End of life strategy probably improved choice of where to die for people with severe respiratory disease

Most people prefer not to die in hospital, but the majority of patients with long-term diseases other than cancer end up dying there | NIHR Signal

In England, an NIHR study based on routine collected national data showed that roll-out of the End of Life Care strategy in 2004 was linked to a reduction in deaths in hospital. The number of deaths here fell by 6% for people with chronic obstructive pulmonary disease (COPD), and 3% for people with interstitial lung diseases. However, hospital deaths did not fall for respiratory patients with other conditions, like heart failure.

The strategy aimed to allow people to die where they chose. It prioritised home care over hospital care, and addressing the needs and preferences of patients and carers.

The fall in the number of hospital deaths is probably the result of the strategy. The results are similar to those observed in cancer care, and the reduction in hospital deaths clearly emerged after the strategy was introduced, and increased after an intensified roll-out in 2008.

To improve impact, early and integrated palliative care approaches are needed, targeting those at highest risk. Particular focus should be on patients with comorbidities and people living in more deprived areas, where place of death has remained unchanged.

Advance care planning uptake among patients with severe lung disease

Sinclair, C. et. al. (2017) BMJ Open. 7:e013415

Objective: Advance care planning (ACP) clarifies goals for future care if a patient becomes unable to communicate their own preferences. However, ACP uptake is low, with discussions often occurring late. This study assessed whether a systematic nurse-led ACP intervention increases ACP in patients with advanced respiratory disease.

Conclusions: Nurse-led facilitated ACP is acceptable to patients with advanced respiratory disease and effective in increasing ACP discussions and completion of formal documents. Awareness of symptom burden, readiness to engage in ACP and relevant psychosocial factors may facilitate effective tailoring of ACP interventions and achieve greater uptake.

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Community-Based Palliative Care & Reduced Emergency Department Visits

Spilsbury, K. Annals of Emergency Medicine. Published online: 3 February 2017

Historically, palliative care evolved to meet the end-of-life needs of cancer patients. It has since become apparent that it benefits noncancer terminal conditions such as renal failure, heart failure, chronic obstructive pulmonary disease, and liver failure, although access to and quality of palliative care for these conditions could be improved. In Australia, there has been evidence of this improved access to palliative care in noncancer conditions during the last 10 years.

The objective of this study was to describe patterns of use of EDs by people in their last year of life and how this varied when they received community-based palliative care. We also investigated whether any patient health, social, and demographic factors modified the rates of ED visits while patients were receiving community-based palliative care.

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What determines duration of palliative care before death for patients with advanced disease?

Bennet, M.L. et al. (2016) BMJ Open. 6:e012576

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Objective For patients with advanced cancer, several randomised controlled trials have shown that access to palliative care at least 6 months before death can improve symptoms, reduce unplanned hospital admissions, minimise aggressive cancer treatments and enable patients to make choices about their end-of-life care, including exercising the choice to die at home. This study determines in a UK population the duration of palliative care before death and explores influencing factors.

Conclusions The current timing of referral to palliative care may limit the benefits to patients in terms of improvements in end-of-life care, particularly for older patients and patients with conditions other than cancer.

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Palliative care for Parkinson’s disease: Patient and carer’s perspectives explored through qualitative interview

Fox, S. et al. Palliative Medicine. Published online: September 28 2016

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Background: Palliative care is recommended for non-malignant illnesses, including Parkinson’s disease. However, past research with healthcare workers highlights unmet palliative needs in this population and referral rates to Specialist Palliative Care are low. Some healthcare workers perceive a ‘fear’ in their patients about introducing palliative care. However, less is known about the views of people with Parkinson’s disease and their carers about palliative care.

Aim: (1) To explore the palliative care and related issues most affecting people with Parkinson’s disease and their families and (2) to examine perceptions about/understanding of palliative care.

Design: This was a qualitative study; semi-structured interviews were conducted, transcribed and analysed using thematic analysis.

Setting/participants: A total of 31 people participated, both people with Parkinson’s disease (n = 19) and carers (n = 12), across three Movement Disorder Clinics in the Republic of Ireland.

Results: People with Parkinson’s disease and their carers were unfamiliar with the term palliative care. When informed of the role of palliative care, most felt that they would benefit from this input. People with Parkinson’s disease and carers experienced a high illness burden and wanted extra support. Crises requiring Specialist Palliative Care involvement may occur at diagnosis and later, with advancing illness. Participants wanted more information about palliative care and especially further supports to address their psychosocial needs.

Conclusion: A holistic palliative care approach could address the complex physical and psychosocial symptoms experienced by people with Parkinson’s disease and their carers, and people with Parkinson’s disease and their carers are open to palliative care. Further research needs to explore how palliative care can be introduced into the routine care for people with Parkinson’s disease.

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Quality of End-of-Life Care Provided to Patients With Different Serious Illnesses

Wachterman, M.W. et al. JAMA Internal Medicine. Published online: 26 June 2016

Importance: Efforts to improve end-of-life care have focused primarily on patients with cancer. High-quality end-of-life care is also critical for patients with other illnesses.

Objective: To compare patterns of end-of-life care and family-rated quality of care for patients dying with different serious illnesses.

Design, Setting, and Participants: A retrospective cross-sectional study was conducted in all 146 inpatient facilities within the Veteran Affairs health system among patients who died in inpatient facilities between October 1, 2009, and September 30, 2012, with clinical diagnoses categorized as end-stage renal disease (ESRD), cancer, cardiopulmonary failure (congestive heart failure or chronic obstructive pulmonary disease), dementia, frailty, or other conditions. Data analysis was conducted from April 1, 2014, to February 10, 2016.

Main Outcomes and Measures: Palliative care consultations, do-not-resuscitate orders, death in inpatient hospices, death in the intensive care unit, and family-reported quality of end-of-life care.

Results: Among 57 753 decedents, approximately half of the patients with ESRD, cardiopulmonary failure, or frailty received palliative care consultations (adjusted proportions, 50.4%, 46.7%, and 43.7%, respectively) vs 73.5% of patients with cancer and 61.4% of patients with dementia (P < .001). Approximately one-third of patients with ESRD, cardiopulmonary failure, or frailty (adjusted proportions, 32.3%, 34.1%, and 35.2%, respectively) died in the intensive care unit, more than double the rates among patients with cancer and those with dementia (13.4% and 8.9%, respectively) (P < .001). Rates of excellent quality of end-of-life care reported by 34 005 decedents’ families were similar for patients with cancer and those with dementia (adjusted proportions, 59.2% and 59.3%; P = .61), but lower for patients with ESRD, cardiopulmonary failure, or frailty (54.8%, 54.8%, and 53.7%, respectively; all P ≤ .02 vs patients with cancer). This quality advantage was mediated by palliative care consultation, setting of death, and a code status of do-not-resuscitate; adjustment for these variables rendered the association between diagnosis and overall end-of-life care quality nonsignificant.

Conclusions and Relevance: Family-reported quality of end-of-life care was significantly better for patients with cancer and those with dementia than for patients with ESRD, cardiopulmonary failure, or frailty, largely owing to higher rates of palliative care consultation and do-not-resuscitate orders and fewer deaths in the intensive care unit among patients with cancer and those with dementia. Increasing access to palliative care and goals of care discussions that address code status and preferred setting of death, particularly for patients with end-organ failure and frailty, may improve the overall quality of end-of-life care for Americans dying of these illnesses.

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