How do cancer patients receiving palliative care at home die? A descriptive study

Context

Data regarding the circumstances of the process of death of terminally ill patients followed at home are lacking.

Objectives

The aim of this study was to describe the characteristics and assess the circumstances of the process of death of terminally ill patients followed at home.

Methods

This was a prospective survey to assess the dying process of advanced cancer patients followed at home. Within a week after death, the principal caregiver was interviewed. Information from the palliative home care team and the caregiver about expectation of death, time of death, professional and nonprofessional people present at time of death, emergency admission to hospital, and administration of drugs to resuscitate was gathered. The principal clinical issues in the last two hours also were recorded.

Results

In total, 181 of 222 caregivers provided information. Most deaths were expected. Palliative home care team physicians and nurses visited the patient on the day of death but were occasionally present at the moment of death. More than three people were generally present at time of death. More than two-thirds of patients died peacefully, without apparent suffering, and 35.7% of them received palliative sedation before dying. In the last two hours, the most frequent clinical issues were ranked as death rattle, dyspnea, and agitation. In 10 cases, emergency drugs for resuscitation were administered.

Conclusion

This study has shown how advanced cancer patients die at home and that palliative home care may be helpful in allowing a death at home, particularly when relatives are actively involved.     

Assessing agreement between terminally ill cancer patients' reports of their quality of life and family caregiver and palliative care physician proxy ratings

Context

Proxy ratings, if valid, may provide an alternative approach to evaluating patient quality of life (QoL) at the end of life.

Objectives

To examine agreement between terminally ill cancer patients’ self-reported QoL and proxy assessment of patient QoL by their family caregiver (FCG) and palliative care physicians (PCPs) at two time points.

Methods

Patients admitted to an acute palliative care unit and their FCGs and PCPs completed the McGill Quality of Life Questionnaire (MQOL) at Days 3 and 6 after admission. Response bias and response precision were examined at the individual and group levels. Furthermore, we examined patient factors affecting agreement and responsiveness of proxy MQOL scores to changes in patients’ QoL between Days 3 and 6.

Results

Statistically and clinically significant mean differences were detected between the patient and both proxy groups’ reports of QoL on Day 3, with the magnitude of the differences decreasing somewhat by Day 6. Proxies underestimated patients’ QoL compared with patients' self-report. Response precision based on intraclass correlation values and proportion of approximate agreement was poor to fair at both time points. Agreement was better for patients with greater physical burden and more cognitive difficulties. Proxies' responsiveness to change from Day 3 to Day 6 was low, and proxies were not able to detect minimally important changes in QoL.

Conclusion

The findings suggest that moderate agreement between patient and proxy ratings of QoL develops over time but that precision at the individual level, which is more clinically relevant, is less reliable. New strategies for improving proxy reliability are needed.     

The use of palliative care services associated with better dying circumstances. Results from an epidemiological population-based study in the brussels metropolitan region

Context

There is some consensus that a “good death” is one which occurs at home, in the presence of loved ones, and is free of distress. Involvement of palliative care services is assumed to improve these circumstances.

Objectives

This population-based study describes characteristics of the end of life of patients dying in Brussels and examines their associations with the involvement of palliative care services.

Methods

In 2007, an anonymous large-scale mortality follow-back survey was conducted in Brussels by mailing questionnaires regarding end-of-life care and characteristics to the attending physicians of a representative sample of 1961 deaths.

Results

Response rate was 41% (n = 701). Of all deaths, 59% were nonsudden. Of these, 12% took place at home. For 27%, the attending physician was informed about the patient’s preferred place of death. When the preference to die at home was known, 66% died at home. At the moment of death, in 47% of nonsudden deaths, loved ones were present. In a quarter of deaths, palliative care services were involved. Involvement with palliative care services was more likely for cancer patients than noncancer patients and was associated with the attending physicians more often being informed about the preferred place of death, with patients more often dying at home, with loved ones more often being present, and with a better feeling of well-being on the last day.

Conclusion

Overall, circumstances at the very end of life are suboptimal in Brussels. This study provides a case for stronger involvement of palliative care as a focal point for policies to improve end-of-life circumstances in a metropolitan area such as Brussels.     

Nurses' attitudes towards sexual relationships between patients in high security psychiatric hospitals in England: an exploratory qualitative study

Background

The issue of relationships between patients in long-term care settings can present nurses with numerous challenges. However, addressing this element of patient care is recognised as an important element of nursing in this sphere of practice. What nurses think about patient sexual relationships and the difficulties of incorporating these into care is closely linked to the care they provide. However, the issue of patients sexual relationships within high security psychiatric hospitals is a relatively poorly researched area of clinical practice.

Aim

To explore the attitudes towards patients’ sexual relationships held by nurses working in high security psychiatric hospitals in England.

Methods and participants

A qualitative methodology was employed with data collected from 10 in-depth interviews with nurses working within secure psychiatric hospitals in England. Interview data were subjected to thematic analysis.

Results

Practitioners reject permissive policy in relation to patients’ sexual relationships on account of perceived perpetuation of abuse and exploitation. Practices and attitudes are dominated by personal (lay) values that seek to restrict patient experience and undermine professional mores whilst also seeming to uphold a professional duty of care.

Conclusion

Lay understandings are constructed as moral rights and priorities that are of higher order concern than professional values or the rights of the individual. This constitutes a clash of values and the minimisation of professional mores within the clinical context raises questions about the role of professional teaching, knowledge and policy in relation to professional socialisation.     

Japanese people's preference for place of end-of-life care and death: a population-based nationwide survey

Context

Japanese people's preferred place of end-of-life care may be affected by their experiences, perceptions, and knowledge related to the end of life.

Objectives

The aims of this study were to clarify the Japanese population's preferences for the place of end-of-life care and death and to identify the determinants of each choice of preferred place of end-of-life care within their experiences, perceptions, and knowledge.

Methods

A total of 2000 Japanese people aged 40–79 years participated in a cross-sectional nationwide survey.

Results

Fifty-five percent (n = 1042) responded. Regarding place of end-of-life care, approximately 44% of the general population preferred home, 15% preferred hospital, 19% preferred palliative care unit, 10% preferred public nursing home, 2% preferred private nursing home, and the remaining 11% was unsure. Multinomial logistic regression analysis revealed that the following factors affect people’s preferences regarding place of care: 1) experiences, such as “visiting hospital regularly” and “experiencing home death of relatives,” 2) perceptions, such as “giving due thought to their own death on a daily basis” and “perceiving lower home palliative care costs to be appropriate after comparing hospital admission fees,” and 3) knowledge of “home care nursing” and “24-hour home palliative system by physicians and nurses using insurance.” These factors correlated with preference for hospital, palliative care unit, or public nursing home, when compared with the preference of home.

Conclusion

The present findings may help to develop an effective end-of-life care system in Japan, in line with people’s various preferred locations for such care.     

Preferences for location of death of seriously ill hospitalized patients: perspectives from Canadian patients and their family caregivers

Previous studies involving palliative patients suggest a preference for dying at home. The purpose of this paper is to examine, prospectively, patient and family caregiver preferences for, and congruence with, location of death for hospitalized patients with cancer and end-stage medical conditions. Questionnaires were administered to 440 eligible in-patients and 160 family caregivers in five hospitals across Canada. This paper reports results of 138 patient/family caregiver dyads who answered a question about preference for location of death. The results suggest that only half of all patients and family caregivers report a preference for a home death. Furthermore, half of the patient/family caregiver dyads disagree on preferred location of death. If one of the primary goals of end of life care is to enhance the quality of life of dying patients and their family caregivers, policies directed towards ensuring that patients die in their location of choice ought to be a priority and resources should be allocated to promote the development of excellent care, not only in the home, but also within our institutional settings.     

Impact of availability of an inpatient hospice unit on the parent hospital's quality of palliative care for Taiwanese cancer decedents, 2001-2006

Context

Hospice care has increasingly been shown to affect quality of palliative care at both the individual and institutional levels. However, an institutional effect has only been addressed in single comprehensive cancer centers/selected community hospitals.

Objectives

To investigate the impact of an inpatient hospice unit on the parent hospital’s quality of palliative care.

Methods

This was a retrospective cohort study using administrative data from the entire population of 204,850 Taiwanese pediatric and adult cancer patients who died in 2001–2006. Outcome variables were adjusted by multivariate logistic regression for five groups of confounding variables: 1) patient demographics and disease characteristics, 2) primary hospital characteristics, 3) primary physician specialty, 4) health care resources at the hospital and regional levels, and 5) historical trend.

Results

Taiwanese cancer patients who received primary care in a hospital with an inpatient hospice unit (whether or not they received hospice care) were significantly less likely to be intubated (adjusted odds ratio [AOR]: 0.71; 95% confidence interval [CI]: 0.58, 0.86) and use mechanical ventilation support (AOR: 0.70; 95% CI: 0.56, 0.87) in their last month of life. They also were more likely to use hospice care before death (AOR: 3.51; 95% CI: 1.57, 7.86). Furthermore, if they used hospice care, they tended to be referred earlier than cancer patients being cared for in a hospital without an inpatient hospice unit.

Conclusion

Integrating both acute care and palliative care approaches to caring for terminally ill cancer patients in the same hospital may influence the quality of palliative care throughout the hospital as evidenced by our findings that these patients have lower likelihood of being intubated with mechanical ventilation support in the last month of life, greater propensity to receive hospice care in the last year of life, and a trend toward earlier referral to hospice care. The generalizability of these results may be limited to patients who died of a noncancer cause and by the two groups not being exactly matched for patients’ characteristics.     

A shared care model pilot for palliative home care in a rural area: impact on symptoms, distress, and place of death

Context

Shared care models integrating family physician services with interdisciplinary palliative care specialist teams are critical to improve access to quality palliative home care and address multiple domains of end-of-life issues and needs.

Objectives

To examine the impact of a shared care pilot program on the primary outcomes of symptom severity and emotional distress (patient and family separately) over time and, secondarily, the concordance between patient preferences and place of death.

Methods

An inception cohort of patients (n = 95) with advanced, progressive disease, expected to die within six months, were recruited from three rural family physician group practices (21 physicians) and followed prospectively until death or pilot end. Serial measurement of symptoms, emotional distress (patient and family), and preferences for place of death was performed, with analysis of changes in distress outcomes assessed using t-tests and general linear models.

Results

Symptoms trended toward improvement, with a significant reduction in anxiety from baseline to 14 days noted. Symptom and emotional distress were maintained below high severity (7-10), and a high rate of home death compared with population norms was observed.

Conclusion

Future controlled studies are needed to examine outcomes for shared care models with comparison groups. Shared care models build on family physician capacity and as such are promising in the development of palliative home care programs to improve access to quality palliative home care and foster health system integration.     

Negotiated dying: a grounded theory of how nurses shape withdrawal of treatment in hospital critical care units

Background

The process of withdrawal of treatment in critical care environments has created ethical and moral dilemmas in relation to end of life care in the UK and elsewhere. Common within this discourse is the differing demands made on health professionals as they strive to provide care for the dying patient and family members. Despite reports that withdrawal of treatment is a source of tension between those nurses and doctors involved in the process, the role of the nurse in facilitating withdrawal of treatment has received relatively little attention.

Objectives

To illustrate how differing dying trajectories impact on decision-making underpinning withdrawal of treatment processes, and what nurses do to shape withdrawal of treatment.

Design

Qualitative methods of enquiry using clinical vignettes and applying Charmaz's grounded theory method.

Methods and settings

Single audio-recorded qualitative interviews with thirteen critical care nurses from four intensive care specialities: cardiac; general; neurological and renal were carried out. Interviews were facilitated by an end-of-life vignette developed with clinical collaborators.

Findings

Across critical care areas four key dying trajectories were identified. These trajectories were shaped by contested boundaries associated with delayed or stalled decision-making around how withdrawal of treatment should proceed. Nurses provided end of life care (including collaborative and action-oriented skills) to shape the dying trajectory of patients so as to satisfy the wishes of the patient and family, and their own professional aims.

Conclusions

Differing views as to when withdrawal of treatment should commence and how it should be operationalised appeared to be underpinned by the requirements of the role that health professionals fulfil, with doctors focusing on making withdrawal of treatment decisions, and nurse's being tasked with operationalising the processes that constitute it. Multidisciplinary teams need a ‘shared’ understanding of each other's roles, responsibilities, aims, and motivations when planning and implementing the dying trajectory of withdrawal of treatment.     

Dying at home: Experience of the Verdun local community service centre

ObjectiveTo demonstrate that it is possible for a team of palliative care nurses in an urban centre to care for more than 50% of their terminally ill patients at home until they die, and that medical care delivered in the home is a determining factor in death at home versus death in a hospital.DesignAnalysis of place of death of terminally ill patients who died in 2012 and 2013 (N = 212) and who had been cared for by palliative care nurses, by type of medical care.SettingThe centre local de services communautaires (CLSC) in Verdun, Que, an urban neighbourhood in southwest Montreal.ParticipantsA total of 212 terminally ill patients.ResultsOf the 212 patients cared for at home by palliative care nurses, 56.6% died at home; 62.6% received medical home care from CLSC physicians, compared with 5.0% who did not receive medical home care from any physician.ConclusionCombined with a straightforward restructuring of the nursing care delivered by CLSCs, development of medical services delivered in the home would enable the more than 50% of terminally ill patients in Quebec who are cared for by CLSCs to die at home—something that most of them wish for.Many articles have been published about the factors that influence the possibility of dying at home for terminally ill patients. When brought together, these factors create a “complete” team of palliative home care professionals, with nursing and medical expertise in palliative home care, 24-hour access to nursing and medical care, access to social workers and occupational therapists able to work with palliative care patients in the home, and home supports, as needed.^1,2 The centre local de services communautaires (CLSC) in Verdun, Que, created such a team.Quebec has a vast network of CLSCs that offer general nursing care; the services of social workers, occupational therapists, and physiotherapists; and various forms of practical support in the home. Very few CLSCs offer dedicated palliative nursing care and even fewer offer medical care in the home to terminally ill patients, in spite of the fact that most of these patients want to remain at home and that access to a palliative home care team reduces hospitalizations and in-hospital deaths of terminally ill patients while providing comparable quality of care.³     

The perceptions and experiences of nurses and bereaved families towards bereavement care in an oncology unit

Background

Existing bereavement literature focuses on the care provided in palliative care units or community settings. However, nurses in oncology units are in a unique position to provide bereavement care, which is care extended to the families after the death of cancer patients. This study aimed to explore the perceptions and experiences of bereavement care among nurses and bereaved family members in an oncology unit in Hong Kong.

Method

Semi-structured qualitative interviews were carried out in one oncology unit in Hong Kong with 15 nurses and ten bereaved family members. All interviews were audiotaped, transcribed verbatim and analysed by using qualitative content analysis.

Results

Among the bereaved family members, three themes emerged: being informed, being supported and being with the patient before and after the patient’s death. Among the oncology nurses, however, the three identified themes were: elements of good bereavement care, emotional response in providing bereavement care and educational needs in the provision of bereavement care. Comparatively, the experiences of and the opinions on bereavement care identified by the bereaved were more specific than those identified by the nurses.

Conclusion

The findings revealed that there is room for improvement in current bereavement care. Family members were committed to patient care and they expressed their need for more involvement in the patient care, which could result in a positive impact on their grief and loss experience. Nurses were committed to quality care, and they expressed their need for more training on knowledge, skills and attitudes to improve their readiness and competencies in the provision of bereavement care.     

Associations between successful palliative trajectories,place of death and GP involvement

Objective

General practitioner (GP) involvement may be instrumental in obtaining successful palliative cancer trajectories. The aim of the study was to examine associations between bereaved relatives’ evaluation of palliative cancer trajectories, place of death, and GP involvement.

Design

Population-based, cross-sectional combined register and questionnaire study.

Setting

The former Aarhus County, Denmark.

Subjects

Questionnaire data on GPs’ palliative efforts and relatives’ evaluations of the palliative trajectories were obtained for 153 cases of deceased cancer patients.

Main outcome measures

A successful palliative trajectory as evaluated retrospectively by the relatives.

Results

Successful palliative trajectories were statistically significantly associated with home death (PR 1.48 (95% CI 1.04; 2.12)). No significant associations were identified between the evaluations of the palliative trajectory at home and GP involvement. “Relative living with patient” (PR 1.75 (95% CI: 0.87; 3.53)) and “GP having contact with relatives” (PR 1.69 (95% CI 0.55; 5.19)) were not significantly associated, but this may be due to the poor number of cases included in the final analysis.

Conclusion

This study indicates that home death is positively associated with a higher likelihood that bereaved relatives will evaluate the palliative trajectory at home as successful. No specific GP services that were statistically significantly associated with higher satisfaction among relatives could be identified, but contact between GPs and relatives seems important and the impact needs further investigation.Key Words: Denmark, family practice, neoplasm, palliative care, primary health care, terminally illGP home visits are associated with death at home in palliative trajectories. However, home death does not necessarily mean a successful palliative trajectory.

• Home death is positively associated with a higher likelihood that the bereaved relative will evaluate the palliative trajectory as successful.
• Interpersonal relationships, which are difficult to quantify, may be of greater importance than structural services in terms of perceived quality.

Most terminally ill cancer patients and relatives wish for patients to die at home [1–3]. However, home death is not necessarily a proxy for a successful palliative trajectory, and many patients spend most of their palliative period at home even though they die in institutions [4]. Furthermore, the numerous professionals involved, e.g. general practitioners (GPs) and community nurses (CNs), and their services may influence patients’ and relatives’ views [5].The fact that a large proportion of cancer patients die in hospital has been linked to the presumed poor services of primary health care professionals [3]. However, satisfaction with GPs is high in spite of dissatisfaction with symptom control [6]. Also, interview studies suggest that 24-hour back-up and GP involvement are important elements in bereaved relatives’ evaluation of palliative trajectories [7–9]. Studies have also shown that GP home visits are positively associated with home death [4–10]. However, it remains unclear what constitutes particularly important GP contributions in achieving successful palliative trajectories. This knowledge could be important for guiding GPs to provide the best possible palliative care.The aim of the study was to examine associations between bereaved relatives’ evaluation of palliative trajectories, place of death, and GP involvement.     

Exploring the perceived changes and the reasons why expected outcomes were not obtained in individual levels in a successful regional palliative care intervention trial: an analysis for interpretations

Context

The Japan Outreach Palliative Care Trial of Integrated Model (OPTIM) study, a mixed-methods study to evaluate the effects of a comprehensive regional palliative care program, revealed that the program provided broad positive outcomes at the regional level: increased home death, palliative care use, patient- and family-reported qualities of care, and health care professionals’ difficulties. Not all participants however obtained positive outcomes and thus exploring the reasons why expected outcomes were observed in individual levels could be of value.

Aims

The primary aims were to explore why expected outcomes were not obtained in individual participants, and the perceived changes in daily practices of physicians and nurses were explored.

Subjects and methods

Postintervention questionnaire survey on 857 patients, 1,137 bereaved family members, 706 physicians, and 2,236 nurses were analyzed.

Results

The reasons for not achieving home deaths included unexpected rapid deterioration, caregivers unavailable, concerns about adequate responses to sudden changes, and physical symptoms uncontrolled, while lack of physician availability at home and lack of information from physicians were less frequently reported. The reasons for not receiving specialized palliative care services were the lack of recommendations from physicians and no information about palliative care services. The reason for evaluating the quality of palliative care as not high was that clinicians tried to relieve symptoms, but there were limited effects and insufficient time. Many physicians and nurses reported that they became more aware of palliative care, that the availability of palliative care specialists and knowledge about palliative care improved, and that they cooperated with other regional health care providers more easily.

Conclusion

The OPTIM study seemed to succeed in optimizing physician availability at home, improves physician information about home care, achieved maximum efforts to relieve patient distress by clinicians, and increased communication among regional health care professionals. To achieve further better outcomes, multiple interventions to the health care system to be performed on the basis of a comprehensive regional palliative care program are proposed.     

Quality of dying and death with cancer in Israel

Background

The quality of dying and death refers to the evaluation of the final days of life and the moment of death with respect to how it is prepared for, faced and experienced by those with a terminal illness. It includes experience in multiple domains: physical, psychological, social, spiritual or existential, the nature of health care, life closure and death preparation, and the circumstances of death.

Aim

To explore the quality of dying and death in cancer patients in Israel and its relationship to place of death and socio-demographic characteristics of the primary caregivers and the deceased.

Design

Retrospective assessment of the quality of dying and death, based on caregiver responses to the Quality of Dying and Death (QODD) questionnaire (overall score ranges from 0 to 100; higher scores reflect better dying and death experiences) 8 to 10 months after the death.

Participants

Ninety-five caregivers of Jewish cancer patients, most of whom were female spouses or children of the deceased.

Results

Mean QODD score was 57.2 (standard deviation [SD]?=?15), which is in the low-moderate range. Place of death, gender and age of the caregiver, and age of the deceased, were associated with QODD score.

Conclusions

This retrospective study in Israel demonstrated that the overall quality of dying and death was regarded as poor by almost half of the caregivers. These findings may reflect the relative lack of specialized palliative care and advance care planning in Israel at the time of this study, which took place between 2006 and 2009. Further research and enhancement of palliative care resources may be needed in Israel and several encouraging recent developments (e.g. staff training and legislation) suggest that such changes are now underway.     

A new set of quality indicators for palliative care: process and results of the development trajectory

Context

In some countries (the United States in particular), quality indicators for palliative care have already been developed. However, these quality indicators often cover one specific setting or target group, for example, palliative cancer care or palliative home care.

Objectives

This article describes the development and initial testing of a set of quality indicators for palliative care, applicable for all settings in which palliative care is being provided for adult patients in The Netherlands.

Methods and Results

In the first phase of the project, an inventory was made of existing relevant quality indicators. Most quality indicators focused on the process or outcome of palliative care, and quality indicators for the structure of palliative care were rare. Most of the existing quality indicators fall within the domain of physical care, and very few concern the social and spirituals domains of palliative care. In the second phase, a new draft set of quality indicators was developed. In addition to the previous inventory of existing indicators, interviews with patients, relatives, and caregivers provided input for the development of the draft set. Drafts of the set were tested among experts. In the third phase, the feasibility and usability of a draft set was established in 14 Dutch care organizations providing palliative care.

Conclusion

As a result of these phases, a set of quality indicators for palliative care has been developed, consisting of 33 indicators for palliative patient care and 10 indicators for support for relatives before and/or after the patient’s death.     

Spirituality in palliative home care: a framework for the clinician

Purpose

Spiritual care at the end of life remains poorly understood despite its promotion by the World Health Organisation. The purpose of this paper was to develop a consensus-based framework of the main elements of spiritual care in palliative home care.

Methods

Expert meeting using the nominal group technique, followed by a two-stage web-based Delphi process, was used. Experts from three stakeholder groups (physicians, professional spiritual care givers and researchers) representing two countries (Belgium and the Netherlands) participated in this study.

Results

Fourteen elements of spiritual care were retained: (1) being sensitive to patient’s fear of the dying process; (2) listening to the patient’s expectations and wishes about the end of life; (3) giving attention to patient’s wishes about the design of the farewell; (4) offering rituals if the patient experiences them as meaningful; (5) listening to the stories, dreams and passions of the patient; (6) helping the patient find strength in inner resources; (7) connecting with the patient in truth, openness and honesty; (8) supporting communication and quality of relationships; (9) making sure the patient feels comfortable and safe; (10) seeing spirituality as an interwoven, though specific dimension; (11) caring for your own spirituality; (12) knowing and accepting your vulnerability; (13) being able to learn from your patient; and (14) having an interdisciplinary team that is there when needed.

Conclusions

The experts agreed to the 14 main elements of spiritual care in palliative home care. There were no differences in this regard between the stakeholder groups. This study provides a first step towards the development of an interdisciplinary spiritual care model in palliative home care.     

Integrating Physician Services in the Home: evaluation of an innovative program

OBJECTIVE

To evaluate a new program, Integrating Physician Services in the Home (IPSITH), to integrate family practice and home care for acutely ill patients.

DESIGN

Causal model, mixed-method, multi-measures design including comparison of IPSITH and non-IPSITH patients. Data were collected through chart reviews and through surveys of IPSITH and non-IPSITH patients, caregivers, family physicians, and community nurses.

SETTING

London, Ont, and surrounding communities, where home care is coordinated through the Community Care Access Centre.

PARTICIPANTS

A total of 82 patients receiving the new IPSITH program of care (including 29 family physicians and 1 nurse practitioner), 82 non-randomized matched patients receiving usual care (and their physicians), community nurses, and caregivers.

MAIN OUTCOME MEASURES

Emergency department (ED) visits and satisfaction with care. Analysis included a process evaluation of the IPSITH program and an outcomes evaluation comparing IPSITH and non-IPSITH patients.

RESULTS

Patients and family physicians were very satisfied with the addition of a nurse practitioner to the IPSITH team. Controlling for symptom severity, a significantly smaller proportion of IPSITH patients had ED visits (3.7% versus 20.7%; P = .002), and IPSITH patients and their caregivers, family physicians, and community nurses had significantly higher levels of satisfaction (P < .05). There was no difference in caregiver burden between groups.

CONCLUSION

Family physicians can be integrated into acute home care when appropriately supported by a team including a nurse practitioner. This integrated team was associated with better patient and system outcomes. The gains for the health system are reduced strain on hospital EDs and more satisfied patients.     

Factors influencing preferences for place of terminal care and of death among cancer patients and their families in Korea

Goals of work This study examined cancer patient and family member preferences—and the reasons for the preferences—regarding place of terminal care and of death.Patients and methods We constructed a questionnaire that included demographic, clinical, and support network data for 371 patients who were treated at any of the seven university hospitals or the National Cancer Center in Korea and 281 of their family members.Main results About half of the interviewed patients and half of the family members expressed a preference for the patient being cared for and dying at home. The preference reflected a wish for patients to live out their lives in privacy and to be with their family when their life ended. Those who expressed a preference to be cared for or to die in a hospital wanted to get medical treatment during the last days of life and to relieve their families of the burden of caring for them. Of the variables examined, support network factors and some sociodemographic factors (sex, family members age, and place of residence) were strongly predictive of preferences.Conclusion A majority of cancer patients preferred to receive terminal care at home. Cancer patients and family members with strong support groups were more likely to prefer the home as the place of terminal care and dying. Hence, improving support networks might increase the proportion of patients receiving home care and dying at home.