Unscheduled care admissions at end-of-life - what are the patient characteristics?

Unscheduled acute hospital admissions and subsequent deaths in hospitals of patients considered palliative are increasing, despite many patients' preference to die at home. A large proportion of these patients are admitted via acute medical units or emergency departments. The integration of primary and secondary care within Wales should enhance the delivery of end-of-life care at home but unscheduled admission for patients with palliative care needs remains prevalent. The aim of our study was to explore the characteristics amongst patients who die shortly after unscheduled hospital admission. A retrospective, observational study was conducted in all unscheduled admissions at end-of-life at a single health board in South Wales, UK over a period of one month. The result showed that 47% of patients who died within 48hrs of unscheduled admission are considered to be palliative. The majority of these patients were admitted via 999 ambulances and out of normal working hours (65%). They were elderly (median age 80) and had a poor performance status (78%). Over 1/3 (39%) were admitted from a nursing or residential home. Less than a quarter (22%) had an advance care plan in place.

Physical and psychological factors and the wish to hasten death in advanced cancer patients.

BACKGROUND: Qualitative research suggests that the wish to hasten death (WTHD) in the advanced stages of disease is mainly related to overall suffering. This quantitative study explores the relationship between the WTHD and psychological and physical factors, including survival, in patients with advanced cancer. METHODS: Cross-sectional study of 101 advanced cancer patients admitted to an acute Palliative Care Unit (PCU) and followed-up for survival. Patients were assessed using the Schedule of Attitudes toward Hastened Death (SAHD). The Hospital Anxiety and Depression Scale (HADS), Eastern Cooperative Oncology Group Performance Status, and the Barthel Index were used to assess psychological and physical status. Survival prognosis was based on the Palliative Prognostic score. RESULTS: The Spanish adaptation of SAHD showed good psychometric properties (Cronbach's alpha 0.92; similar concurrent/discriminant validity to the original). The mean total score on SAHD was 4.9 (standard deviation [SD] = 5.3). SAHD scores were positively correlated with HADS-Total (r = 0.332, p < 0.01), HADS-Depression (r = 0.397, p < 0.01), Eastern Cooperative Oncology Group Performance Status (r = 0.276, p < 0.01), and Palliative Prognostic score (r = 0.248, p < 0.05) and negatively correlated with the Barthel Index (r = -0.324, p < 0.01). Women scored higher than men on SAHD (6.2, SD = 5.9 vs. 4.2, SD = 4.8, p < 0.01). No association was found between WTHD and survival (r = -0.12, p > 0.05). CONCLUSIONS: Both psychological and physical impairment (as well as poorer prognosis) are associated with higher scores on SAHD, supporting the idea that WTHD emerges in response to overall suffering. Although we observed a direct relationship between physical status and survival, the latter was not related to any of the psychological factors or WTHD.

Towards a classification model to identify hospice candidates in terminally ill patients.

This paper presents a Rough Set Theory (RST) based classification model to identify hospice candidates within a group of terminally ill patients. Hospice care considerations are particularly valuable for terminally ill patients since they enable patients and their families to initiate end-of-life discussions and choose the most desired management strategy for the remainder of their lives. Unlike traditional data mining methodologies, our approach seeks to identify subgroups of patients possessing common characteristics that distinguish them from other subgroups in the dataset. Thus, heterogeneity in the data set is captured before the classification model is built. Object related reducts are used to obtain the minimum set of attributes that describe each subgroup existing in the dataset. As a result, a collection of decision rules is derived for classifying new patients based on the subgroup to which they belong. Results show improvements in the classification accuracy compared to a traditional RST methodology, in which patient diversity is not considered. We envision our work as a part of a comprehensive decision support system designed to facilitate end-of-life care decisions. Retrospective data from 9105 patients is used to demonstrate the design and implementation details of the classification model.

Where people die: a multilevel approach to understanding influences on site of death in America.

Despite documented preferences for home death, the majority of deaths from terminal illness occur in hospital. To better understand variation in place of death, we conducted a systematic literature review and a multilevel analysis in which we linked death certificates with county and state data. The results of both components revealed that opportunities for home death are disproportionately found in certain groups of Americans; more specifically, those who are White, have greater access to resources and social support, and die of cancer. From the multilevel analysis, the higher the proportion minority and the lower the level of educational attainment, the higher the probability of hospital death while investment in institutional long-term care, measured by regional density of nursing home beds and state Medicaid payment rate, was associated with higher probability of nursing home death. These results reinforce the importance of both social and structural characteristics in shaping the end-of-life experience.

Validation of the palliative performance scale in the acute tertiary care hospital setting.

BACKGROUND: Physicians are often asked to prognosticate patient survival. However, prediction of survival is difficult, particularly with critically ill and dying patients within the hospitals. The Palliative Performance Scale (PPS) was designed to assess functional status and measure progressive decline in palliative care patients, yet it has not been validated within hospital health care settings. OBJECTIVE: This study explores the application of the PPS for its predictive ability related to length of survival. Other variables examined were correlates of symptom distress in a tertiary academic setting. METHODS: Patients were assigned a score on the PPS ranging from 0% to 100% at initial consultation. Standardized symptom assessments were carried out daily, and survival was determined by medical record review and search of the National Death Index. RESULTS: Of 261 patients seen since January 2002, 157 had cancer and 104 had other diagnoses. PPS scores ranged from 10% to 80% with 92% of the scores between 10% and 40%. Survival ranged from 0 to 30 months, with a median of 9 days. By 90 days, 83% of patients had died. Proportional hazards regression estimates showed that a 10% decrement in PPS score was associated with a hazard ratio of 1.65 (95% confidence interval [CI]: 1.42-1.92). Proportional odds regression models showed that a lower PPS was significantly associated with higher levels of dyspnea. CONCLUSION: The PPS correlated well with length of survival and with select symptom distress scores. We consider it to be a useful tool in predicting outcomes for palliative care patients.

Symptoms and care of dying elderly patients in an acute hospital.

INTRODUCTION: We aimed to study the symptoms and the care of elderly patients dying in an acute hospital in Singapore. METHODS: Over a one year period, we retrospectively studied all patients admitted to the Department of Geriatric Medicine and all other patients aged more than 75 years old who were admitted and died during the same admission to all other units in an acute hospital. There were 189 such patients. Demographical data, information on the patients' background and prevailing medical problems, symptoms, intervention and treatment methods were obtained from the patients' medical records and analysed. RESULTS: The patients were frail and old. 17 percent had bedsores and 20 percent had limb contractures noted at the point of admission. 20 percent had known terminal disease. 88 percent of the deaths were expected and 12 percent unexpected. In spite of the deaths being anticipated, 25 percent of them were subjected to cardiopulmonary resuscitation and 17 percent were intubated at the point of collapse. The majority (81 percent) of relatives of the 160 patients whose deaths were anticipated and had family had no acceptance problems. 52 (31 percent) of the 167 expected deaths had input from palliative care. These patients were more dependent, (p-value equals 0.018; odds ratio [OR] = 2.5; 95 percent confidence interval [CI] 1.2-5.2), less likely to undergo resuscitation (p-value is less than 0.001; OR = 0.16; 95 percent CI, 0.06-0.44), and were more likely to be on treatment for their symptoms (p-value is equal to 0.001; OR = 7.7; 95 percent CI, 2.1-28.8). CONCLUSION: The common symptoms experienced by the elderly at the end of life are difficulty with breathing, fever, pain and respiratory secretions. A number of patients were not on any treatment for these problems though the proportion is less where there is palliative input.

Ethnic differences in the place of death of elderly hospice enrollees.

Elderly minorities are more likely to die in inpatient settings than their Caucasian counterparts. It is not known whether this difference is due to cultural preferences for place of death or decreased access to hospice. This analysis examines ethnic differences in the place of death of elderly hospice patients. Using data from a large, national hospice provider, elderly (> or = 65) African-American, Hispanic, and Caucasian decedents admitted to hospice between January 1, 2000, and December 31, 2003, were identified. Of the 115,854 eligible decedents, 78.3% were Caucasian, 10.7% African American, and 11% Hispanic. Hispanics and African Americans were more likely to die in inpatient hospice settings than Caucasians (38.5%, 38.5%, and 32%, respectively). After adjustment for demographic and hospice use variables, older African Americans had higher odds than older Caucasians of dying in an inpatient hospice setting than a nursing home (odds ratio (OR)=1.12, 95% confidence interval (CI)=1.07-1.19). However, African-American ethnicity was not a significant predictor of death in an inpatient setting versus home (OR=1.03, 95% CI=0.97-1.08)). Hispanics had lower odds than Caucasians of death in an inpatient hospice setting than at home (OR=0.88, 95% CI=0.84, 0.93) and higher odds of death in an inpatient setting than a nursing home (OR=1.45, 95% CI=1.37-1.53). Admission to hospice reduces but does not eliminate ethnic differences in place of death. Further research should examine the effect of individual and cultural preferences for place of death on decisions to enroll in hospice.

Physicians as medical center "extenders" in end-of-life care: physician home visits as the lynch pin in creating an end-of-life care system.

The article reviews a successful community-based end-of-life home care program. Specifically, physician visits were compared in the models of care studied, and it was concluded that the community-based model patients benefited significantly over the standard model of care patients due to the use of physicians.

The schedule of attitudes toward hastened death: validation analysis in terminally ill cancer patients.

OBJECTIVE: The faithful translation of the English version of the Schedule of Attitudes toward Hastened Death (SAHD) into Greek and its validation as an assessment tool in terminally ill cancer patients receiving palliative treatment. METHODS: 120 terminally ill cancer patients attending a Palliative Care Unit, at the University of Athens, Greece, between June 2003 and November 2003 for palliative treatment. RESULTS: SAHD would be a useful instrument for measuring desire for hastened death with valid psychometric properties in a Greek cancer population. The SAHD demonstrated high reliability. Desire for hastened death was significantly associated with Hospital Anxiety and Depression Scale (HAD) depression (r = 0.607, p < 0.0005) and substantially correlated with HAD anxiety (r = 0.502, p < 0.0005). "Pain intensity" had a moderate correlation with SAHD scores (r = 0.28, p = 0.01) and SAHD scores correlated significantly with "pain interference in mood" (r = 0.38, p = 0.01) and in "enjoyment of life" (r = 0.34, p = 0.03). SAHD correlation with quality of life was statistically significant (r = -0.38, p < 0.01) as was health status (r = -0.36, p < 0.01). Patients with a Poor Performance Status (from Eastern Cooperative Oncology Group scale) correlated significantly with high scores in SAHD (p = 0.038). Factor analysis supported the unidimentionality of the measurement. SIGNIFICANCE OF RESULTS: SAHD could be a useful and valid instrument for measuring desire for hastened death in Greek terminally ill cancer patients.

Help-seeking behaviors of blacks and whites dying from coronary heart disease.

OBJECTIVES: This study sought to determine whether blacks and whites with life-threatening cardiac events differ in likelihood of help seeking, types of help sought, or likelihood of reaching the hospital before death. DESIGN: Death certificates were used to identify all coronary heart disease-related deaths occurring in 1988-89 among 45- to 74-year-old, black and white, non-institutionalized residents of three contiguous inner-city districts in Boston, Massachusetts, USA. An informant was interviewed about the decedent's health status, access to care and pre-mortal help-seeking behaviors. RESULTS: Among the 232 decedents analyzed, there were no racial differences in the likelihood of help seeking. Among those who sought help, there were no racial differences in the likelihood of reaching the hospital. However, blacks were more likely than whites to engage in two specific help-seeking behaviors: calling the 911 emergency system, and trying to reach an emergency room. CONCLUSION: In an area where blacks and whites were similar with respect to socioeconomic status and access to care, race did not affect the likelihood of help seeking or the likelihood of succeeding in reaching the hospital before death.

Development of terminal cancer prognostic score as an index in terminally ill cancer patients.

Cancer patients, families, clinicians, and health-policy administrators need accurate information about the prognosis of survival of terminally ill cancer patients. The aim of this study was to compare survival times and prognostic factors, and develop a new prognostic index for terminally ill cancer patients. This prospective study was performed on 91 patients with solid tumor, and therefore, no longer subjects of anti-cancer therapy. Association was sought between survival times and a range of clinical characteristics. The median survival time of 91 terminal cancer patients was 54.0 days. Univariate analysis showed that 11 factors provide statistically significant prognostic survival information. Multivariate analysis adjusted for the primary tumor site demonstrated that severe anorexia (aRR 1.95, 95% C.I. 1.24-3.05), severe diarrhea (aRR 3.49, 95% C.I. 1.10-11.05), and mild confusion (aRR 1.94, 95% C.I. 1.15-3.27) are independent negative predictors of survival. The Terminal Cancer Prognostic score (TCP score), which was based on three predictors proved to be a significant predictor. The TCP score might be a useful index for predicting survival.

[The terminally ill patient. Grupo de Estudios de Etica Cliínica de la Sociedad Médica de Santiago]. / El enfermo terminal. Grupo de Estudios de Etica Clínica, de la Sociedad Médica de Santiago.

The classification of a patient as terminally ill is based on an expert diagnosis of a severe and irreversible disease and the absence of an effective available treatment, according to present medical knowledge. Terminal diseases must not be confused with severe ones, since the latter may be reversible with an adequate and timely treatment. The physician assumes a great responsibility at the moment of diagnosing a patient as terminally ill. The professional must assume his care until the moment of death. This care must be oriented to the alleviation of symptoms and to provide the best possible quality of life. Also, help must be provided to deal with personal, legal and religious issues that may concern the patient.

El enfermo terminal / The terminally ill patient

The classification of a patient as terminally ill is based on an expert diagnosis of a severe and irreversible disease and the absence of an effective available treatment, according to present medical knowledge. Terminal diseases must not be confused with severe ones, since the latter may be reversible with an adequate and timely treatment. The physician assumes a great responsibility at the moment of diagnosing a patient as terminally ill. The professional must assume his care until the moment of death. This care must be oriented to the alleviation of symptoms and to provide the best possible quality of life. Also, help must be provided to deal with personal, legal and religious issues that may concern the patient

El cuidado paliativo y su importancia psicosocial : un nuevo campo de intervención para el Trabajador Social del Paraguay

Estudio descriptivo con énfasis en variables clínico-sociales, para el estudio del cuidado paliativo de los enfermos terminales, enfocado hacia las necesidades psicosociales de diferentes nosocomios, pero foclizado en la Unidad de Cuidados Paliativos del Instituto Nacional del Cáncer y Quemado