollment among children with intellectual disability. The interaction between intellectual disability and residential care was not related to hospice length of stay. Residential care did not attenuate or intensify the relationship between intellectual disability and hospice length of stay. The author concludes that the findings highlight the role of residential care in facilitating hospice enrollment for children with intellectual disability, and that more research is needed to understand the capability of residential care staff to identify children with intellectual disability earlier in their end-of-life trajectory and initiate longer hospice length of stays.
DeCourcey DD, Silverman M, Oladunjoye A, et al.: Patterns of care at the end of life for children and young adults with life-threatening complex chronic conditions. J Pediatr 2017. [E-pub ahead of print]. DOI: https://dx-doi-org.web.bisu.edu.cn/10.1016/j.jpeds.2017.09.078.
The aim of this study was to characterize patterns of care at the end of life for children and young adults with life-threatening complex chronic conditions (LT-CCCs) and to compare them by LT-CCC type. A cross-sectional survey of bereaved parents (n = 114; response rate of 54%) of children with noncancer, noncardiac LT-CCCs who received care at a quaternary care children's hospital and medical record abstraction were completed. Results demonstrated that the majority of children with LT-CCCs died in the hospital (62.7%) with more than one-half (53.3%) dying in the intensive care unit. Those with static encephalopathy, congenital and chromosomal disorders, and pulmonary disorders were significantly less likely to die at home compared with those with progressive central nervous system (CNS) disorders. Almost 50% of patients died after withdrawal or withholding of life-sustaining therapies, 17.5% died during active resuscitation, and 36% died while receiving comfort care only. The mode of death varied widely across LT-CCCs, with no patients with pulmonary disorders dying receiving comfort care only compared with 66.7% of those with CNS progressive disorders. A majority of patients had palliative care involvement (79.3%); however, in multivariable analyses, there was distinct variation in receipt of palliative care across LT-CCCs, with patients having CNS static encephalopathy and pulmonary disorders significantly less likely to have palliative care involvement than those with CNS progressive disorders. The authors conclude that significant differences in patterns of care at the end of life exist depending on LT-CCC type, and that attention to these patterns is important to ensure equal access to palliative care and targeted improvements in end-of-life care for these populations.