Background: After-hours support from hospice providers is instrumental to patients with serious illness who choose to remain at home, particularly at end of life. Utilisation of out-of-hours support has been much characterised in terms of frequency and nature of calls, but more needs to be known to inform service customisation and resource allocation to optimise care. To this end, we stratify reasons for using the after-hours helpline according to time sensitivity, and to explore disease and person factors associated with urgent calls.Method: Electronic medical records for incoming calls from external parties outside workhours within a large home hospice in Singapore were analysed inductively, to identify patterns and associations along study objectives. Individual code books for caller type and call reasons were created and tested in vivo, and later administered to extracted data. Patients that accessed the helpline were tracked for different outcomes, including hospital admissions and on-call home visits. Logistic regression modelling was performed to categorise call reasons by urgency and to identify disease and person factors associated with time sensitive calls.Results: More than 5,000 calls to the helpline were made over a two-year period (2019-2020), predominantly by family caregivers (88.4%). These were in relation to 2,303 unique patients (38.9% of total patients served). After-hours calls were made an average of 2.3 times by patients across various lengths of service. Only 11.9% of calls were deemed time sensitive or urgent, requiring home visits by on-call staff (4%) or resulting in admission to hospital (7.9%). The majority were managed by primary care teams on the next workday (65.1%) and the remainder sorted during the after-hours call itself (22.3%). Call reasons or presenting issues were classified into two groups according to urgency. Calls in the year 2020, from the younger patient, preferred place of death outside the home, and caller types other than patient or healthcare worker were significantly associated with urgent calls. Conclusion:Deeper characterisation of after-hours calls offers possibilities: service redesign for optimal resourcing and customised training for better care. Ultimately, planners, providers, and patients all stand to benefit.
Background Home-based palliative care (HPC) is considered to moderate the problem of rising healthcare utilization of cancer patients at end-of-life. Reports however suggest a proportion of HPC patients continue to experience high care intensity. Little is known about differential trajectories of healthcare utilization in patients on HPC. Thus, we aimed to uncover the heterogeneity of healthcare utilization trajectories in HPC patients and identify predictors of each utilization pattern. Methods This is a cohort study of adult cancer patients referred by Singapore Health Services to HCA Hospice Service who died between 1st January 2018 and 31st March 2020. We used patient-level data to capture predisposing, enabling, and need factors for healthcare utilization. Group-based multi-trajectory modelling was applied to identify trajectories for healthcare utilization based on the composite outcome of emergency department (ED) visits, hospitalization, and outpatient visits. Results A total of 1572 cancer patients received HPC (median age, 71 years; interquartile range, 62–80 years; 51.1% female). We found three distinct trajectory groups: group 1 (31.9% of cohort) with persistently low frequencies of healthcare utilization, group 2 (44.1%) with persistently high frequencies, and group 3 (24.0%) that begin with moderate frequencies, which dropped over the next 9 months before increasing in the last 3 months. Predisposing (age, advance care plan completion, and care preferences), enabling (no medical subsidy, primary decision maker), and need factors (cancer type, comorbidity burden and performance status) were significantly associated with group membership. High symptom needs increased ED visits and hospitalizations in all three groups (ED visits, group 1–3: incidence rate ratio [IRR] 1.74–6.85; hospitalizations, group 1–3: IRR 1.69–6.60). High home visit intensity reduced outpatient visits in all three groups (group 1–3 IRR 0.54–0.84), while it contributed to reduction of ED visits (IRR 0.40; 95% CI 0.25–0.62) and hospitalizations (IRR 0.37; 95% CI 0.24–0.58) in group 2. Conclusions This study on HPC patients highlights three healthcare utilization trajectories with implications for targeted interventions. Future efforts could include improving advance care plan completion, supporting care preferences in the community, proactive interventions among symptomatic high-risk patients, and stratification of home visit intensity.
Background: Terminal discharge is an emergent procedure for dying patients in hospital to return home. While reports on hospital staff experience exist, perspectives from community partners are lacking. Aim:We profile a cross section of decedent patients, and report clinician experience from a community hospice service.Design: A mixed-methods approach. Electronic medical records were analysed for characteristics, trajectories and service utilisation, comparing terminally discharged and regular care patients over one year. Hospice care coordinators participated in an open-ended questionnaire and responses were analysed qualitatively. Settings/participants:The study was conducted in the largest home-based hospice service in Singapore. 260 referrals were received for terminal discharge in 2020, out of 3700 patients served. All five discharge coordinators responded to the questionnaire.Results:Only 228 of 260 terminally discharged patients reached home; 18 died before home visits could be made, and 10 outlived their prognoses. The ratio of cancer to non-cancer patients (1:1) in the terminal discharge group differed from the service’s norm (4:1). Moreover, median length of service for this group (4 days) was 10 times shorter compared to decedents from regular service. This group also received on average three times higher service touchpoints (phone calls and home visits). Thematic analyses of survey responses revealed varying understanding of terminal discharge with concomitant implications; patchy handover between services that compromised care quality; and areas for improvement are suggested.Conclusions:Given its primacy and potential impact, active engagement of all stakeholders to optimise the management of terminal discharge is indicated.
Background The phenomenon of restlessness, agitation, or cognitive disturbances experienced by dying patients is well-known in palliative care; more than half of these patients will experience delirium symptoms at end-of-life. When not identified early and effectively managed, delirium symptoms could lead to caregiver and patient distress and harm. Methods Eighty patients with a prognosis of 7 days or less will be recruited for an open-label randomised control trial. The two arms compare oral-transmucosal haloperidol 2.5 mg vs olanzapine 5 mg over 72 h. The severity of agitation, delirium and toxicities of treatments will be compared at the 24th, 48th and 72nd hour after drug administration. Discussion This trial is the first to compare anti-psychotics in the management of delirium at the dying stage in the home hospice setting using the oral transmucosal route. Ethical considerations, as well as recruitment procedures, are discussed. Trial registration This study was registered in ClinicalTrials.gov – identifier NCT04750395
Cite this article as: Chong PH. "So good; so late": the strange love-hate relationship with paediatric palliative care. Ann Palliat Med 2022.
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