Author Interviews, Brigham & Women's - Harvard, COVID -19 Coronavirus, Critical Care - Intensive Care - ICUs, End of Life Care / 14.12.2020 Interview with: Isaac Chua, MD, MPH Division of General Internal Medicine and Primary Care Brigham and Women's Hospital What is the background for this study? Response: Patient surveys have shown that most people prefer to die at home at the end-of-life. However, during the initial wave of the COVID-19 pandemic, anecdotal evidence from our colleagues and findings from a prior study published in the Journal of the American Geriatrics Society suggested that majority of COVID-19 decedents died in a medical facility. However, less is known about care intensity at the end-of-life according to place of death among patients who died of COVID-19. Therefore, we characterized end-of-life care by place of death among COVID-19 decedents at Mass General Brigham (MGB), the largest health system in Massachusetts.  (more…)
Author Interviews, End of Life Care, Hearing Loss / 09.07.2020 Interview with: Elizabeth Blundon PhD Department of Psychology University of British Columbia – Vancouver What is the background for this study? Response: Many healthcare workers have noticed that dying patients appear to be comforted by the words of their loved ones, even when patients appear to be unconscious and are no longer able to communicate. There is a persistent belief, therefore, that hearing may persist into the last hours of someone's life. Our study attempts to detect evidence of hearing among a small group of unresponsive hospice patients at the end of life. To do this, we compared the brain activity of young, healthy control participants, with the brain activity of hospice patients, both when the patients were awake and responsive, and again when they became unresponsive. The brain activity we measured was in response to a complex series of tone-patterns, where participants were asked to identify by pressing a button (control participants) or by counting (hospice patients) every time they heard a tone-pattern that was different from the rest of the series.   (more…)
Author Interviews, Critical Care - Intensive Care - ICUs, End of Life Care, Primary Care, Pulmonary Disease, University of Pennsylvania / 07.10.2019 Interview with: Gary Weissman, MD, MSHP Assistant Professor of Medicine Pulmonary, Allergy, and Critical Care Division Palliative and Advanced Illness Research (PAIR) Center University of Pennsylvania Perelman School of Medicine What is the background for this study? Response: There are millions of hospitalizations every year in the United States (US) that include a stay in an intensive care unit (ICU). Such ICU stays put strain on health system resources, may be unwanted by patients, and are costly to society. As the population of the US gets older and more medically complex, some have argued that we need more ICU beds and a larger ICU workforce to keep pace. We hypothesized that some proportion of these ICU admissions could be prevented with early and appropriate outpatient care. Such a strategy would alleviate some of the strains and costs associated with ICU stays. If an appreciable proportion of ICU stays were preventable in this way, it would strengthen support for an alternative population-health based framework instead of further investments in the ICU delivery infrastructure.  (more…)
Author Interviews, Cancer Research, End of Life Care, JAMA / 19.09.2019 Interview with: Donald Sullivan, MD, MA, MCR Associate Professor of Medicine & Associate Fellowship Program Director Division of Pulmonary & Critical Care Medicine Oregon Health & Science University Investigator, Center to Improve Veteran Involvement in Care (CIVIC) VA-Portland Health Care System What is the background for this study?
  • Patients with lung cancer suffer from considerable physical and psychological symptom burden and palliative care is underutilized or delivered too close to death to provide meaningful benefits for these patients. Palliative care is associated with improved quality of life for these patients, but the findings regarding a survival benefit are not clear.
  • Palliative care is distinct from hospice. Palliative care is meant to be delivered along with disease-modifying therapy and focuses on improving quality of life by addressing pain and other problems, including physical, psychosocial and spiritual for patients and their families. Hospice care is focused on reducing suffering, pain and anxiety at the very end of life; typically within a few months of death.
ASCO, Author Interviews, Cancer Research, Cost of Health Care, End of Life Care / 17.09.2019 Interview with: Richy Agajanian, M.D. Chief Medical Officer and Senior Regional Director The Oncology Institute of HopeRichy AgajanianM.D. Chief Medical Officer and Senior Regional Director The Oncology Institute of Hope and Innovation What is the background for this study? Response: Cancer patients and their families face status-quo treatment protocols and reimbursement models which often result in confusion and unnecessary pain and suffering in the final weeks or months of life while also causing enormous financial burden. To help combat these issues, The Oncology Institute, in collaboration with the Stanford University School of Medicine and CareMore Health, released the study, Enhancing community capacity to deliver value-based cancer care at the end-of-life. This study evaluated the effect of using lay health workers (LHWs), who are non-physician members of the community who have received specialized training to support patient care and navigation, on end-of-life cancer care outcomes, quality and cost.  (more…)
Author Interviews, Cognitive Issues, End of Life Care, Gender Differences, JAMA / 16.08.2019 Interview with: Dr. Nathan Stall, MD Geriatrician and Research fellow Women’s College Research Institute       Dr. Paula Rochon, MD, MPH, FRCPC Periatrician and Vice-President of Research Women’s College Hospital What is the background for this study? Response: The advanced stages of the dementia are characterized by profound memory impairment, an inability to recognize family, minimal verbal communication, loss of ambulatory abilities, and an inability to perform basic activities of daily living. Nursing homes become a common site of care for people living with advanced dementia, who have a median survival of 1.3 years. In the advanced stages of the disease, the focus of care should generally be on maximizing quality of life. Our study examined the frequency and sex-based differences in burdensome interventions received by nursing home residents with advanced dementia at the very end of life. Burdensome interventions include a variety of treatment and procedures that are often avoidable, may not improve comfort, and are frequently distressing to residents and their families. We found that in the last 30 days of life, nearly one in 10 nursing home residents visited an emergency department, more than one in five were hospitalized, and one in seven died in an acute care setting. In addition, almost one in 10 residents received life-threatening critical care; more than one in four were physically restrained; and more than one in three received antibiotics. (more…)
Author Interviews, End of Life Care, JAMA, Kidney Disease / 08.07.2019 Interview with: Dr. Ann M. O’Hare, MD Professor,Division of Nephrology University of Washington Investigator, VA HSR&D Center of Excellence Affiliate Investigator, Group Health Research Institute Seattle, WA What is the background for this study? Response: We know that survival for people undergoing dialysis is generally quite limited.  Only a few studies have attempted to elicit how patients undergoing dialysis understand prognosis and how their prognostic awareness might be related to their interest in planning for the future, their preferences for resuscitation and the kind of care they would want if they were seriously ill or dying. (more…)
Alzheimer's - Dementia, Author Interviews, End of Life Care, JAMA, University of Pennsylvania / 30.04.2019 Interview with: Emily Largent, PhD, JD, RN Assistant ProfessorMedical Ethics and Health Policy Perelman School of Medicine Leonard Davis Institute of Health Economics University of Pennsylvania What is the background for this study? What are the main findings?  Response:  Public support for aid in dying in the United States is rapidly growing.  As a result, we’re now seeing debates about whether to expand access to aid-in-dying to new populations – such as people with Alzheimer’s disease – who wouldn’t be eligible under current laws. With those debates in mind, we asked currently healthy people who recently learned about their risk for developing Alzheimer’s disease dementia (i.e., due to the presence of amyloid, an Alzheimer’s disease biomarker) whether they would be interested in aid-in-dying. Our findings suggest that about 20% of individuals with elevated amyloid may be interested in aid-in-dying if they become cognitively impaired.   (more…)
Author Interviews, End of Life Care, Health Care Systems, JAMA / 08.04.2019 Interview with: Cindy L. Cain, PhD Assistant Professor Department of Sociology University of Alabama at Birmingham Birmingham, AL 35233 What is the background for this study? What are the main findings? Response: The End of Life Option Act permits terminally ill Californians to request a prescription for medications that would hasten death, providing they meet all requirements of the law and follow the steps outlined by their health care provider. However, the law also allows health care providers and organizations to opt out of participating. Until now, we did not know how common it was for entire health care organizations to opt out. In this study, we found that 61% of the surveyed hospitals prohibited physician participation in the End of Life Option Act. Thirty-nine percent of hospitals did allow participation in the law; these participating hospitals were less likely to be religiously affiliated and more likely to be nonprofit. (more…)
Author Interviews, Cancer Research, Cannabis, End of Life Care, NYU / 28.03.2019 Interview with: Arum Kim, MD Assistant Professor Medicine and Rehabilitation Medicine NYU School of Medicine Director of the Supportive Oncology Program Perlmutter Cancer Center What is the background for this study?   Response: There is increasing interest in medical marijuana and its applications for patients with cancers. Despite increasing access, little is known regarding doses of cannabinoids - specifically delta-8-tetrahydrocannabinol (delta-8-THC)  and cannabidiol (CBD), methods of drug delivery, and differences in patterns of use between cancer and non-cancer patients. (more…)
Author Interviews, Brigham & Women's - Harvard, Critical Care - Intensive Care - ICUs, End of Life Care, JAMA / 21.03.2019 Interview with: Joanna Paladino, MD Director of Implementation, Serious Illness Care Program | Ariadne Labs Brigham and Women's Hospital | Harvard T.H. Chan School of Public Health Palliative Care | Dana-Farber Cancer Institute Instructor | Harvard Medical School and Dr. Rachelle Bernacki MD MS Director of Quality Initiatives Psychosocial Oncology and Palliative Care Senior Physician, Assistant Professor of Medicine Harvard Medical School Dr. Paladino's responses: What is the background for this study? What are the main findings? Dr. Paladino: People living with serious illness face many difficult decisions over the course of their medical care. These decisions, and the care patients receive, should be guided by what matters most to patients, including their personal values, priorities, and wishes. These conversations don’t often happen in clinical practice or do so very late in the course of illness, leaving patients exposed to getting care they don’t want. Doctors and nurses want to have these important discussions, but there are real challenges, including insufficient training and uncertainties about when and how to start the conversation. We designed an intervention with clinical tools, clinician training, and systems-changes to address these challenges. When tested in a randomized clinical trial in oncology, we found that the intervention led to more, earlier, and better conversations between oncology clinicians and their patients with life-limiting cancer. These findings demonstrate that it is possible to ensure reliable, timely, and patient-centered serious illness conversations in an outpatient oncology practice. (more…)
Author Interviews, End of Life Care, JAMA, Kidney Disease / 22.01.2019 Interview with: Susan P. Y. Wong, MD MS Assistant Professor Division of Nephrology University of Washington VA Puget Sound Health Care System What is the background for this study? Response: Patients who reach the advanced stages of kidney disease  must often face the difficult decision of whether to undergo maintenance dialysis. While maintenance dialysis is a remarkable therapy that has extended the lives of many patients, its benefits do not necessarily accrue in older patients with significant comorbidity and functional impairment. It is also a very demanding form of therapy that comes with its own burdens and complications. Based on our prior research in the national VA health system, 1 in 7 patients with very advanced kidney disease (or their decision makers) do not pursue dialysis. We wanted to understand how these decisions to forgo initiation of maintenance dialysis unfold. (more…)
Author Interviews, End of Life Care, Hearing Loss, JAMA / 28.09.2018 Interview with: Tae-Min Rhee, M.D. Chief of Undersea and Diving Medicine, Underwater Medical Institute, National Maritime Medical Center, Republic of Korea Navy, Changwon Republic of Korea What is the background for this study? Response: The sudden sensorineural hearing loss (SSNHL) has an incidence of 5 to 20 per 100,000 person-years in the general population and sometimes results in permanent deafness followed by considerable socio-economic costs. The causes of SSNHL are often unclear, and in these cases there are no treatment of choice that is proven to be effective. In addition, spontaneous recovery is not uncommon in SSNHL, making it difficult to predict the natural course of the disease, and thus a well-controlled clinical trial is rare in spite of its clinical significance. Many treatment options (systemic or intratympanic steroids, antiviral agents, vasodilators, and hyperbaric oxygen therapy) have been suggested and tried to date, but only systemic steroid therapy has been the most effective among them. However, for the cases with contraindications to steroids, or steroid-refractory SSNHL, there is paucity of information on the second line treatment option. Hyperbaric oxygen therapy (HBOT), i.e., high-pressurized oxygen therapy, is a method of treating patients within a chamber saturated with 100% oxygen maintained at a high pressure of 2.0 to 2.5 atm. Cochlea is an organ that relies more on the diffusion of oxygen than the direct vascular supply, and thus it is known to be vulnerable to ischemia. Since this is suggested as one of the main pathophysiology of SSNHL, we wanted to prove the hypothesis that, by providing high-pressure oxygen, the partial pressure of oxygen delivered to the inner ear is maximized, and the additional or complementary therapeutic effects can be observed. A number of reports have been published for 20 years, but there is no systematically organized evidence except a Cochrane Review in 2012. Therefore, our research team tried to integrate the evidence through a comprehensive meta-analysis and to provide important clues for further research.  (more…)
Author Interviews, End of Life Care / 19.07.2018 Interview with: Ann H Cottingham MA MAR Indiana University School of Medicine Indianapolis,IN. What is the background for this study? What are the main findings? Response: Advance care planning provides patients with cancer an opportunity to reflect on future care and treatment options with their physician and family and identify and document their preferences in preparation for a time when they may be unable to speak for themselves. Advance care planning increases both quality of life and satisfaction with care, however the majority of patients with cancer have not participated in these important conversations. Common emotional responses to cancer, such as feelings of anxiety, fear, and sadness, pose one barrier to planning as they can keep patients from thinking about or discussing sensitive topics related to their illness. We conducted a pilot study to explore whether training in mindfulness, the psychological process of bringing one's attention to experiences occurring in the present, could enhance the ability of patients and families to consider and discuss emotionally challenging topics -- such as end-of-life preparations -- and support timely advance care planning. Twelve patient-family caregiver pairs participated in a pilot study of Mindfully Optimizing Delivery of End-of-Life (MODEL) Care, which combined mindfulness meditation, mindful communication practices, and information about advance care planning. MODEL Care focused on developing emotional and communication capacities to enable patients and their family caregivers to respond to the experience of living with advanced cancer and to talk about the disease and future care preferences with greater ease. The study found that MODEL Care successfully supported patients and their family caregivers in thinking about and then talking about the care they would want to receive if they become unable to speak for themselves, enhancing their ability to respond to emotional challenges, and decreasing barriers to end-of-life planning. MODEL Care improved patient and caregiver ability to cope, lowered emotional reactivity, and enhanced ability to respond to issues that incited emotion. It also strengthened the patient-caregiver relationship and enhanced communication with each other. MODEL Care also improved both patient and family caregiver communication with the physicians caring for the patient.   Patients noted that the practices enabled them to cope more effectively with the symptoms of their disease, including pain. Caregivers reported changes in their loved one's ability to cope with their disease following the mindfulness sessions. (more…)
Author Interviews, Cost of Health Care, End of Life Care, Medicare, Science / 06.07.2018 Interview with: Amy Finkelstein PhD John & Jennie S. MacDonald Professor of Economics MIT Department of Economics National Bureau of Economic Research Cambridge MA 02139 What is the background for this study? What are the main findings? Response: Although only 5% of Medicare beneficiaries die in a given year, they account for almost 25% of Medciare spending. This fact about high end of life spending has been constantly used to refer to inefficiency of the US healthcare system. A natural observation is that the fact is retrospective, and it motivated us to explore a prospective analog, which would take as an input the probability of someone dying in a given year rather than her realized outcome. We therefore used machine learning techniques to predict death, and somewhat to our surprise we found that at least using standardized and detailed claims-level data, predicting death is difficult, and there are only a tiny fraction of Medicare beneficiaries for whom we can predict death (within a year) with near certainty. Those who end up dying are obviously sicker, and our study finds that up to half of the higher spending on those who die could be attributed to the fact that those who die are sicker and sick individuals are associated with higher spending.   (more…)
Author Interviews, Cost of Health Care, Critical Care - Intensive Care - ICUs, End of Life Care, NEJM, University of Pittsburgh / 30.05.2018 Interview with: Douglas B. White, M.D., M.A.S. Director of the Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center’s Program on Ethics and Decision Making in  Department of Critical Care Medicine University of Pittsburgh What is the background for this study?  Response: We set out to test the effectiveness of PARTNER (PAiring Re-engineered ICU Teams with Nurse-driven Emotional Support and Relationship-building). PARTNER is delivered by the interprofessional team in the ICU, consisting of nurses, physicians, spiritual care providers, social workers and others who play a part in patient care. The program is overseen by nurse-leaders in each ICU who receive 12 hours of advanced communication skills training to support families. The nurses meet with the families daily and arrange interdisciplinary clinician-family meetings within 48 hours of a patient coming to the ICU. A quality improvement specialist helps to incorporate the family support intervention into the clinicians’ workflow. PARTNER was rolled out at five UPMC ICUs with different patient populations and staffing. It was implemented in a staggered fashion so that every participating ICU would eventually get PARTNER. Before receiving PARTNER, the ICUs continued their usual methods of supporting families of hospitalized patients. None of the ICUs had a set approach to family communication or required family meetings at regular intervals before receiving PARTNER. A total of 1,420 adult patients were enrolled in the trial, and 1,106 of these patients’ family members agreed to be a part of the study and its six-month follow-up surveys. The patients were very sick, with about 60 percent dying within six months of hospitalization and less than 1 percent living independently at home at that point. (more…)
Author Interviews, Cost of Health Care, End of Life Care, Geriatrics, JAMA, Medicare / 23.05.2018 Interview with: William B Weeks, MD, PhD, MBA The Dartmouth Institute What is the background for this study? What are the main findings? Response: The background for the study is that a common narrative is that end-of-life healthcare costs are driving overall healthcare cost growth.  Growth in end-of-life care has been shown, in research studies through the mid 2000’s, to be attributable to increasing intensity of care at the end-of-life (i.e., more hospitalizations and more use of ICUs). The main findings of our study are that indeed there have been substantial increases in per-capita end-of-life care costs within the Medicare fee-for-service population between 2004-2009, but those per-capita costs dropped pretty substantially between 2009-2014.  Further, the drop in per-capita costs attributable to Medicare patients who died (and were, therefore, at the end-of-life) accounts for much of the mitigation in cost growth that has been found since 2009 in the overall Medicare fee-for-service population. (more…)
Author Interviews, End of Life Care / 06.05.2018 Interview with: Mara Buchbinder, PhD Associate Professor Department of Social Medicine University of North Carolina at Chapel Hill Chapel Hill, NC 27599-7240 What is the background for this study? What are the main findings? Response: The legal landscape of medical aid-in-dying in the United States is changing rapidly. Just a few weeks ago, Hawaii became the 8th jurisdiction in the US to permit a physician to prescribe a lethal dose of medication to a terminally ill patient for the purpose of ending the patient’s life. However, even in states where aid-in-dying is legal, patients still face substantial barriers to access. The Vermont Study on Aid-in-Dying, a qualitative, descriptive study of the implementation of Vermont’s assisted dying statute, found that patients encounter barriers concerning the safeguards built into the law, the cost of medication, the ability to find a physician willing to prescribe, and knowledge about the law. (more…)
Author Interviews, Cost of Health Care, End of Life Care, JAMA / 01.05.2018 Interview with: R. Sean Morrison, MD Ellen and Howard C. Katz Professor and Chair Brookdale Department of Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai New York, NY 10029 What is the background for this study? What are the main findings? Response: Palliative care is team based care that is focused on improving quality of life and reducing suffering for persons with serious illness and their families.  It can be provided at any age and in concert with all other appropriate medical treatments.  Palliative care has been shown to improve patient quality of life, patient and family satisfaction, and in diseases like cancer and heart failure, improve survival.  A number of individual studies have shown that palliative care can reduce costs by providing the right care to the right people at the right time. This study pooled data from six existing studies to quantify the magnitude of savings that high quality palliative care provides. (more…)
Author Interviews, End of Life Care, Heart Disease, JAMA, Technology / 27.02.2018 Interview with: Larry A. Allen, MD, MHS Associate Professor, Medicine Associate Head for Clinical Affairs, Cardiology Medical Director, Advanced Heart Failure Aurora, CO 80045 What is the background for this study? What are the main findings? Response: Deciding whether or not to get a left ventricular assist device (LVAD) is one of the most challenging medical decisions created by modern medicine. LVADs improve overall survival but also come with serious risks and lifestyle changes. Particularly for older patients with multiple medical problems, this is a complex choice. Our research group at the University of Colorado spent years systematically developing unbiased pamphlet and video decision aids for patients and caregivers. We also developed a clinician-directed decision support training for LVAD program staff. The DECIDE-LVAD trial studied the implementation and effectiveness of this decision support intervention with patients and their caregivers in 6 hospitals in the U.S. When compared to previously used education materials, the decision aids appeared to improve patients’ decision quality and lowered the total number of patients getting LVADs. (more…)
Author Interviews, Brigham & Women's - Harvard, Diabetes, End of Life Care, JAMA / 01.01.2018 Interview with: Dr. Laura A. Petrillo MD Instructor in Medicine Harvard Medical School, and Palliative Care Physician Massachusetts General Hospital What is the background for this study? What are the main findings? Response: Hospice is end-of-life care focused on maximizing quality of life. Hospice often involves reducing or stopping treatments that are unlikely to have short-term benefit in order to avoid uncomfortable side effects. About a quarter of Americans die in nursing homes, and some of them receive hospice care in their final days. We looked at whether adults with type 2 diabetes experience low blood sugar while on hospice in veterans’ nursing homes, since low blood sugar signals inappropriately aggressive diabetes treatment in patients close to death and contributes to unnecessary discomfort. We found that one in nine people experienced low blood sugar at least once while receiving hospice care. Among people who were on insulin, the number was one in three. (more…)
Author Interviews, End of Life Care, JAMA, UCSF / 20.11.2017 Interview with: Kara Bischoff, MD Assistant Clinical Professor, Hospital Medicine & Palliative Care Director of Quality Improvement for the Palliative Care Service UCSF Department of Medicine What is the background for this study? What are the main findings? Response: Care planning, which we define as including both advance care planning and goals of care discussions, are a common need in seriously ill patients and a key function of palliative care teams. However, few studies have looked at how often and how care planning is being done by inpatient palliative care teams throughout the United States, and similarly few studies have examined the precise impact of these care planning activities. Therefore, using data from a large quality improvement registry in palliative care called the Palliative Care Quality Network, we examined: 1) the characteristics of hospitalized patients who are referred to inpatient palliative care consult services, 2) the activities that occurred during those inpatient palliative care consults, and 3) the outcomes that resulted. In looking at data from 73,145 patients who referred for an inpatient palliative care consult, we found that care planning was the most common reason for inpatient palliative care consultation, requested for 71.9% of patients who were referred to palliative care. Further, care planning needs were found in more than half (58%) of palliative care patients even when the consult was requested for reasons other than care planning. Patients referred to palliative care for care planning were somewhat older than patients referred for other reasons, they were less likely to have cancer, and were more often full code at the time of referral. Through care planning conversations, palliative care clinicians frequently identified surrogates and clarified patients’ preferences for life-sustaining treatments (including code status). For instance, 31% more patients chose a code status of DNR/DNI after a conversation with the palliative care team. However, we also found that legal forms such as advance directives and Physician Orders for Life-Sustaining Treatments (POLST) forms were completed for just 3.2% and 12.3% of the patients see by palliative care teams, respectively. This highlights an important quality gap in need of improvement. (more…)
Author Interviews, End of Life Care, JAMA / 10.04.2017 Interview with: Charles D. Blanke, M.D., F.A.C.P., F.A.S.C.O. CHAIR, SWOG Professor, OHSU Knight Cancer Institute Marquam II What is the background for this study? What are the main findings? Response: Oregon’s Death with Dignity Act as a voter initiative which law in 1997 – the first of its kind in the nation. Now, physician aid-in-dying is spreading quickly, with the states of Washington, Vermont, Colorado, and California passing similar legislation, as well as the District of Columbia, and Montana (through a court ruling). Millions of Americans lives in states where they would have the opportunity, if they were terminally ill, to take a lethal dose of medication with a doctor’s prescription. My team here at SWOG, a global cancer research community that designs and conducts publicly funded clinical trials, wanted to look at Oregon’s 18 years of aid-in-dying data and answer some simple questions: Who is using the law? Why? Are the drugs effective? What are the trends in actually taking the prescribed medications? We found that use of law has mostly increased over time – and substantially increased in 2014 and 2015. We found that predominantly white, older, well-educated people, take advantage of the law, and many of them – 77 percent – have underlying terminal cancer. The medication is also 99.4 percent effective. (more…)
Author Interviews, End of Life Care, Geriatrics, Medicare, Yale / 04.04.2017 Interview with: Shi-Yi Wang MD, PhD. Department of Chronic Disease Epidemiology Yale School of Public Health New Haven, CT What is the background for this study? What are the main findings? Response: Care at the end of life is often fragmented and poorly coordinated across different health providers. Multiple transitions in care settings can be burdensome to patients and their families as well as costly to society. Despite these concerns about care transitions in the end of life, we lack contemporary data on the number, timing, and overall pattern of healthcare transitions in the last 6 months of life. This study adds to the extant literature by understanding transition trajectories, national variation of the transitions, and factors associated with transitions. We found that more than 80% of Medicare fee-for-service decedents had at least one health care transition and approximately one-third had ≥ 4 transitions in the last 6 months of life. We produced Sankey diagrams to visualize the sequences of healthcare transitions. The most frequent transition pattern involving at least four transitions: home-hospital-home (or skilled nursing facility)-hospital-healthcare setting other than hospital. There was substantial geographic variation in healthcare transitions in the United States. We found that several factors were associated with a significantly increased risk of having multiple transitions, including female gender, blacks, residence in lower income areas, presence of heart disease or kidney disease. (more…)
Author Interviews, BMC, End of Life Care, Pulmonary Disease / 31.03.2017 Interview with: Dr Sabrina Bajwah MBChB MRCGP MSc MA PhD Consultant Palliative Medicine, King’s College NHS Foundation Trust Honorary Senior Lecturer King's College London Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation London, UK What is the background for this study? Response: Where people die is often important to them and their families, as well as being important for planning health care services. Most people want to die at home, but instead most die in hospital. While the trends have been studied in cancer, other diseases, such as respiratory, are rarely looked at even though they are common and increasing causes of death. Chronic Obstructive Pulmonary Disease (COPD) and Interstitial Pulmonary Diseases (IPD) are common respiratory conditions. Both conditions result in a high use of hospital services, especially among people in advanced stages. This leads to high healthcare costs.1 In the UK in 2010, it is estimated that IPD costs £16.2 million per year in hospitalisations.2 The NHS spends more than £810 million annually managing COPD, with inpatient stays accounting for around £250 million annually. Understanding which factors affect place of death is vital for planning services and improving care, especially given our ageing population, rising chronic diseases and the high costs of hospital admissions. Strategies in many countries have sought to improve palliative care and reduce hospital deaths for non-cancer patients, but their effects are not evaluated. We aimed to determine the trends and factors associated with dying in hospital in COPD and IPD, and the impact of a national end of life care (EoLC) strategy3 to reduce deaths in hospital. This study analysed a national data set of all deaths for COPD and IPD, covering 380,232 people over 14 years. (more…)
Author Interviews, End of Life Care, JAMA / 08.02.2017 Interview with: Nathan A. Gray, M.D. Duke Palliative Care Durham, NC 27710 What is the background for this study? What are the main findings? Response: The estimated number of undocumented immigrants living in the United States has been stable in recent years, but lengths of residence in the country are rising. This aging population of undocumented immigrants can expect to face an increasing burden of chronic disease and end-of-life needs, but may experience challenges in obtaining hospice care in the last months of life as many are uninsured and none are eligible for the Medicare Hospice Benefit. While hospice agencies do provide charity care, little is known about hospice agency approaches to caring for undocumented immigrants. We surveyed a national sample of hospice agencies and found that many hospice agencies do not enroll undocumented immigrants or place restrictions on the number enrolled. More than half of agencies sampled had received requests for enrollment of undocumented immigrants in the past year. Offering unrestricted enrollment was more common among larger, not-for-profit hospices in our sample. (more…)
Author Interviews, BMJ, End of Life Care, Opiods, Pain Research / 21.01.2017 Interview with: Dr. Katherine Irene Pettus, PhD, OSB Advocacy Officer International Association for Hospice and Palliative Care Vice Chair, Vienna NGO Committee on Drugs Secretary NGO Committee on Ageing, Geneva What is the background for this study? Response: The background for this study is analysis of the three international drug control treaties, official attendance and participation at meetings of the Commission on Narcotic Drugs for the past four years, ongoing discussion of national opioid consumption rates with INCB, and years of home hospice visits in developing countries. (more…)
Author Interviews, End of Life Care, Transplantation / 09.01.2017 Interview with: Beatriz Domínguez-Gil, MD, PhD Organización Nacional de Trasplantes Madrid Spain What is the background for this study? What are the main findings? Response: Organ shortage remains the most important barrier to the development of transplantation therapies. It leads to deaths on the waiting list, poor quality of life, increased costs to healthcare systems and emerging unethical practices as organ trafficking, mostly in the form of transplant tourism. Shortage of organs to meet the transplantation needs is a universal problem – also in Spain. The potential of donation from the deceased is decreasing or expected to decrease in most developed countries, which makes it imperative to conceive new ways of increasing organ availibility. In 2008, ONT conceived the 40 donors pmp plan, which includes the three strategies that are described in the paper: -          The identification of possible donors outside of the ICU to pose the option of intensive care to facilitate organ donation. -          The promotion of the expanded and non-standard risk donor. -          The development of donation after circulatory death The three strategies have made the country not only reach, but even surpass the objective of 40 donors pmp (43,4 in 2016). (more…)
Author Interviews, Cancer Research, End of Life Care / 23.12.2016 Interview with: Yu Uneno, M.D. Department of Therapeutic Oncology, Graduate School of Medicine, Kyoto University Kyoto city, Kyoto Japan What is the background for this study? What are the main findings? Response: Prognosis prediction is one of the most important issues to make an optimal treatment decision for both cancer patients and health care professionals. Previous prognosis prediction models were developed using data from single time point (at the baseline, for example), limiting the use of the models at the similar situation. Recently, we have developed the Six Adaptable Prognostic (SAP) models which can be repeatedly used at any time point after the initiation of treatment for patients with cancer receiving chemotherapy. Those models use only three laboratory items (albumin, neutrophil, lactate dehydrogenase) which are routinely monitored in daily clinical practice. (more…)
Author Interviews, End of Life Care, JAMA, University of Pittsburgh / 30.11.2016 Interview with: Dr. Dio Kavalieratos, PhD Assistant Professor of Medicine Section of Palliative Care and Medical Ethics Division of General Medicine Institute of Clinical Research University of Pittsburgh What is the background for this study? What are the main findings? Response: The field of palliative care has seen a dramatic surge in research and clinical implementation over the past decade. The last systematic review of palliative care trials was published in 2008. In that review, the authors reported very weak evidence for palliative care, as well as major methodological limitations in the trials that had been done to date. Since then, several landmark trials have been published, some with very compelling findings such increased survival. Therefore, an up-to-date review was in order. There also had not previously been enough trials to perform a meta-analysis. A meta-analysis is the statistical process of combining the results of multiple trials, which gives you an overall effect for an intervention, in this case, palliative care. We were able to conduct the first meta-analysis of the effect of palliative care with three important outcomes: patient quality of life, patient symptom burden, and patient survival. (more…)