Quality End Of Life Care Research Articles

Racial disparities in utilization of palliative care among inpatients admitted for lung cancer.

e24166 Background: Multiple national database-based studies have shown that Black and Hispanic patients are less likely to receive palliative care options at end-of-life (EOL) inpatient care leading to higher costs and poorer quality of life. To the best of our knowledge, there is no reported data specifically considering lung and pleural malignancies. Methods: We analyzed hospitalizations across the United States in 2019 from the National Inpatient Sample dataset, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. We identified adult non-emergent hospitalizations with ‘malignant neoplasm of the lung and bronchus’ (including mesothelioma) listed as the principal reason for hospitalization using the International Classification of Diseases, 10th revision, clinical modification codes C34.0, C34.1, C34.2, C34.3, C34.8, C34.9, and their sub-branches. StataCorp Stata software was used to extract data and compute mortality and palliative care consult utilization among various demographic factors such as sex, age, race, and payer status. Results: Of 67,425 total hospitalizations, 9.4% resulted in mortality. Of these 6338 patients that died, 73.1% were White, 13% Black, 5.8% Hispanic, 3.9% Asians/Pacific Islanders, 0.6% Native Americans, and 3.3% were other races. Palliative care was consulted in 63% of the patients whose admission resulted in death. 64.9% of the White patients, 58.6% of the Black patients, 62.6% of Hispanic patients, 67.7% of Asians/Pacific Islanders, 60% Native Americans, and 59.6% of other races were offered palliative care prior to their death. The average age among the admissions which resulted in death was 69.03 years. Conclusions: While most admissions resulting in mortality were among the White population, there was still a clear discrepancy in the number of Black patients on whom palliative care was consulted. Possible reasons include poor healthcare literacy, physician mistrust, and cultural preferences. Clinicians should consider and suggest early palliative care consultation in the care of Black patients and other minority racial groups to improve the quality of EOL care.

Effect of a quality-improvement intervention on end-of-life care in cardiac intensive care unit: a single center experience

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Fondazione di Comunità Milano. Background Patients admitted to Cardiac Intensive Care Units (CICUs) have increasingly complex medical conditions; consequently, palliative care (PC) should be an integral component of their management. Although there are robust experiences emanating from other intensive care settings, there has been less discussion about the role of PC in CICUs and the delivery of end-of-life (EOL) care in this context is still very challenging. A 2019 we conducted a survey showing compelling evidence of problems with the quality of EOL care in our Tertiary Referral Hospital's CICU, with physicians often unaware of patients’ anticipated directives and very poor involvement of PC. Purpose To identify educational interventions to enhance EOL care in patients with advanced heart failure (HF) admitted to our CICU. Methods This is a before–after study showing the effect of interventions for CICU staff on competence in EOL care. The intervention was a multifaceted education program delivered by two trainers: an Associate Professor/philosopher of Law and a Clinical Psychologist. A controlled trial design was undertaken with baseline and 2 years follow-up measurement of both objective and self-perceived competence. The training intervention was a 10 hours face-to-face course involving the following techniques: a) focus group: used as a qualitative tool to identify the team's training needs; b) staff support case: clinical debriefing after challenging EOL cases; c) empowerment of communication skills. Questionnaires completed by participants were used to measure self-perceived competence. Records of all patients died with advanced HF between 2021 and 2022 (31 patients) were obtained to evaluate how therapeutic limitation was managed compared with the survey conducted between 2018 and 2019 (21 patients). The primary outcome measure was the development of objective competence in EOL management in terms of: a) report of therapeutic limitation in the prescription charts; b) adequate analgo-sedation evaluated according to pain and existential suffering control; c) early involvement of PC; d) report of patients’anticipated directives. The secondary outcome was represented by staff clinical improvements in communication, collaboration and shared decision making. Results See table. Conclusions A 2019 survey in our CICU showed that the management of advanced HF patients was aggressive. The medical and nursing staff was not sufficiently equipped with adequate practical knowledge as far as it concerns law, ethics and communication techniques. According to these observations we have planned interventions aimed at training our professionals to be knowledgeable, confident and skilled to discuss this kind of questions. After interventions, staff felt more involved and more comfortable, and reported more clarity in transitioning patients; as a consequence, we observed improvement in EOL managing.

Aotearoa New Zealand emergency ambulance services and the provision of end-of-life care: a short survey.

To characterise emergency ambulance service (EAS) clinical roles and experiences (including cultural competency and pastoral care) in the delivery of end-of-life (EOL) and palliative care in Aotearoa New Zealand. A nine question online survey was distributed to St John and Wellington Free Ambulance clinicians. Four questions enabled voluntary free-text comments to be submitted for thematic analysis. A further opportunity for free-text comments was available at the end of the survey. There were 444 participants, which is 14% of the paid ambulance workforce. 63% reported that they frequently transported EOL care patients to hospital when they could be better managed at home. EAS clinicians depend heavily on informal collegial support for pastoral care as formal debriefs are rarely offered. There were 671 free-text comments. Dominant themes included the importance of seniority, the need for further education, the importance of documented care plans and the need for better integration with community services, including hospice. More can and should be done to ensure EAS clinicians are supported to deliver quality EOL care for patients alongside other community providers.

A Qualitative Descriptive Study of Nurse-Patient Relationships Near End of Life.

The end of life (EOL) period represents a challenging time for patients with cancer as they face disruptions in their relationships with their oncology healthcare providers (HCPs) when moving toward hospice care. Poor communication and severed or altered relationships in physician-patient relationships have been shown to occur near EOL, leading to perceptions of abandonment and other negative consequences for quality EOL care. Little is known, however, about nurse-patient relationships near EOL in the cancer setting. The purpose of this qualitative descriptive study was to describe the relationships between patients with cancer and their cancer nurses near EOL. A qualitative descriptive methodology was used via semistructured interviews. A total of 9 participants with advanced cancer were enrolled in and completed the study. Data analysis occurred through qualitative content analysis. The overarching theme woven throughout the narratives was "Good Communication Fosters Nurse-Patient Relationships." Three additional themes emerged from this main theme: 1) "Valuing Professionalism in the Relationship," 2) "Embracing Personhood in the Relationship," and 3) "An Unimaginable Termination." Patients with cancer continued to perceive good communication and strong relationships with their cancer nurses even as EOL approached. Themes consistent with negative alterations in these relationships or perceptions of abandonment were not identified. Cancer nurses can foster nurse-patient relationships through patient-centered communication techniques. Spending adequate time engaging with patients as individuals is also recommended. Perhaps most importantly, nurse-patient relationships should continue to be supported as EOL approaches.

End-of-Life Experiences Among "Kinless" Older Adults: A Nationwide Register-Based Study.

Background: The population of older adults who are unpartnered and childless (i.e., "kinless") is increasing across the globe, and may be at risk for lower quality end-of-life (EoL) experiences due to lack of family support, assistance, and advocacy. Yet, little research exists on the EoL experiences of "kinless" older adults. Objectives: To document associations between family structure (i.e., presence or absence of partner or child) and intensity of EoL experiences (i.e., visits to medicalized settings before death). Design: The study design is a cross-sectional population-based register study of the population of Denmark. Subjects: Participants include all adults age 60 years and older who died of natural causes in Denmark from 2009 to 2016 (n = 137,599 decedents). Results: "Kinless" older adults (reference = has partner, has child) were the least likely group to visit the hospital (two or more times; odds ratio [OR] = 0.74, confidence interval [CI] = 0.70-0.77), emergency department (one or more times; OR = 0.90, CI = 0.86-0.93), and intensive care unit (one or more times; OR = 0.71, CI = 0.67-0.75) before death. Conclusions: "Kinless" older adults in Denmark were less likely to experience medically intensive care at the EoL. Further research is needed to understand factors associated with this pattern to ensure that all individuals receive high quality EoL care regardless of their family structure and family tie availability.

The clinical decision-making process involved in end of life care for people with dementia in primary care: A protocol paper.

This article is a report of a study protocol designed to explore what factors inform healthcare professionals' clinical decision-making when providing end of life care for people with dementia in primary care. The proposed study will adopt a qualitative study design, utilizing an ethnographic approach. A mixed sample group of registered healthcare professionals, including district nurses, specialist nurses and general practitioners, will be purposively sampled and recruited from one health board in Wales, which will cover three settings in primary care. A multi-method approach will be utilized to provide rich data, including non-participant observation, semi-structured interviews, and review of key documents. Data will be managed using NVivo 12 and analysed thematically. Ethics approval was gained in April 2022. Little is known about the end of life care decision-making process of healthcare professionals caring for people with dementia in primary care settings. This study will therefore address this pertinent gap. The study findings may also be transferable to healthcare professionals working in similar clinical settings across the UK. It is anticipated that this study will inform the subsequent development of an intervention that can be used by healthcare professionals to support decision making and subsequently the provision of quality end of life care in primary care for people with dementia.

Psychometric Evaluation of the Veterans Affairs Bereaved Family Survey in Community Nursing Homes.

For over a decade, the Department of Veterans Affairs (VA) has used the Bereaved Family Survey (BFS) to measure the quality of end-of-life (EOL) care in VA inpatient settings. In 2019, VA developed a revised version of the BFS to evaluate the quality of EOL care for Veterans who received hospice services in VA-contracted community nursing homes (CNHs). The purpose of this analysis was to evaluate the psychometric properties and factor structure of the BFS-CNH. The BFS-CNH was administered to the next-of-kin of Veterans who died in a VA-contracted CNH with hospice care between October 2019 and April 2020. Exploratory factor analysis (EFA) was used with the 10 core items of the BFS-CNH that were derived from the inpatient BFS to evaluate whether the BFS-CNH exhibited a similar factor structure to the inpatient version. Cronbach's alpha was used to assess internal consistency/reliability of the identified factors and linear regression models were used to evaluate construct validity of the identified BFS-CNH factor scores and individual items. The EFA revealed a three-dimension solution that corresponded to factors on the inpatient BFS, including Care and Communication, Emotional and Spiritual Support and Death Benefits. Cronbach's alpha coefficients for all three factors indicated acceptable internal consistency. Our findings provide support for use of the BFS-CNH to evaluate the quality of EOL care provided to Veterans in CNHs and lay the foundation for future comparisons of BFS ratings between VA inpatient and CNH settings.

Palliative Care and End-of-Life Outcomes in Patients Considered for Liver Transplantation: A Single-Center Experience in the US Midwest.

Introduction: Previous research has shown limited palliative care (PC) utilization among patients evaluated for liver transplantation (LT) despite the cohort's significant symptom burden, high frequency of hospitalization and risk of rapid decompensation. Our aim was to evaluate patient characteristics and end-of-life (EOL) outcomes (i.e. ICU utilization, code status, advance care planning) associated with the use of PC services in patients who were evaluated for LT. Methods: We performed a single-center cross-sectional study comprised of 223 deceased patients evaluated for LT between 1/1/2017 and 12/31/2021. We evaluated demographic characteristics and EOL outcomes for differences between patients who received PC consultation and those who did not. EOL outcomes associated with PC use were assessed using logistic and linear regression analysis adjusted for patient demographics. Results: Patients who received PC consultation were younger (mean 57 vs. 61; P = 0.048), had higher Model for end-stage Liver Disease (MELD) scores (27.5 vs. 22; P = 0.001), higher rates of hepatic encephalopathy (96% vs. 84%, P = 0.005), and were more frequently declined for LT (77% vs. 57%; P = 0.008). Patients who received PC services were less likely to die in the ICU (OR = 0.07 [0.02-0.18]) and were more likely to have documented advance care planning (OR = 3.16 [1.47-6.97]), family meetings (OR = 6.58 [2.72-17.08]), and goals-of-care discussions (OR = 14.83 [4.39-69.29]). Conclusion: For patients being evaluated for LT, PC utilization differed based on demographics, disease complications and severity, and transplant status. Those who received PC services had higher quality EOL care planning and fewer ICU admissions.

Classifying End-of-Life Patterns: Evidence From the National Health and Aging Trends Study.

End-of-life (EOL) care quality encompasses multiple domains, which are typically studied in silos. This paper explores interrelationships across domains and how they simultaneously shape patterns of EOL care quality. Secondary analysis using National Health and Aging Trends Study. Latent class analysis was used to identify subgroups of decedents according to quality of symptoms and needs management, care experience, care processes, and site of death. Multinomial logistic regression was employed to investigate the association between decedent characteristics and class membership. Five groups of decedents were identified. Multiple sites of death with high care coordination (Class 4: 35%) comprised decedents with least concerns regarding symptom management and care experience. Decedents in Predominantly home deaths with no hospice use (Class 1: 26%), predominantly hospital deaths with low hospice use (Class 2: 18%), and multiple sites of death with hospice use (Class 3: 7%) presented similar symptom management and care experience patterns. Multiple sites of death with low care coordination (Class 5: 14%) comprised decedents experiencing poor quality EOL care across multiple domains. Non-Hispanic Black and Hispanic decedents were more likely to be in Class 2 and decedents with dementia diagnosis in Class 4. There is considerable heterogeneity in EOL care patterns. Assessing quality based on discrete metrics in silos may lead to unintended consequences like stinting of necessary care or increased caregiving burden on families. There is a need for greater focus on patient-centeredness and how care processes and structures interact in the context of shifting care patterns, care preferences, and payment reforms.

The explorations of the awareness, contemplation, self-Efficacy, and readiness of advance care planning, and its predictors in Taiwanese patients while receiving hemodialysis treatment

BackgroundEnd-stage renal disease (ESRD) is a major chronic illness worldwide, and Taiwan reports one of the highest incidence rates of ESRD with 529 cases per million population (pmp). A number of patients with ESRD patients might require lifelong hemodialysis (HD) or peritoneal dialyses (PD). Due to the progression of dialysis, patients are likely to experience other chronic comorbidities, anxiety and depression, frequent hospitalizations, and higher rates of mortality compared to patients with other types of chronic illnesses. As a result, dialysis patients are prone to experience advance care planning (ACP) needs, such as whether they withdraw from receiving dialysis while approaching their end-of-life (EOL). Yet, existing studies have shown that dialysis patients seldom receive timely consultation regarding ACP and there are limited studies examining ACP amongst Taiwan HD patients.PurposeThe purpose of this study was to examine ACP awareness, contemplation, self-efficacy and readiness; and factors influencing ACP readiness.DesignThis cross-sectional descriptive study with convenience sampling was conducted in the out-patient HD unit at a regional teaching hospital in southern Taiwan. A total of 143 ESRD patients undergoing HD treatments were recruited. A 55-item ACP engagement survey containing the subscales of awareness, contemplation, self-efficacy, and readiness was employed. The data were analyzed with t-tests, one-way ANOVAs, Pearson’s correlations and multiple regressions.ResultsThe results of our investigation revealed that approximately half of the participants (n = 67, 46.9%) were not informed of ACP. Although they reported considering their EOL, medical decisions and desired care, they demonstrated significantly low self-efficacy in discussing ACP (t= -5.272, p < 0.001). HD duration influenced all four ACP subscales; religious beliefs significantly influenced ACP-self-efficacy and readiness; and marital status, education, and primary decision-maker status significantly influenced ACP-readiness. The predictors of ACP-readiness were high self-efficacy and being the primary decision-maker (Adjusted R2 61%).ConclusionMost of the HD patients in this study had low ACP-awareness, contemplation, self-efficacy, and readiness, and most had not completed any ACP-related advance directives (AD). Healthcare professionals should proactively provide HD patients with ACP-related information and answer patients’ and medical decision-makers’ questions in a timely manner, thereby improving the quality of EOL care.

Disparities in place of death from prostate cancer revealed by disaggregation of Asian race.

187 Background: Place of death (PoD) is a surrogate determinant of health care inequity in patients with cancer. Aggregation of Asian Americans, a diverse group, may mask significant health disparities in end-of-life care. Methods: De-identified death certificate data were obtained via the National Center for Health Statistics. All adult (&gt; 18 years of age) prostate cancer deaths from 2018 to 2019 were included. Multinomial logistic regression was used to test for differences in place of death associated with sociodemographic variables. Results: From 2018 through 2019, 81,292 adults died from prostate cancer. Overall, most Asians were less likely to die at home (p &lt; 0.05) or nursing facility (p &lt; 0.05) compared to White patients. Significant differences in nursing facility use was noted in disaggregated analysis, with Samoan patients 12.44 times more likely to die in a hospice facility compared to hospital (CI 2.89, 53.6; p &lt; 0.001) and Chinese patients 100 times less likely to die in a hospice facility (CI 0.01, 0.02; p &lt; 0.001) to give two notable examples. Chinese (OR 0.26), Guamanian (OR 0.2), and Vietnamese race (OR 0.05) had the lowest likelihood of dying at home, with odds ratio lower than Black race (OR 0.3) (Table). Conclusions: Increased attention to PoD over recent years has highlighted issues around equity in end-of-life care. Overall, our data underscore important differences among Asian subpopulations and possible barriers to quality end of life care that would otherwise be masked with data aggregation. It is well known that resources are needed to allow death at home or at a nursing facility. Further qualitative work is planned to investigate culture differences contributing to PoD differences for patients with cancer through the lens of the social determinants of health.

Patients' perceptions of treatment benefits and correlation with end-of-life quality markers in advanced malignancy.

188 Background: High-quality end-of-life (EOL) care is a recognized goal for modern cancer care delivery. Illness perception is often inaccurate among patients with cancer and may be associated with the quality of EOL care. We surveyed patients receiving palliative cancer-directed therapies to assess associations between accuracy of perceived likelihood of treatment response and recognized EOL quality measures in a cohort of patients with advanced solid malignancies. Methods: Patients and their oncologists were surveyed regarding perceived benefits of palliative cancer-directed therapies. Accuracy of perception was calculated as patient-assessed minus physician-assessed likelihood of benefit, expressed as a score from -100 to 100, with positive scores indicating that the patient was more optimistic than the oncologist with regards to treatment response. For deceased patients, data on quality of EOL measures, including timing of recent chemotherapy, emergency room (ER) visits, hospitalizations, and intensive care unit (ICU) admissions, hospice enrollment, and location of death were collected. The primary outcome consisted of a composite of ER visit, hospitalization, or ICU admission within 30 days, and/or chemotherapy within 14 days of death. We tested for associations between the unadjusted mean and 95% confidence interval perception of treatment response and EOL metrics. Results: Of 69 patients, median age was 67 years (interquartile range: 61-75), and 50% were male. Cancers included lung (32%), gastrointestinal (22%), genitourinary (16%) and gynecological (16%). Treatments at time of enrollment included cytotoxic chemotherapy (65%), immunotherapy (23%) and oral targeted therapy (12%). Most patients (67%) enrolled in hospice &gt; 7 days prior to death, and 59%, 19%, and 46% were hospitalized, had ICU admission, or an ER visit within 30 days of death, respectively. 12% received cancer-directed systemic therapy in the last 14 days of life. Patients’ accuracy of estimated treatment response was lower for patients with the composite quality outcome, suggesting poorer EOL quality, though this was not statistically significant (20.5, 95% CI: 12.4–28.7 vs. 28.5, 95% CI: 18.0–38.9, p = 0.24). Patients enrolled in hospice &gt; 7 days before death had less accurate perception of treatment benefit (28.1, 95% CI: 20.5–35.8 vs. 13.5, 95% CI: 2.5–24.4, p = 0.03). There was no significant difference for other individual EOL quality measures (all p≥0.17). Conclusions: In this cohort of patients with advanced solid cancer, higher EOL quality measures did not correlate with accuracy of perception of treatment responses. Patients who were more optimistic compared to their treating oncologists were more likely to be enrolled in hospice for &gt; 7 days before death. Improving EOL care for patients with advanced cancer requires more than ensuring accurate patient understanding of treatment goals.

11 Implementation of a Hospice Transition Protocol in an Emergency Department to Facilitate End-of-Life Care

11 Implementation of a Hospice Transition Protocol in an Emergency Department to Facilitate End-of-Life Care

Trends in quality indicators of end-of-life care for women with gynecologic malignancies in Ontario, Canada

ObjectiveA large body of research has validated several quality indicators of end-of-life (EOL) cancer care, but few have examined these in gynecologic cancer at a population-level. We examined patterns of EOL care quality in patients with gynecologic cancers across 13 years in Ontario, Canada. MethodsWe conducted a population-based, retrospective cohort study of gynecologic cancer decedents in Ontario from 2006 to 2018 using linked administrative health care databases. Proportions of quality indices were calculated, including: emergency department (ED) use, hospital or intensive care unit (ICU) admission, chemotherapy ≤14 days of death, cancer-related surgery, tube or intravenous feeds, palliative home visits, and hospital death. We used multivariable logistic regression to examine factors associated with receipt of aggressive and supportive care. ResultsThere were 16,237 included decedents over the study period; hospital death rates decreased from 47% to 37%, supportive care use rose from 65% to 74%, and aggressive care remained stable (16%). Within 30 days of death, 50% were hospitalized, 5% admitted to ICU, and 67% accessed palliative homecare. Within 14 days of death, 31% visited the ED and 4% received chemotherapy. Patients with vulvovaginal cancers received the lowest rates of aggressive and supportive care. Using multivariable analyses, factors associated with increased aggressive EOL care use included younger age, shorter disease duration, lower income quintiles, and rural residence. ConclusionsOver time, less women dying with gynecologic cancers in Ontario experienced death in hospital, and more accessed supportive care. However, the majority were still hospitalized and a significant proportion received aggressive care in the final 30 days of life.

Emergency department staff perceptions of their roles in providing end of life care

BackgroundEnd of life care in the emergency department is environmentally and culturally challenging. The aim of this study was to determine Australian emergency department doctors and nurses’ perceptions of their roles in providing end of life care in this environment. MethodsPerceptions of end-of-life care roles were identified through semi-structured interviews with doctors and nurses using Dieklemann’s seven interpretative stages of analysis guided by phenomenological interpretive underpinnings (hermeneutics). Nine nurses and seven doctors were recruited using purposive sampling. Organisations for emergency doctors (Australasian College for Emergency Medicine: ACEM) and emergency nurses (College of Emergency Nursing Australasia: CENA) were approached to advertise the study and recruit participants across Australia via email. ResultsResults were categorised into four themes namely: role perception; the intensive nature of the role; emotional burden; and role integration. The participants stated that end of life care was provided according to their professional roles and responsibilities. Doctors and nurses had distinct tasks, some of which overlapped. The accounts of the participants in relation to their understanding of each other’s roles highlighted differences in how nurses perceived the role of doctors, and vice versa. The participants spoke about aspects that had an impact on their role of practicing end of life care in the emergency department setting. ConclusionsIn this study, all participants expressed concern for dying patients in the emergency department. The delivery of quality end of life care was believed to be paramount and required staff to work together to achieve the best outcome for the dying patient and their families. Regardless of the similarities and differences that were perceived within their roles, the nurses and doctors believed that their main objective was to ensure that comfort care was provided to dying patients.

Australian residential aged care home staff experiences of implementing an intervention to improve palliative and end-of-life care for residents: A qualitative study.

Access to high-quality and safe evidence-based palliative care (PC) is important to ensure good end-of-life care for older people in residential aged care homes (RACHs). However, many barriers to providing PC in RACHs are frequently cited. The Quality End-of-Life Care (QEoLC) Project was a multicomponent intervention that included training, evidence-based tools and tele-mentoring, aiming to equip healthcare professionals and careworkers in RACHs with knowledge, skills and confidence in providing PC to residents. This study aims to understand: (1) the experiences of healthcare professionals, careworkers, care managers, planners/implementers who participated in the implementation of the QEoLC Project; and (2) the barriers and facilitators to the implementation. Staff from two RACHs in New South Wales, Australia were recruited between September to November 2021. Semi-structured interviews and thematic data analysis were used. Fifteen participants (seven health professionals [includes one nurse, two clinical educators, three workplace trainers, one clinical manager/nurse], three careworkers and five managers) were interviewed. Most RACH participants agreed that the QEoLC Project increased their awareness of PC and provided them with the skills/confidence to openly discuss death and dying. Participants perceived that the components of the QEoLC Project had the following benefits for residents: more appropriate use of medications, initiation of timely pain management and discussions with families regarding end-of-life care preferences. Key facilitators for implementation were the role of champions, the role of the steering committee, regular clinical meetings to discuss at-risk residents and mentoring. Implementation barriers included: high staff turnover, COVID-19 pandemic, time constraints, perceived absence of executive sponsorship, lack of practical support and systems-related barriers. The findings underline the need for strong leadership, supportive organisational culture and commitment to the implementation of processes for improving the quality of end-of-life care. Furthermore, the results highlight the need for codesigning the intervention with RACHs, provision of dedicated staff/resources to support implementation, and integration of project tools with existing systems for achieving effective implementation outcomes.

1292P A review of in-hospital end-of-life care (EOLC) for oncology patients during the COVID-19 pandemic

Globally, 40 to 60% of all patient deaths occur in an acute hospital setting. Patients with cancer make up a significant proportion of those who die in hospitals. Clinicians involved in their care should be competent at recognising dying and documenting the quality of EOLC delivered to patients and families. Continued evaluation and audit of the care of the dying patient is essential for quality improvement at an organisational level. The management of patients who died in Cork University Hospital under the Oncology Service’s care between 1 January 2021 and 31 December 2021 was analysed. Paper and electronic records were reviewed, and patient care was assessed using the Oxford Quality Indicators (QIs) for EOLC. Ethical approval was granted by the Cork University Hospital Quality and Patient Safety Department. 66 patients were identified (M:F 29:37). The median age at time of death was 64 years [30-82]. The average length of admission resulting in death was 12.4 days [0-44]. 6% of patients died in the emergency department and 12% of patients died in the intensive care unit. The risk of dying was documented in 95.5% of cases and was communicated to 65.2% of patients and 82.8% of patients’ families. There was a do not attempt cardiopulmonary resuscitation (DNACPR) order in place for 89.4% of patients. Unnecessary investigations and interventions were stopped for 71.2% of patients. Symptom assessment was documented in 81.8% of cases. What was important to the patient was documented as explored in 24.2% of cases. 10.6% of patients were offered a chaplain or faith advisor. The inpatient palliative care team were involved in 77.2% of cases. Using the Oxford QIs for EOLC, the average quality score was 3.5, on a scale of 1-5: 1 (very poor): 0%, 2 (poor): 21.2%, 3 (satisfactory): 33.3%, 4 (good): 19.7%, 5 (excellent): 25.8%. The average EOLC quality score was 3.5. Oncology patients at our centre received, on average, satisfactory-to-good quality EOLC. Shortcomings identified have led to the development of a care of the dying Pro-forma to improve EOLC delivery and a survey of bereaved relatives to identify gaps in care. Holistic care of the dying is a fundamental part of the cancer care spectrum and needs to be prioritised in the acute hospital setting.

Confucian Familism and Shared Decision Making in End-of-Life Care for Patients with Advanced Cancers.

Shared decision-making (SDM) has been institutionally recognized as clinically effective by many Western healthcare systems. Nevertheless, it appears culturally unattractive in China, a country that adheres to Confucian familism which strongly prefers collective family decisions. This study examined this conflict and assessed the influence of Confucian familism on SDM in end-of-life (EOL) care for advanced cancer patients. Between August and November 2018, 188 EOL advanced-cancer patients were randomly recruited from 640 cancer hospital medical records at a Tertiary A-level hospital in Shandong province. Eventually, 164 (87.23%) sample patients were included in the statistical analysis after the non-responsive cases (4.79%) and missing value (7.98%) were removed. SDM was measured through SDM-Q-9, and the patient’s siblings were used as indicators of Confucian Familism. Of the 164 patients, the mean SDM score was 38/100; 47.6% were thoroughly unfamiliar with their treatment plans and fell outside the decision-making procedure. Each patient had four siblings on average. Ceteris paribus, more siblings led to lower SDM. Moreover, being 56–65 years old and open-minded were associated with higher SDM, while higher satisfaction of the quality of EOL care yielded lower SDM. In conclusion, Confucian familism weakened patient–clinician SDM in EOL care for advanced cancer patients.

Factors associated with death places among elderly patients receiving home-based care.

The quality of end-of-life (EOL) care for patients receiving home-based care is a critical issue for health care providers. Dying in a preferred place is recognized as a key EOL care quality indicator. We explore the factors associated with death at home or nursing facilities among elderly patients receiving home-based care.This retrospective study was based on a medical chart review between January 2018 and December 2019 of elderly patients. Multivariate analysis was conducted by fitting multiple logistic regression models with the stepwise variable selection procedure to explore the associated factors.The 205 elderly patients receiving home-based care were enrolled for analysis. The mean participant age was 84.2 ± 7.8 years. Multiple logistic regression indicated that significant factors for elderly home-based patients who died at home or nursing facilities were receiving palliative service (odds ratio [OR], 3.21; 95% confidence interval [CI], 1.37–7.51; P = .007), symptoms of nausea or vomiting (OR, 5.38; 95% CI, 1.12–25.84; P = .036), fewer emergency department visits (OR, 0.07; 95% CI, 0.03–0.16; P < .001), and less intravenous third-generation cephalosporin use (OR, 0.15; 95% CI, 0.03–0.75; P = .021) in the last month of life. Patients with dementia had a lower probability of dying at home or nursing facilities than patients with other diagnosis (OR, 0.34, 95% CI, 0.13–0.90; P = .030).Among elderly home-based patients, receiving palliative service, with nausea or vomiting, and fewer emergency department visits in the last month of life favored home or nursing facilities deaths. Practitioners should be aware of the factors with higher probabilities of dying at home and in nursing facilities. We suggested that palliative services need to be further developed and extended to ensure that patients with dementia can receive adequate EOL care at home and in nursing facilities.

Hospice Care Preferences and Its Associated Factors among Community-Dwelling Residents in China.

Hospice care is a comprehensive approach addressing patients’ physical, psychosocial, and spiritual needs at the end of life (EoL). Despite the recognition of its effectiveness in improving the quality of EoL care, little is known about hospice care in mainland China. In this study, we aimed to examine the preferences for hospice care and its related factors among community-dwelling residents in mainland China. Participants were recruited using a convenience sampling method, and 992 community-dwelling residents responded to an online survey from June 2018 to August 2019. The majority (66.7%) of the participants were female, and the mean age was 48.4 years. Approximately 28% of the participants had heard of hospice care, and 91.2% preferred to receive hospice care if diagnosed with a terminal illness. Participants who had heard of hospice care, and with higher levels of education (bachelor’s degree or above) and health insurance coverage were more likely to accept hospice care than their counterparts. Community-based education on hospice care is imperative to improve public knowledge and the acceptance of hospice care. Meanwhile, there is a need to develop policies to integrate and expand hospice care into clinical settings.