¿Conocen los profesionales de cuidados intensivos el documento de voluntades anticipadas? Revisión crítica / Are palliative care proffesionals aware of the advanced care planning document? Critical review

JUSTIFICACIÓN: Las instrucciones previas o documento de voluntades anticipadas (IP/DVA) constituyen un conjunto de documentos en los que el paciente puede dejar constancia de cómo desea morir o ser tratado al final de su vida, con el fin de que su voluntad sea respetada. En 1998 surgió una nueva corriente, Advance Care Planning (Planificación Anticipada de las Decisiones). En ella, el DVA aparece como una herramienta, resultado final de un amplio proceso de comunicación que exige a los profesionales sanitarios una formación acorde para proporcionar una mejor atención sanitaria al final de la vida. A este respecto, son varios los estudios que muestran que una inadecuada formación en los cuidados al final de la vida, especialmente en las unidades de cuidados intensivos (UCI), dificulta las habilidades y actitudes en la comunicación, los cuidados y el respeto del DVA con todas las medidas que contempla y, en definitiva, dificulta mantener la dignidad en el proceso de la muerte del paciente. OBJETIVO: Analizar la competencia (conocimientos, habilidades y actitudes) de médicos y enfermeras de las UCI de la Comunidad de Madrid sobre las IP o DVA. DISEÑO: Estudio observacional, descriptivo y transversal. LUGAR Y PERÍODO: Nueve hospitales de la Comunidad de Madrid, entre octubre y diciembre de 2010. PARTICIPANTES: Se encuestó a una muestra de conveniencia cuyos criterios de inclusión fueron todos los médicos y enfermeras de las UCI de adultos de los nueve hospitales. INTERVENCIÓN: Cuestionario ad hoc estructurado, anónimo, autocumplimentado, con variables dicotómicas y escala de tipo Likert. RECOGIDA DE DATOS Y ANÁLISIS: Las variables estudiadas fueron: sociodemográficas, de conocimientos, habilidades y actitudes. Para la entrega de los cuestionarios se contactó con las supervisoras de las unidades y jefes de servicio, se hizo una charla informativa, se colgaron carteles informativos y se repartieron los cuestionarios a través de los investigadores y personas de enlace. Para la recogida de las encuestas se dispuso de urnas ubicadas en las unidades. La entrega de formularios se realizó mediante consentimiento informado previo y el estudio fue aprobado por el Comité de Ética e Investigación Clínica del Hospital Clínico San Carlos de Madrid. as variables cualitativas se describieron mediante frecuencias absolutas y relativas porcentuales de sus categorías, y se buscaron asociaciones con la prueba de ji cuadrado o el test exacto de Fisher. En las variables objeto de análisis se calculó su intervalo de confianza para un error a del 5 %, a través del programa estadístico SPSS V. 18.0. RESULTADOS: Se entregaron 649 encuestas en total y se recogieron 331 al terminar el periodo de recepción (3 meses). La tasa de respuesta fue del 51 %. De las características sociodemográficas destaca que el 73,4 % (243) de los profesionales eran mujeres y el 67,2 % (222) con más de 31 años; del total, el 20,5 % (68) eran médicos y el 79,5 % (263) profesionales de enfermería. Los resultados obtenidos con relación a los conocimientos muestran que el 64,4 % de los encuestados afirma no conocer los diferentes documentos que existen para expresar últimas voluntades. Con relación a las medidas concretas que contemplan las IP, como son la limitación del esfuerzo terapéutico, los cuidados paliativos, la donación de órganos, el rechazo a la obstinación terapéutica y la asignación de un representante legal, tan solo el 9,7 % de los profesionales las conocían todas. El 82,8 % opinaba que el DVA es un instrumento útil para los profesionales en la toma de decisiones. El 50,2 % opinaba que los DVA no se respetan. El 85,3 % de los médicos respetaría el DVA de un paciente en caso de urgencia vital, frente al 66,2 % de las enfermeras (p = 0,007). Solo el 19,1 % de los médicos y el 2,3 % de las enfermeras conocían si los pacientes que llevaban a su cargo poseían un DVA (p < 0,001). CONCLUSIONES: Aunque los profesionales sanitarios muestran conocimientos escasos sobre las IP, presentan una actitud favorable hacia su utilidad. Sin embargo, la mayoría no conocen si los pacientes que están a su cargo poseen un DVA e incluso algunos profesionales, a pesar de conocerlo, en caso de urgencia vital no lo respetarían. Se hace necesaria una mayor formación sobre las IP

El valor del Instrumento Diagnóstico de la Complejidad en Cuidados Paliativos para identificar la complejidad en pacientes tributarios de cuidados paliativos / The value of the Diagnostic Tool for Complexity in Palliative Care for the assessment of palliative patients

INTRODUCCIÓN: Actualmente no existe una definición unánime en cuidados paliativos (CP) del término complejidad. Su correcta y objetiva valoración ayudaría a clasificar al paciente, permitiendo a los profesionales saber si se requieren recursos avanzados o convencionales de CP. OBJETIVOS: Describir la complejidad de los pacientes tributarios de CP en Sevilla mediante el Instrumento Diagnóstico de la Complejidad en Cuidados Paliativos examinando el servicio sanitario prestado. MATERIAL Y MÉTODOS: Estudio observacional descriptivo transversal, con reclutamiento prospectivo. La herramienta Instrumento Diagnóstico de la Complejidad en Cuidados Paliativos se aplicó a 74 pacientes tributarios de CP. Los datos se analizaron con el programa estadístico SSPS versión 20 y se analizaron las variables con el test chi-cuadrado. RESULTADOS: Tanto el equipo de recursos convencionales como el avanzado de CP tratan a pacientes independientemente de su complejidad (p = 0,482). El elemento de complejidad más prevalente fue el cambio brusco del nivel de autonomía funcional (n=27), sin que exista correlación con el equipo implicado. El elemento más prevalente para activar el equipo avanzado de CP es la naturaleza oncológica de la enfermedad (n=39; p = 0,018). CONCLUSIONES: La distribución de la complejidad en los pacientes tratados por recursos convencionales y avanzados de CP en el área estudiada es homogénea. Ello puede ser un indicador de la falta de adecuación de los recursos sanitarios con respecto a la complejidad del paciente. La implementación del Instrumento Diagnóstico de la Complejidad en Cuidados Paliativos podría solventar este problema ya que ayuda a especificar cuándo y por qué se deriva un paciente a CP, evitando el exceso o defecto de dicha derivaciones

INTRODUCTION: There is currently no unanimous definition of the term complexity in palliative care (PC). The correct and objective assessment would help to classify palliative patients to enable health care professionals in their determination whether advanced or conventional PC resources are required. AIM: To describe the palliative patients' complexity, by using the Diagnostic Tool for Complexity in Palliative Care, and to examine the health care service provided. MATERIAL AND METHODS: A descriptive, cross-sectional, observational study with prospective recruiting was conducted by applying the Diagnostic Tool for Complexity in Palliative Care to 74 patients requiring PC in Seville, Spain. Data were analyzed using the statistical program SPSS version 20 and variables were analyzed using the chi-squared test. RESULTS: Both conventional and advanced PC teams treat patients regardless their degree of complexity (p= 0.482). The most prevalent complexity element was sudden change in the level of functional autonomy (n= 27), but there was no correlation with the team involved. The most prevalent element to drive involvement of the advanced PC team was the oncological nature of the disease (n= 39, p= 0.018). CONCLUSIONS: The distribution of complexity in PC patients treated by both conventional and advanced PC teams in the study area is homogeneous. This may be an indicator of the lack of appropriate health care resources as regards the complexity of the patient. Implementing the Diagnostic Tool for Complexity in Palliative Care may solve this problem by specifying when and why a PC patient is referred, and thus avoiding the excess or absence of such referrals

Establecimiento de la situación de enfermedad terminal en enfermedades oncológicas y no oncológicas: estudio retrospectivo con historias clínicas / Indentifying terminal illness situation in cancer and non cancer diseases: A retrospective study using clinical records

OBJETIVO: Conocer cómo y en qué momento del proceso de enfermedad se identifica la situación terminal en las historias clínicas de pacientes con enfermedades avanzadas oncológicas y no oncológicas; las expresiones y argumentos registrados para definirla y la presencia de factores pronósticos. MÉTODO: Estudio observacional y retrospectivo de las historias clínicas de los pacientes que fallecieron en 4 hospitales de Granada (España) en el año 2010, por enfermedad oncológica, enfermedad pulmonar crónica/EPOC, insuficiencia cardiaca crónica, enfermedad hepática avanzada e insuficiencia renal crónica. Se revisaron los informes clínicos de ingreso, el informe de alta y la evolución médica y enfermera correspondientes a los últimos 3 meses de vida del paciente. Se registraron los datos sociodemográficos, clínicos y específicos relacionadas con el pronóstico de enfermedad terminal. RESULTADOS: Se revisaron 202 historias clínicas. En un 51,5% de los casos consta el establecimiento de la situación de enfermedad terminal. Un 33,6% han sido registrados como paciente en situación terminal entre los 7 días y las últimas 48h antes del fallecimiento. Se produce una mayor identificación de situación terminal en pacientes oncológicos (p = 0,004). Las expresiones que más se emplean en las historias son «enfermedad terminal» (32,7%) en el caso de pacientes de cáncer y «mal pronóstico» (41,3%) en pacientes no oncológicos. Los argumentos que más se emplean son cuestiones relativas a un mal pronóstico (42,2%) y al estadio de la enfermedad (39,8%), especialmente en los pacientes de cáncer. No existen diferencias entre los pacientes identificados como en situación terminal y aquellos que no, en relación con la edad, el sexo, la comorbilidad y el tiempo de evolución de la enfermedad. CONCLUSIONES: Este trabajo muestra la dificultad de los clínicos en identificar la fase terminal de forma temprana y una actitud poco favorable a registrarla en las historias clínicas. Esta conducta puede constatarse por la frecuente utilización de expresiones ambiguas y por la falta de criterios y argumentos para señalar la situación terminal

AIM: To know how and when terminal illness situation is identified in advanced cancer and non-cancer patients in medical records, and which expressions and arguments are used when this situation is established, as well as the presence of prognosis factors. METHOD: Observational, retrospective study of medical records of patients who died of oncological disease, COPD disease, chronic heart failure, advanced liver disease, and chronic renal failure in 4 hospitals in Granada (Spain). Medical records including hospitalisation reports, discharge documents, and medical and nurse evaluations of the last 3 months of life were reviewed. Sociodemographic, clinical, and specific data related to the prognosis of terminal illness were recorded. RESULTS: From the 202 medical records reviewed, 51.5% patients were identified as in terminal illness situation. One third (33.6%) of them were identified between 7 days and the last 48h before death. Doctors tend to identify more cancer-patients than non-cancer patients as in terminal illness situation (P=.004). The most used expressions in medical records are 'terminal disease' in cancer patients (32.7%) and 'poor prognosis' in non-cancer patients (41.3%). The arguments most used are related to poor prognosis (42.2%), and related to the stage of the disease (39.8%), especially in cancer PATIENTS: There are no statistical differences between patients identified as terminally ill, and patients not identified, related to age, gender, comorbidity and time of evolution. CONCLUSIONS: This paper shows how difficult it is for clinicians to identify terminal illness at an early stage, and an unfavourable attitude towards reporting it in medical records. This attitude could be confirmed by the frequent use of ambiguous expressions regarding terminally ill, the lack of criteria and arguments to identify this situation

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.

Comentario al caso: Nutrición en paciente oncológico / Commentary on the case: Nutrition in oncological patient

No disponible

O Testamento Vital e a Relação Médico-Paciente na perspectiva da Autonomia Privada e da Dignidade da Pessoa Humana / Living Will and Doctor-Patient Relationship from the perspective of Autonomy and Human Dignity

Este trabalho realizou reflexões jurídicas acerca das disposições de vontade do paciente, testamento vital, regulamentado pelo Conselho Federal de Medicina. O objetivo primordial foi demonstrar, sob uma perspectiva jurídica, que o instrumento se coaduna com o ordenamento jurídico brasileiro. Para essa reflexão, foram utilizadas literaturas em ética e bioética sobre o assunto e disposições concernentes ao tema. Buscou‐se estabelecer o testamento vital como garantia da prevalência da autonomia do paciente terminal como instrumento garantidor do direito de morrer com dignidade. Analisou‐se que embora ainda não esteja expressamente positivado no ordenamento jurídico brasileiro, a interpretação dos princípios da autonomia privada e da dignidade da pessoa humana, permitem a conclusão incontestável de que o negócio jurídico encontra guarida na ordem constitucional pátria. Observou‐se que para garantir a validade do testamento vital é essencial as disposições de vontade, permitindo que as relações médico‐pacientes transcorram dentro dos cuidados necessários à dignidade e autonomia no final da vida (AU)

This paper reflects on the legal provisions of the patient's will, living will, regulated by the Federal Council of Medicine. The objective was to demonstrate, in a legal perspective, that the instrument is consistent with the Brazilian legal system. For this reflection, ethics and bioethics literature concerning the issue were used. The aim was to establish the living will to guarantee the prevalence of terminal patient's autonomy as a guarantor instrument of the right to die with dignity. Subsequently, it was examined that although not expressly positive in Brazilian law, the interpretation of the principles of human autonomy and dignity, allows the undeniable conclusion that the legal business finds lodgment in the constitutional order. It was observed that to ensure the validity of living wills is essential the disposition of the will, allowing to doctor‐patient relationship to occurs inside the necessary parameters to apply dignity and autonomy at the end of life (AU)

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.

Dependencia funcional y deterioro cognitivo de pacientes con cáncer avanzado atendidos en domicilio / No disponible

Objetivo: evaluar la dependencia funcional y deterioro cognitivo de los pacientes con cáncer avanzado atendidos en sus domicilios dentro de un programa de cuidados paliativos desarrollado por una Unidad de Hospitalización a Domicilio perteneciente a un hospital de tercer nivel («agudos»). Material y método: se analizan 1.423 pacientes que corresponden a la totalidad de enfermos de cáncer avanzado atendidos por la unidad entre enero de 2000 y diciembre de 2005. Resultados: destaca la fuerte dependencia física y marcado deterioro cognitivo de los pacientes al ingreso en programa con media de índice de Barthel de 34 y test de Pfeiffer mayor de 4 en el 50% de los casos. La estancia media fue de 12,5 días (DS 18). El 56% (797) de los pacientes falleció en su propio domicilio, el 10,8 (153) reingresó en nuestro hospital y el 6,8 (97) se derivó a una Unidad de Cuidados Paliativos de hospital sociosanitario. Los pacientes que fallecieron en el domicilio eran mayores (71 años) que los que reingresaron en el hospital (66) (p < 0,01) y presentaron al ser incluidos en programa mayor nivel de dependencia funcional (Barthel medio: 22,3 y 49,5 respectivamente, p < 0,001) y deterioro cognitivo (Pfeiffer medio 5,8 vs. 2,5, p < 0,001). Conclusiones: la complejidad relacionada con la dependencia funcional y el deterioro cognitivo de los pacientes y, como consecuencia, con la carga de cuidados que necesitan, no determina el lugar de la muerte. La edad de los enfermos es un factor modulador de la ubicación del paciente a lo largo de la evolución de su enfermedad (AU)

Objective: To assess functional dependence and cognitive deterioration in patients with advanced cancer cared for at home as part of a palliative care programme developed by a Hospitalisation at Home Unit at a level-three (acute) hospital. Material and method: 1,423 patients were analyzed, representing all patients with advanced cancer cared for at the Unit between January 2000 and December 2005. Results: It was noted that patients had major physical dependence and marked cognitive deterioration when they entered the program, since 50% of cases presented a mean of 34 on the Barthel index and over 4 in Pfeiffer's test. Mean stay was 12.5 days (SD 18). 56% of patients (797) died at home, 10.8% (153) were readmitted to our hospital, and 6.8% (97) were referred to a palliative care unit of a socio-sanitary hospital. Patients who died at home were older (71 years) than those who were readmitted to hospital (66) (p < 0.01), and on entry to the program they displayed a higher level of functional dependence (Barthel mean: 22.3 and 49.5 respectively, p < 0.001) and cognitive deterioration (Pfeiffer mean 5.8 vs.2.5, p < 0.001). Conclusions: The complexity of patients' functional dependence and cognitive deterioration, and the resulting care burden, does not determine the place of death. Patient age is a regulatory factor with regard to where patients are cared for as their disease progresses (AU)

Cuidados paliativos en el anciano: bases para una asistencia sanitaria adecuada / Palliative care in the elderly: principles for an adequate medical care

Los Cuidados Paliativos son un método adecuadopara la asistencia sanitaria del pacienteanciano al final de su vida. Los criterios de terminalidadidentifican una población de pacientesque se beneficiarían de un manejo clínico basadoen los cuidados paliativos. La organización dela asistencia sanitaria paliativa debe incluir unaadecuada evaluación del paciente, un plan decuidados, el trabajo en equipo, la coordinaciónentre niveles asistenciales y la mejora continuadade la calidad

Palliative care provides an adequate health carefor the elderly at the end of life. Predictors ofend-stage disease identify a population of patientswho would benefit from a palliative orientedcare. The management of palliative oriented healthcare should include an adequate patient evaluation,care plan, team work, coordination of healthcare assistance levels and improving qualitymanagement

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.