ABSTRACT
Purpose: Signals of end-of-life decline observed in daily habits, such as mealtime participation, are important for moving towards comfort-focused goals of care in the final months of life of long-term care (LTC) residents. It is unclear how eating issues observed in real-time in LTC homes are used as indicators of suspected end of life. The study quantifies nutrition and key non-nutrition related signals (eg, general decline, unstable vitals) documented to describe end-of-life decline and the subsequent time to death. Patients and Methods: A retrospective chart review identified the first documented conversation where end-of-life decline was considered by members of the care team (eg, nurses, physicians, dietitian, family member) for 76 randomly selected decedents from 9 LTC homes in southwestern Ontario, Canada. Time (days) to death was calculated. A directed content analysis of the free-text description of the suspected end-of-life decline was used to categorize signals. Cox proportional hazards regression analysis tested the risk of mortality associated with each categorized signal. Results: Time to death of residents (mean age = 88 ± 7 years; 60% female) from the first documentation of potential end-of-life decline ranged from 0 days to over 2 years prior to death (median = 27.5 days). Seven nutrition-related and 18 non-nutrition related signals were identified. Swallowing difficulty (HR = 2.99; 95% CI = 1.41, 6.33), cognitive decline (HR = 0.40; 95% CI = 0.20, 0.77), delirium (HR = 13.23; 95% CI = 1.57, 111.69), and cancer (HR = 0.18; 95% CI = 0.07, 0.48) were associated with time to death. Conclusion: This study provides insight into the signals used by care providers in LTC to suspect that residents are declining towards the end of life and identifies four signals that were associated with time to death. When identified by care providers as indicators of end-of-life decline, swallowing difficulty and delirium predicted a shorter time to death, while cancer and cognitive decline predicted a longer time to death. Recognition of nutrition and non-nutrition related signals may be leveraged to systematically introduce timely comfort care conversations.
ABSTRACT
The detailed kinetic properties of hydrogen atom abstraction by methylperoxy (CH3Ȯ2) radicals from alkanes, alkenes, dienes, alkynes, ethers, and ketones are systematically studied in this work. Geometry optimization, frequency analysis, and zero-point energy corrections were performed for all species at the M06-2X/6-311++G(d,p) level of theory. The intrinsic reaction coordinate calculation was consistently performed to ensure that the transition state connects the correct reactants and products, and one-dimensional hindered rotor scanning results were performed at the M06-2X/6-31G level of theory. The single-point energies of all reactants, transition states, and products were obtained at the QCISD(T)/CBS level of theory. High-pressure-limit rate constants of 61 reaction channels were calculated using conventional transition state theory with asymmetric Eckart tunneling corrections over the temperature range of 298.15-2000 K. Reaction rate rules for H atom abstraction by CH3Ȯ2 radicals from fuel molecules with different functional groups are constructed, which can be used in the development of combustion models of these fuels and fuel types. In addition, the influence of the functional groups on the internal rotation of the hindered rotor is also discussed.