Death at Home Following a Targeted Advance-Care Planning Process at Home: The Kitchen Table Discussion

OBJECTIVE: To determine whether home health agency patients' preferences to die at home can be honored following a structured, professionally facilitated advance-care planning (ACP) process provided in the home. DESIGN: A case series of patients who were identified by their home health agency nurses as having a life-limiting illness and then referred for social service assessment, followed for at least 6 months, with median follow-up of 191 days. SETTING: A large, urban, home health agency owned by a not-for-profit integrated healthcare system. PARTICIPANTS: Eighty-four adult patients (median age 75, range 37-94) receiving home care services other than hospice. INTERVENTION: Formally structured social work visits at patients' homes to discuss end-of-life issues, with communication of results to home health nurses and attending physicians. Social workers performed standard psychosocial assessments, obtained patient and family preferences regarding end-of-life care, and provided education about hospice services. MEASUREMENTS: Acceptance of the ACP process, preferences for location of end-of-life care, location of care at the end of life, adequacy of timing of intervention as measured by length of life after ACP, and use of hospice services. RESULTS: Eighty-three of 84 participants (99%) were willing to complete an ACP process in the home setting. Of the 54 patients expressing a clear preference for location of end-of-life care, 46 (82%) wanted this care to be at home. Thirty-nine (46%) of the participants died within 90 days of ACP; 58 (69%) died by the end of the study. Forty-three (75%) of these deaths occurred at home or in a hospice residence. Fifty-one (61%) patients used home, residential, or nursing home-based hospice services during the study. CONCLUSION: In this series of seriously ill home health patients, most preferred to die at home and virtually all were willing to participate in a home-based ACP process. Facilitating ACP among such patients and their families was associated with end-of-life care at home. Use of hospice services was common following ACP in this population.     

Home care clients’ participation in fall prevention activities

Objective: To determine whether home care clients have accessed or been influenced by fall prevention programs. Methods: Mail survey of 4743 home care clients from several home care agencies. Results: Among the clients, 47.2% completed the survey and 46% had fallen within the last year. Faller and non‐fallers differed in attitude to falls and fall risk factors. Only 15% of fallers and 7% of non‐fallers had taken part in a fall prevention program and only 8% knew how to access information about such activities. Conclusions: Fall prevention strategies should be targeted at the home care population. Such programs should take into consideration the specific needs of this group.     

Deaths associated with acquired haemophilia in France from 2000 to 2009: multiple cause analysis for best care strategies

Deaths occurring in the context of acquired haemophilia (AH) may be related to inter-connected causes and mechanisms including bleeding, specific or older patient co-morbidities or iatrogenic complications. However, their magnitude remains unknown. This study aimed to determine the respective weight and frequency of the various causes of death in AH. Multiple-cause analysis based on death certificates data is used in this purpose. Over a 10-year period (2000-2009), 121 deaths with AH as a cause were registered in France. All the deaths were of adults (extremes: 47 and 99 years; mean age: 80.7 years). The average number of causes per death certificate was 4.7. AH was the underlying cause of death (UCD) in 69.4% of the cases, and was more frequent in the older subjects. In contrast, before age of 75 years, AH was more often a contributing cause of death. No postpartum or obvious thromboembolism-related deaths were registered. Haemorrhagic shock was the most frequent direct cause of death (DCD), followed by infectious events, cardiac dysfunction, metabolic and nutritional disorders with muscle wasting and decubitus complications, and cancers (52.9%, 26.4%, 7.5%, 5.8% and 4.1%, respectively). However, when AH was not reported as an UCD, infections become the first DCD (32.4%) followed by bleeding events (16.2%). Best prophylactic and curative strategies for infections are particularly required to improve the prognosis in AH. Moreover, as several of its DCD correspond also to steroids side effects, best tolerated immunosuppressant regimen with steroid-sparing agents adjoining are particularly awaited in AH population.     

艾滋病自检的研究进展

艾滋病自检的形式包括自助采样送检和自测两种。虽然艾滋病自检的提出已有20多年的历史,但自检本身仍存在很大争议,一方面,艾滋病自检有利于保护检测者隐私,赋予人们自我管理感染艾滋病风险的权利,使得它在人群中有一定的需求;另一方面,自检又存在缺乏准确性、专业咨询和支持等问题,使得管理部门对放开自检心存顾虑。目前世界范围内,艾滋病自检基本处于研究阶段。中国对艾滋病自检研究很少,有必要加强相关研究,正确引导自检,扬长避短,使其为扩大艾滋病检测面服务。     

Cost‐Effectiveness of a Barcelona Home Care Program for Individuals with Multimorbidity

To improve the efficiency and effectiveness of care and optimize healthcare resources, a home healthcare program was created for individuals with multiple chronic conditions. Demographic and clinical characteristics of the 261 individuals (mean age 84) included in the program from its inception in 2011 through 2013 (mean stay in the program 203 ± 192 days) were prospectively analyzed. The number of hospital admissions, length of stay, and costs for individuals admitted to the program were compared for two time periods: the 6 months before admission to the program and their stay in the program. After admission to the program, the number of hospital admissions and the hospital length of stay per person per month decreased from 0.36 ± 0.21 to 0.19 ± 0.52 (P < .001) and from 3.5 to 1 day (P < .001), respectively. Surveys of randomly selected patients and caregivers showed high satisfaction with the program. Costs per person per day decreased from €54.65 (US$73.12) to €17.91 (US$23.96), a reduction of 67.1%. Fewer admissions and shorter hospital stays enabled the hospital to eliminate five acute beds for every 50 individuals admitted to the program. In conclusion, home care for individuals with chronic illness with multimorbidity reduced the number of hospital admissions and length of stay, resulting in good patient satisfaction and lower costs.     

Factors influencing death at home in terminally ill cancer patients

Aim: The purpose of this study is to investigate factors affecting terminally ill cancer patients dying at home. Material: Ninety‐two terminally ill cancer patients who were receiving home medical care services and died between April 2005 and December 2006 were included in the study. The data included patients' and caregivers' demographic characteristics, disease‐related information, place of death, and status of home care support. To identify the factors predicting the place of death, multivariate logistic regression analyses were performed. Results: Patients of families who had no preference regarding the place of death or a preference for death at home were more likely to die at home (vs preference for hospital death, odds ratio = 5.87, 95% confidence interval = 1.02–36.53; odds ratio = 90.35, 95% confidence interval = 8.15–1001.51, respectively) after adjusting for potential confounders. Meanwhile, if the patient's family preferred that the patient not die at home, the patient's place of death was not at his/her home irrespective of his/her preference. Conclusion: The results suggested the stronger involvement of families' preferences regarding the patients' place of death over patients' own preferences. Therefore, factors affecting families' preferences need to be clarified for the dissemination of death at home for terminally ill cancer patients.