Evaluation of a pilot of nurse practitioner led, GP supported rural palliative care provision.

BACKGROUND: Providing end of life care in rural areas is challenging. We evaluated in a pilot whether nurse practitioner (NP)-led care, including clinical care plans negotiated with involved health professionals including the general practitioner(GP), ± patient and/or carer, through a single multidisciplinary case conference (SMCC), could influence patient and health system outcomes. METHODS: Setting - Australian rural district 50 kilometers from the nearest specialist palliative care service. PARTICIPANTS: Adults nearing the end of life from any cause, life expectancy several months. Intervention- NP led assessment, then SMCC as soon as possible after referral. A clinical care plan recorded management plans for current and anticipated problems and who was responsible for each action. Eligible patients had baseline, 1 and 3 month patient-reported assessment of function, quality of life, depression and carer stress, and a clinical record audit. Interviews with key service providers assessed the utility and feasibility of the service. RESULTS: Sixty-two patients were referred to the service, forty from the specialist service. Many patients required immediate treatment, prior to both the planned baseline assessment and the planned SMCC (therefore ineligible for enrollment). Only six patients were assessed per protocol, so we amended the protocol. There were 23 case conferences. Reasons for not conducting the case conference included the patient approaching death, or assessed as not having immediate problems. Pain (25 %) and depression (23 %) were the most common symptoms discussed in the case conferences. Ten new advance care plans were initiated, with most patients already having one. The NP or RN made 101 follow-up visits, 169 phone calls, and made 17 referrals to other health professionals. The NP prescribed 24 new medications and altered the dose in nine. There were 14 hospitalisations in the time frame of the project. Participants were satisfied with the service, but the service cost exceeded income from national health insurance alone. CONCLUSIONS: NP-coordinated, GP supported care resulted in prompt initiation of treatment, good follow up, and a care plan where all professionals had named responsibilities. NP coordinated palliative care appears to enable more integrated care and may be effective in reducing hospitalisations.

Tendências nos locais de óbito no Brasil e análise dos fatores associados em idosos de 2002 a 2013 / Trends in place of death in Brazil and analysis of associated factors in elderly populations from 2002 to 2013

Introdução: A distribuição dos locais de óbito (LDO) é influenciada por aspectos socioculturais, condições econômicas e políticas públicas. É a principal preocupação no suporte oferecido no fim da vida e para o gerenciamento do sistema de saúde, mas há dados limitados sobre os LDO em países de média renda, como o Brasil. Método: Foram utilizados dados populacionais do Sistema de Informação sobre Mortalidade para identificar as taxas de mortalidade nacional e regional, de 2002 a 2013. As distribuições dos LDO foram comparadas entre grupos etários (<60 e ≥60 anos), e para sexo e estado civil no grupo de idosos. Foram analisadas as diferenças entre as regiões nacionais. Resultados: No Brasil, os LDO ocorreram principalmente nos hospitais, com média de 66,7%, seguidos pelo domicílio, com 21,4%. Outras instituições de saúde representam menos de 3% de todos os óbitos. O número de mortes nas idades avançadas aumentou. Houve diferenças da distribuição dos LDO entre as regiões. No Norte e no Nordeste, por exemplo, verificaram-se taxas mais altas de mortes em domicílio. Para a população idosa, houve pouca diferença entre os sexos na distribuição dos LDO, e ser casado aumentou a chance de óbito em ambiente hospitalar. Conclusão: Os óbitos no Brasil se limitam aos hospitais e domicílios. As taxas em hospitais aumentaram durante os últimos anos, enquanto houve redução de óbitos em domicílio, apesar do aumento do número de óbitos em idades avançadas e por doenças não transmissíveis. A distribuição dos LDO pode ser influenciada por fatores sociais e demográficos, mas políticas de saúde específicas para o suporte oferecido no fim da vida são limitadas no Brasil.

Background: Place of death (POD) distribution is influenced by sociocultural aspects, economic conditions and public policies. It is a central concern in end-of-life support and for healthcare system management, but there is limited information about POD in middleincome countries such as Brazil. Methods : Population data collected from the Brazilian Information about Mortality System were used to identify national and regional mortality rates, from 2002 to 2013. POD distribution was compared between age groups (<60 or ≥60 years old), and for gender and marital status in elderly population. Differences across national regions were analyzed. Results : In Brazil, POD is mostly allocated in hospitals with mean of 66.7%, followed by 21.4% at home. Other health care facilities account for less than 3% of all deaths. The number of deaths in older ages has increased. There were differences in POD distribution among regions. The North and the Northeast, for example, reported higher rates of home deaths compared with other regions. For the elderly population, there was a little difference between gender in POD distribution, and being married increased the odds of dying in hospital settings. Conclusion: Deaths in Brazil is limited to hospital and at home occurrences. In-hospital rates are increasing over the last years, while deaths at home have decreased despite the increase in number of deaths in older ages and due non-communicable diseases. POD distribution may be influenced by social and demographic factors, but specific health policies to support end-of-life care is limited in Brazil.