What determines duration of palliative care before death for patients with advanced disease? A retrospective cohort study of community and hospital palliative care provision in a large UK city

Abstract

ObjectiveFor 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.DesignThis retrospective cohort study analysed referrals to three specialist palliative care services; a hospital-based inpatient palliative care team, and two community-based services (hospices). For each patient referred to any of the above services we identified the date of first referral to that team and calculated the median interval between first referral and death. We also calculated how referral time varied by age, sex, diagnosis and type of palliative care service.Participants4650 patients referred to specialist palliative care services in Leeds UK between April 2012 and March 2014.ResultsMedian age of the sample was 75 years. 3903 (84.0%) patients had a diagnosis of cancer. Age, diagnosis and place of referral were significant predictors of duration of palliative care before death. Age was independently associated (J=2 672 078, z=−392046.14, r=0.01) with duration of palliative care regardless of diagnosis. Patients over 75 years have 29 fewer days of palliative care than patients under 50. Patients with non-cancer diagnoses have 13 fewer days of palliative care than patients with cancer. Additionally, patients referred to hospital palliative care receive 24.5 fewer days palliative care than those referred to community palliative care services.ConclusionsThe 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.

The care experiences of patients who die in residential hospice: A qualitative analysis of the last three months of life from the views of bereaved caregivers

“…The quality of end-of-life care received in settings such as hospices is critical, considering that the majority of patients who die receive palliative care for less than two months (Bennett et al, 2016;NHPCO, 2015;Tanuseputro et al, 2016). Furthermore, it is common for patients to access palliative care from multiple settings and providers (Lawson et al, 2006;Walker et al, 2011), and to transition between care settings during the last weeks of life (Hanratty et al, 2014).…”

Managing clinical uncertainty: An ethnographic study of the impact of critical care outreach on end‐of‐life transitions in ward‐based critically ill patients with a life‐limiting illness

“…These figures highlight the lack of advance care planning (ACP), advocated by the UK government (Department of Health, ; Gold Standards Framework, ); as a result, care preferences may not reflect those of families or patients. The role that these rapid response teams, such as MET and CCOT, have in EOL decision‐making highlights challenges in terms of decision‐making leadership and autonomy to challenge (Bennett et al., ; Calzavacca et al., ; Pattison et al., ; Tan & Delaney, ). Despite exponential worldwide growth in these teams, little guidance exists for CCOTs and METs about dealing with transition points in life‐limiting illness.…”

“…One systematic review emphasised that LOMT decision-making constituted up to a third of medical emergency team (MET) calls and LOMTs occurred more frequently than resuscitation interventions such as endotracheal intubation (Tan & Delaney, 2014). Many patients in these studies undergoing LOMTs had a cancer diagnosis (Coombs, Nelson, Psirides, Suter, & Pedersen, 2016;Tan & Delaney, 2014), highlighting that this patient group in particular encounter difficulties in decisionmaking and poor care as a consequence (NCEPOD, 2008;Hui et al, 2012;Bennett, Ziegler, Allsop, Daniel, & Hurlow, 2016). Clinical uncertainty refers to where doubt about prognostic accuracy affects and delays decision-making about treatment (Fisher & Ridley, 2012).…”

“…CCOT, have in EOL decision-making highlights challenges in terms of decision-making leadership and autonomy to challenge (Bennett et al, 2016;Calzavacca et al, 2010;Pattison et al, 2015;Tan & Delaney, 2014). Despite exponential worldwide growth in these teams, little guidance exists for CCOTs and METs about dealing with transition points in life-limiting illness.…”

Factors affecting hospice care use among long-term care facility residents in Canada

“…The work described in this thesis has several implications for researchers. Finding from the work described in this thesis indicate that accuracy of end-stage diagnosis and effectiveness of hospice eligibility criteria were restrictive, which may limit the benefits to residents in terms of improvements in end-of-life care, particularly for residents with several medical problems but no specific terminal diagnosis (Bennett, Ziegler, Allsop, Daniel, & Hurlow, 2016). Further longitudinal study about standardized assessment of terminal status or more effective hospice eligibility criteria with less dependency on a specific life expectancy of six months or less is needed to help make better use of limited hospice care resources.…”