Home hospitalization for palliative cancer care: factors associated with unplanned hospital admissions and death in hospital

Abstract

Background Home hospitalization at the end of life can sometimes be perturbed by unplanned hospital admissions (UHAs, defined as any admission that is not part of a preplanned care procedure), which increase the likelihood of death in hospital. The objectives were to describe the occurrence and causes of UHAs in cancer patients receiving end-of-life care at home, and to identify factors associated with UHAs and death in hospital. Methods A retrospective, single-center study (performed at a regional cancer center in the city of Lille, northern France) of advanced cancer patients discharged to home hospitalization between January 2014 and December 2017. We estimated the incidence of UHA over time using Kaplan-Meier method and Kalbfleish and Prentice method. We investigated factors associated with the risk UHA in cause-specific Cox models. We evaluated factors associated with death in hospital in logistic regressions. Results One hundred and forty-two patients were included in the study. Eighty-two patients (57.7 %) experienced one or more UHAs, a high proportion of which occurred within 1 month after discharge to home. Most UHAs were related to physical symptoms and were initiated by the patient’s family physician. A post-discharge palliative care consultation was associated with a significantly lower incidence of UHAs. Sixty-five patients (47.8 % of the deaths) died in hospital. In a multivariate analysis, living alone and the presence of one or more children at home were associated with death in hospital. Conclusions More than 40 % of cancer patients receiving end of life home hospitalization were not readmitted to hospital, reflecting the effectiveness of this type of palliative care setting. However, over half of the UHAs were due to an acute intercurrent event. Our results suggest that more efforts should be focused on anticipating these events at home – primarily via better upstream coordination between hospital physicians and family physicians.

Symptom evolution in the dying

“…We found that symptom-related goals of care were more often not achieved in hospitals than in other settings. This finding could be the result of patient selection, as complex symptom management during the dying phase may have been a common reason for admitting patients to the hospital 11. Percentages of patients with uncontrolled symptoms in the dying phase in our study were lower than what has been found in other studies.…”

“…This finding could be the result of patient selection, as complex symptom management during the dying phase may have been a common reason for admitting patients to the hospital. 11 Percentages of patients with uncontrolled symptoms in the dying phase in our study were lower than what has been found in other studies. Reported percentages vary between 22.2% and 52.6% for pain; between 22.1% and 41.2% for dyspnoea and between 3.9% and 25% for nausea and vomiting.…”

Utilization of palliative care resource remains low, consuming potentially avoidable hospital admissions in stage IV non-small cell lung cancer: a community-based retrospective review

“…Admitted patients spent a median of 7 days in the hospital with the majority suffering subsequent inhospital death. Previous data of cancer patients suggest an increased likelihood of in-hospital death following unplanned hospital admissions, contrary to patient wishes to spend their final days at home [23]. Outpatient palliative care referral was associated with a reduction in the number of patients being admitted into the ICU in their last 30 days, similar to other studies reporting a lower rate of ICU admissions when referring early palliative care to advanced cancer patients [24].…”

Diagnostic accuracy of a predictive scoring tool for patients who are eligible for home discharge from a palliative care unit

“…Similarly, we found that a "calorie intake of 520 kcal or more on the first day" could be a useful factor for patients to be discharged home. Furthermore, multiple empirical studies have shown that "home" being the family's preferred place of care is a particularly strong factor facilitating discharge to home (7)(8)(9)(10)15,16).…”

“…Staying at a preferred place, principally at home, is of great importance for dying patients; moreover, patients who die at home experience higher 'quality of death' than those who die at acute hospitals (1)(2)(3)(4). Empirical data, however, indicates that a considerable number of patients do not die in places of their own choosing (5)(6)(7)(8)(9)(10). In recent years, an increasing number of medical institutions have been proactively providing discharge support.…”