End Of Life Research Articles

The congruence between the preferred and actual places of death among terminal cancer patients in China.

Dying in a preferred place is important for a good death. Currently, no study has evaluated the extent to which the preferences for the place of death (PoD) are met among terminal cancer patients in China. This study examined the congruence between the preferred and actual PoD and its predictors among terminal cancer patients in China. Between 2015 and 2023, 845 terminal cancer patients from four tertiary hospitals in Wuhan, China, were enrolled and followed till death. Face-to-face surveys at baseline and telephone-based interviews in the last month of patients' lives were combined to learn patients' preferred PoD. Data on patients' actual PoD were collected from families within 1 month after patients' death. Of the 410 patients who died, 62.7% of them died in hospitals. The agreement between patients' preferred and actual PoD was fair (κ = 0.221). The congruence between patients' preferred and actual PoD was 63.0, 36.6%, and 0 for hospital death, home death, and hospice facility/nursing home death separately. Patients were more likely to die in their preferred places if their preferred place and family caregivers' belief of patients' preferred PoD was congruent (odds ratio [OR] = 6.464, p = 0.001), or if caregivers had a medically related occupation (OR = 4.577, p = 0.003); if patients were hospitalized at least twice in the last month of life (OR = 0.422, p = 0.000), or the quality of care received by patients in the last 48 h was rated good by the families (OR = 0.373, p = 0.011), patients were less likely to die in their preferred places. The congruence between patients' preferred and actual PoD was fair. Advance care planning (ACP) needs to be popularized in China, and the quality of care in hospice facilities and nursing homes should be improved. The necessary policy support for hospice care should be made to respect cancer patients' end-of-life (EoL) care preferences in China.

Discourse Analysis in End-of-Life Communication: A Systematic Review

ABSTRACT Discourse analysis (DA) has emerged as a valuable method for examining communication between participants in end-of-life (EOL) care. However, there remains a gap in synthesizing the findings of discourse analytic studies focused on communication within EOL care settings. The aim of this study was to synthesize DA studies in EOL care. A systematic review was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analyses (Prisma) guidelines. An electronic database of Web of Science (WOS), MEDLINE, PubMed, and Embase was performed. 14 peer-reviewed studies published in English before January 10 2024, were included. Thematic analysis identified three overarching themes: (1) caregivers’ discursive stances on EOL care, (2) discursive practices of participants in shared decision-making conversations, and (3) discursive resources in talking illness trajectories. Findings suggest that DA has the potential to provide insights into understanding communication practices in EOL care and examining an individual’s stance on issues about EOL care, thus informing clinical practice and improving patient-centered care.

RESEARCH ACTIVITY ON PV WASTE RECYCLING IN ENEA

ENEA is dedicating significant efforts to the research activity concerning the treatment of End-of-Life (EoL) photovoltaic panels (PVs), which is a worldwide emergent issue to be urgently solved. With PVs typically having a lifespan of 25 years, the volume of PV waste is projected to increase rapidly by 2030. This issue is compounded by the composition of photovoltaics, which includes hazardous materials, necessitating the development of technological solutions to mitigate the environmental impact of commonly used recycling methods. Additionally, strategic materials present in PVs make the valorization of recovered materials highly advantageous. ENEA is actively involved in several research projects focused on EoL PVs recycling. This article will outline the main objectives of these projects and present the key findings achieved by ENEA's research team.

Paying for advance care planning in medicare: Impacts on care and spending near end of life

Spending at end of life (EOL) accounts for a large and growing share of healthcare expenditures in the US, and often reflects aggressive care with questionable value for dying patients. Using a novel instrumental variables approach, we conduct the first study on the causal effect of Medicare reimbursement for advance care planning (ACP)—the process of discussing and recording patient preferences for goals of care—on care utilization, spending, and mortality outcomes for critically ill Medicare patients. We find that billed ACP services substantially increase hospice use and hospice spending within a year, accompanied by corresponding increase in one-year mortality. The impacts of ACP services on hospice use and spending are especially prominent among patients with dementia and those of lower socioeconomic status. Among decedents, death is significantly less likely to occur in the hospital, and total and inpatient spending within the last 30 days of life fall significantly. Our findings suggest that paying for ACP services can be effective in improving hospice use for critically ill Medicare patients, with the (possibly intended) consequence of increased one-year mortality.

The Paradox of Palliative Care at the End of Life: Higher Rates of Aggressive Interventions in Patients with Pancreatic Cancer.

Background: Palliative care has shown benefit in patients with cancer; however, little is known about the overall utilization of palliative care services in patients with pancreatic cancer and the impact of aggressive end-of-life interventions. This study aimed to explore the incidence of palliative care consultations (PCCs) in hospitalized patients with pancreatic cancer in the United States and the association between palliative care consultations and the use of aggressive interventions at the end of life. Methods: We conducted a retrospective study of patients hospitalized with pancreatic cancer. We examined patient records for 6 months prior to death for the presence of PCCs and aggressive end-of-life (EOL) interventions-emergency department visits, chemotherapy, and ICU stays. The use of EOL interventions was compared between those who did and those who did not receive PCCs, using Chi-square and Whitney U tests. Results: Of the 2883 identified patients, 858 had evidence of a PCC in their record in the last 6 months of life. Patients receiving PCCs were older at the time of death and more likely to receive chemotherapy (22.4% vs. 10.6%) in the last 6 months of life compared to those not receiving a palliative care consult. Similarly, patients with PCCs were more likely to have aggressive interventions in the EOL period. Conclusions: Less than 30% of patients with pancreatic cancer received a PCC. Those who received a PCC had more aggressive interventions in the end-of-life period, differing from what the prior literature has shown. Future investigations are necessary to explore the components and timing of PC and investigate their influence on the utilization of aggressive interventions and patient-centered outcomes.

Extended end-of-life carbon assessment and savings: A case study of steel-framed modular buildings in Hong Kong

Modular construction (MC) advances conventional approaches such as material efficiency, shorter construction time, and reduced onsite waste, leading to lower carbon emissions in some stages. However, the End-of-Life (EoL) carbon has never been made explicit, particularly for MC, and there remains a lack of evidence on how much carbon emissions are generated and reduced from the EoL stage of modular buildings. To address the gaps, the present study proposes an EoL carbon estimation model for MC based on the life cycle assessment (LCA) method. The developed model was empirically validated through a case study of a typical high-rise steel-framed modular residential building in Hong Kong. The results reveal that net carbon emissions during the EoL stage could be −764.40 kg CO2 eq./m2, presenting the great carbon savings potential of MC. Compared to those in traditional on-site construction areas, steel modular components have far greater capabilities to mitigate carbon emissions, as most of them can be reused. Nevertheless, an average of 41.56 kg CO2 eq./m2 of carbon is still released in the EoL stage, most of which is contributed by transportation, followed by waste disposal, demolition, and waste processing. This study makes an original contribution to understanding the extent of EoL carbon emissions and the potential of carbon savings in steel modular buildings. Also, these findings unveil the practical significance of reusing modules for EoL carbon mitigation and provide useful suggestions for demolition contractors and policymakers to mitigate carbon emissions to further promote the transition towards carbon neutrality.

Sustainable end-of-life management of abandoned and derelict vessels through the lens of circular economy

Boats require End-of-Life (EOL) management, especially those built with fibre-reinforced plastic/polymer materials because they are hard to dispose and have negative effects on the environment. The main challenge with EOL boats or abandoned and derelict vessels (ADVs) is the lack of sustainable disposal options for recycling and reusing composite plastics, which should be safe, managed, sustainable, and economically viable. Most efforts have focused on dealing with ADVs in water rather than on land. This study provides a systematic review of 101 studies of End-of-Life Boat (ELB) management and seeks methods to deal with derelict vessels, challenges in their management, potential solutions, and a comparison and assessment of EOL opportunities in terms of sustainability and circular economy. Research gaps were identified, and suggestions for future research directions were proposed. The marine industry faces gaps in practical implementation and understanding of sustainable principles and lacks effective regulations, cost-effective methods, and suitable technologies for sustainable management, particularly for recycling and reusing. The present review highlights the importance of a harmonized approach, financing mechanisms, sustainable dismantling and transport, material reuse and upcycling, industry partnerships, centralized recycling systems, and investments in research and innovation as crucial elements for enhancing the circular economy.

End of life care for people with dementia and comorbid cancer: recent studies and research gaps.

This narrative review examines recent research on end of life (EOL) care for people with dementia and comorbid cancer, highlighting the complexity and challenge of providing effective EOL care for this group and areas of interest for future research. People with cancer and dementia and their family/supporters have more complex care and support needs at EOL that are less well met than those of older adults with cancer alone, including questionable use of aggressive EOL care interventions, poorer access to specialist palliative care teams and poor pain management. Those diagnosed with dementia at the same time as, or after their cancer diagnosis, are at greater risk of aggressive EOL care and EOL cancer treatment and care plans that are not able to meet their care needs as dementia progresses. There is a lack of research on EOL care for people with cancer and dementia. There is little understanding of what good care for this population looks like and if and how EOL care can best meet the needs of people with cancer and dementia or their carers/supporters. More research is needed to inform improved care for this population.

Ethical and Practical Issues with the Use of Antimicrobial Agents during the End of Life.

The use of antimicrobials in patients receiving end-of-life (EOL) care, which is generally defined as supportive care provided to patients anticipated to live less than 1 year, has been actively debated in the realm of palliative care medicine due to the nebulous nature of the topic. In this article, we explore the use of antimicrobial use near EOL as it relates to both the ethical and practical issues that face physicians. We also discuss the reasons underlying the scarcity of prospective studies on this topic.

Machine Learning for Targeted Advance Care Planning in Cancer Patients: A Quality Improvement Study

ContextPrognostication challenges contribute to delays in advance care planning (ACP) for patients with cancer near the end of life (EOL). ObjectivesExamine a quality improvement mortality prediction algorithm intervention's impact on ACP documentation and EOL care. MethodsWe implemented a validated mortality risk prediction machine learning model for solid malignancy patients admitted from the emergency department (ED) to a dedicated solid malignancy unit at Duke University Hospital. Clinicians received an email when a patient was identified as high-risk. We compared ACP documentation and EOL care outcomes before and after the notification intervention. We excluded patients with intensive care unit (ICU) admission in the first 24 hours. Comparisons involved chi-square/Fisher's exact tests and Wilcoxon rank sum tests; comparisons stratified by physician specialty employ Cochran-Mantel-Haenszel tests. ResultsPreintervention and postintervention cohorts comprised 88 and 77 patients, respectively. Most were White, non-Hispanic/Latino, and married. ACP conversations were documented for 2.3% of hospitalizations preintervention vs. 80.5% postintervention (P<0.001), and if the attending physician notified was a palliative care specialist (4.1% vs. 84.6%) or oncologist (0% vs. 76.3%) (P<0.001). There were no differences between groups in length of stay (LOS), hospice referral, code status change, ICU admissions or LOS, 30-day readmissions, 30-day ED visits, and inpatient and 30-day deaths. ConclusionIdentifying patients with cancer and high mortality risk via machine learning elicited a substantial increase in documented ACP conversations but did not impact EOL care. Our intervention showed promise in changing clinician behavior. Further integration of this model in clinical practice is ongoing.

Greenhouse gas equivalents and water consumption of product sample packaging in dermatology

Sampling refers to the free supply of small product samples. In this process, the packaging can be disproportionate to the contents leading to raw material consumption and, in the case of poor recyclability, environmental pollution. In this article, calculations regarding the ratio between packaging and product weight for commonly used types of packaging (sachet, tube, jar) of dermatological product samples are presented. The usefulness of sampling is discussed considering environmental and economic criteria. A total of 43 dermatological product samples from different manufacturers were manually weighed and classified. Packaging was disassembled into its structural components. The proportional weights or the weight of the bottle/tube body were calculated with database values for the respective material in terms of greenhouse gas equivalents (CO2eq) and freshwater consumption. Subsequently, atotal sum for the impact of each packaging was formed. Only the material and manufacturing process were considered because there were no valid data available for transport, utilization, and end of life (EoL) impacts. The smallest and lightest product sample (1.24 g) generated ca. 15 g CO2eq and approximately 700 ml of freshwater consumption. The largest and heaviest product sample (37 g) generated 53 g CO2eq and 5.78 l of freshwater consumption. Assuming an annual distribution of 10 million units of the 43product samples examined here, ca. 8000 t of CO2eq are produced by the packaging alone. Additionally, 880,000,000 l of water are used and approximately 2300 t of packaging waste are generated. Sampling shows an unfavorable ratio between CO2eq/water consumption and utility, especially in comparison to larger units of packaging. Millions of product samples are distributed annually in doctor's practices, hospitals and pharmacies, particularly in dermatology. The practice of sampling should be questioned both ecologically and economically.

1890P End-of-Life (EOL) systemic anticancer treatment (SACT) and health services use before and during the COVID-19 pandemic

1890P End-of-Life (EOL) systemic anticancer treatment (SACT) and health services use before and during the COVID-19 pandemic

A multi-life cycle assessment of external wall insulation strategies in an Irish domestic retrofit

European Union (EU) policy and initiatives are driving both building renovation and the uptake of low-embodied carbon and circular design in the construction sector. The European Performance of Buildings Directive (EPBD) recast (2021) introduces global warming potential (GWP) methodology, and the future state will likely be embodied carbon targets for which life cycle assessment (LCA) of buildings will be required. External wall insulation (EWI) will have an important role to play in meeting targets. In this context, this paper compares the carbon emission payoff of three alternative EWI strategies that address conventional, low-carbon and circular solutions to EWI respectively, in the retrofit of an existing dwelling. The circular strategy is based on design for disassembly (DfD). Whereas standard LCA is based on a single building life cycle, the literature reviewed shows that the environmental impact assessment of DfD requires a multi-life cycle approach. In the absence of standardised methods for assessment, four multi-cycle LCA methods are selected and applied holistically in a case study investigation. Three allocation methods, 100:0, linear degressive (LD) and enhanced linear degressive (CELD), provide a range of emissions from ‘conservative’ to ‘best case’ over three building life cycles and the fourth method, the Van Gulck method, assesses the benefits of circularity through the concept of ‘multi-cycling’ based on one building life cycle. As each method of assessment will deliver different results, carbon emission payoff is not a fixed value. Findings show that with multiple use, the circular strategy pays off due to avoided production emissions and benefits from end-of-life (EoL) processes that DfD facilitates, that the upfront carbon cost of the circular strategy is minor relative to the carbon emission savings that reuse brings, and that the margin of improvement relative to the alternative strategies increases with each subsequent reuse.

Bereaved Parents’ Perspectives on Financial Toxicity at End of Life for Children with Cancer: A Qualitative Study

ObjectiveTo explore financial toxicity (FT) experienced by the parents of children with cancer at end-of-life (EOL), including exploring differences by race and ethnicity. Study designWe performed secondary analysis of semi-structured interviews of bereaved parents’ perspectives on quality EOL care. Fifty-five interviews were conducted in California and Alabama representing 48 children (0-21 years at time of death) who died of cancer ≥6 months prior. Quotes related to FT were identified and iteratively grouped into themes without an a priori framework. ResultsMost participants were non-Hispanic White (30; 55%), and the most common diagnoses were non-central nervous system solid tumors (16; 33%) and central nervous system tumors (16; 33%). Children died at a mean age of 11 and a median of 4 years prior to the interview. Almost all parents (52; 95%) discussed FT, including all Black and Hispanic parents. Parents identified transportation, housing, other basic needs, funeral costs, and medical costs as well as work disruptions as contributors to FT at EOL. Barriers to financial wellness included navigating insurance, insufficient financial support from the hospital, and long-term FT from treatment. Many parents discussed how the hospital and community served as facilitators of financial wellness. In some cases, finances prevented families from accessing nursing services and mental health support and affected EOL decisions. ConclusionsAs FT affected almost all families’ EOL experience, pediatric oncology programs should routinely screen for FT at EOL and ensure they have the resources to respond.

Racial Disparities in Palliative Care at End-of-Life in Children with Advanced Heart Disease in the South

To examine specialty pediatric palliative care (SPPC) and end-of-life (EOL) care for children with advanced heart disease in Alabama, including rates of and disparities in SPPC involvement. We performed a retrospective study from electronic health records of children (≤21 years at death) who died with advanced heart disease at a single institution between 2012 and 2019 (n=128). The main outcome was SPPC consult; we assessed clinical and sociodemographic factors associated with SPPC. The median age at death was 6 months (IQR=1-25 months) with 80 (63%) ≤1 year; 46% were Black and 45% non-Hispanic White. Seventy (55%) children had critical congenital heart disease, 45 (35%) non-critical congenital heart disease, and 13 (10%) acquired heart disease. Twenty-nine children (22%) received SPPC. Children ≤1 year at time of death and Black children were less likely to receive SPPC (adjusted odds ratio [95% confidence interval]: 0.2 [0.1-0.6], reference >1 year; 0.2 [0.1-0.7], reference non-Hispanic White). SPPC was associated with death while receiving comfort-focused care (30.6 [4.5-210]), do not resuscitate orders (8.2 [2.1-31.3]), and hospice enrollment (no children without SPPC care were enrolled in hospice) but not medically intense EOL care (ICU admission, mechanical ventilation, hemodialysis, or CPR) or death outside the ICU. Children dying with advanced heart disease in Alabama did not have routine SPPC involvement; infants and Black children had lower odds of SPPC. SPPC was associated with more comfort-focused care. Disparities in SPPC utilization for children with advanced heart disease need further examination.

Older Adults in CCRCs: Their Social Engagement, Processes and Solutions

ABSTRACT As the older adult population continues to grow, the demand for Continuing Care Retirement Communities (CCRCs) is increasing in the United States. Older adults living in CCRCs may, however, experience social isolation and loneliness if they lack meaningful and sustained social engagement – seen as the quintessence of fulfilled human living. To date, the social engagement preferences and priorities of older adults who live in CCRCs remain under researched. We therefore utilized participatory action research to explore the social engagement goals, processes and solutions of older adults living in CCRCs. An Interpretive Phenomenological Analysis (IPA) approach was adopted to explore the perspectives of 25 older adults living in a CCRC (females = 75%; mean age = 85; mean length of stay = 4.3 years). Thematic analysis of interview data identified three main themes, in addition to subthemes, critical to maintaining social wellbeing in a CCRC: 1) meaningful engagement with CCRC committees and clubs, and contributions to community led by those who live there; 2) opportunities and challenges associated with resilient living, as well as end-of life concerns; and 3) a sense of belonging and connectedness contributing to social community and health wellness. The findings suggest that the social engagement of older adults who live in a CCRC can be enhanced by introducing and promoting initiatives that bring joy, a sense of purpose, belonging, and fulfillment. This engagement needs to align with individuals’ preferences and priorities to ensure satisfying lives and a sense of community.

Systemic anticancer therapy near the end of life: an analysis of factors influencing treatment in advanced tumor disease

Systemic anticancer treatment (SACT) for advanced cancer patients with limited prognosis before death is associated with high toxicity and reduced quality of life. Guidelines discourage this approach as low-value care. However, a significant number of patients continue to receive SACT in the last 30 days of life. A retrospective study was carried out at the University Hospital Krems, encompassing the analysis of patients who were diagnosed with a solid tumor and died between 2017 and 2021, with a particular focus on the use of end-of-life (EOL) SACT. A total of 685 patients were included in the study. SACT was applied in 342 (49.9%) patients, of whom 143 (41.8%, total population: 20.9%) patients received SACT within the last 30 days of life. Median time from last SACT to death was 44.5 days. The analysis of potential factors impacting the administration of EOL SACT revealed the following significant findings: type of SACT [P < 0.001, targeted therapy odds ratio (OR) 5.09, 95% confidence interval (CI) 2.26-11.48; chemotherapy/targeted therapy OR 3.60, 95% CI 1.47-8.82; immune checkpoint inhibitor OR 2.32, 95% CI 1.37-3.92], no referral to palliative care (PC) (P= 0.009, OR 1.86, 95% CI 1.16-2.96), no admission to PC ward (P < 0.001, OR 2.70, 95% CI 1.67-4.35), and poor Eastern Cooperative Oncology Group (ECOG) performance status (≥2, P < 0.001, OR 3.35, 95% CI 1.93-5.83). The timing of SACT near the EOL is significantly influenced by several factors, including the type of SACT, referral to PC services, admission to PC unit, and ECOG performance status. These findings underscore the complexity of treatment decisions in advanced cancer care and highlight the need for personalized, patient-centered approaches that consider both clinical and patient-related factors to optimize care at the EOL.

Telemedicine-based serious illness conversations, healthcare utilization, and end of life care among patients with advanced lung cancer.

Little is known about serious illness conversations (SIC) conducted during telemedicine visits and their impact on end-of-life (EOL) outcomes for patients with advanced cancer. We conducted a retrospective analysis telemedicine visits for patients with metastatic lung cancer conducted during the first surge of the COVID-19 pandemic (October 3, 2020-October 6, 2020). We used natural language processing (NLP) to characterize documentation of SIC domains (ie, goals of care [GOC], limitation of life-sustaining treatment [LLST], prognostic awareness [PA], palliative care [PC], and hospice). We used unadjusted logistic regression to evaluate factors associated with SIC documentation and the relationship between SIC documentation and EOL outcomes. The study included 634 telemedicine visits across 360 patients. Documentation of at least one SIC domain was present in 188 (29.7%) visits with GOC and PA being the most discussed domains. Family presence (odds ratio [OR], 1.66; P = .004), progressive or newly diagnosed disease (OR, 5.42; P < .000), age ≥ 70 (OR, 1.80; P = .009), and male sex (OR, 2.23; P < .000) were associated with a greater likelihood of discussing ≥ 1 SIC domain. Of the 61 patients who died within 12 months of the study period, having ≥ 1 SIC domain discussed was associated with a lower likelihood of hospitalization in the last 30 days of life (OR, 0.27; P = .020). In this study of telehealth visits, we identified important factors associated with an increased likelihood of having documentation of an SIC and demonstrated that SIC documentation correlated with lower likelihood of hospitalization at EOL.

Patterns and determinants of patient sharing in end-of-life health services: Empirical evidence from the Italian National Health Service

ABSTRACT End-of-life (EoL) care is critical for cancer patients, who tend to have high service needs that are dispersed across organizations and different levels of care. Although EOL has been widely studied, little is known about the patterns of coordination among EoL health care providers and how they contribute to the care of cancer patients. This study adopts a network perspective to examine the complex patterns of patient sharing among health care providers involved in EoL care, using data on the use of EoL health care services by 266 cancer patients in a large Local Health Authority in Italy. We conducted a social network analysis of the structural properties of the emerging network and used logistic regression-quadratic assignment procedures (LR-QAP) to explore how characteristics of health care providers, their collaborative network, and their distances predict the likelihood of observing patient sharing relationships. Our results show that complementarities in terms of medical specialization and co-location of services positively predict the likelihood of cancer patient sharing. This probability is also positively related to the difference in terms of eigenvector centrality as well as the degree of network transitivity. We discuss the policy implications of our findings.

Embracing Endings: Unveiling the Connection Between Final Conversations, the Opportunity Model for Presence, and Coping With the Death of Our Parents.

This study examines adult children's loss of a parent through final conversations and communal coping. By looking at survivors' experiences through the lens of the opportunity model for presence (OMP) during the end-of-life (EOL) process, a model that provides a path of engagement leading to a good or bad death and consequent bereavement processes, we quantitatively test the relationships between two communication constructs before and after death of a parent. While final conversations as one construct did not lead to appraisal or action coping, results illustrate that final conversation topics of identity, instrumental, love, and everyday talk, were significantly related to shared appraisal. Instrumental talk and love were significantly related to joint action. Joint action and shared appraisal together led to participants engaging in all three types of coping. Final conversations as a whole, was important for bereavement outcomes, whereas communal coping's role in these relationships was convoluted.