Many older people die in hospitals, whereas research indicates that they would prefer to die at home. Little is known about the factors associated with place of death. The aim of the present study was to investigate the care received by older people in the last 3 months of their life, the transitions in care and the predictors of place of death. In this population-based study, interviews were held with 270 proxy respondents to obtain data on 342 deceased participants (79% response rate) in the Longitudinal Aging Study Amsterdam. In the last 3 months of life, the utilisation of formal care increased. Half of the community-dwelling older people and their families were confronted with transitions to institutional care, in most cases to hospitals. Women relied less often on informal care only, and were more dependent than men on institutional care. For people who only received informal care, the odds of dying in a hospital were 3.68 times the odds for those who received a combination of formal and informal home care. The chance of dying in a hospital was also related to the geographical region. The authors argue that future research is needed into the association that they found in the present study, i.e. that decedents who received both formal and informal care were more likely to die at home. In view of the differences found in geographical region in relation to place of death, further investigation of regional differences in the availability and accessibility of care is indicated.

Objective: This study examined the features of informal end-of-life care of older people living in the community and the association between informal care characteristics and dying at home. Methods: Retrospective data were obtained from interviews and self-administered questionnaires of 56 persons who had been primary caregivers of older relatives in the last three months of their lives. Results: Results showed that informal caregivers of terminally ill older people living in the community provided a considerable amount of personal, household, and management care. Secondary informal caregivers and formal caregivers assisted resident primary caregivers less often than nonresident primary caregivers. Primary caregivers who felt less burdened, who gave personal care more intensively, and/or who were assisted by secondary caregivers, were more likely to provide informal end-of-life care at home until the time of death. Conclusions: Our study showed that informal care at the end of life of older people living in the community is complex, since the care required is considerable and highly varied, and involves assistance from secondary informal caregivers, formal home caregivers as well as institutional care. Burden of informal care is one of the most important factors associated with home death. More attention is needed to help ease the burden on informal caregivers, specifically with regard to resident caregivers and spouses. Since these resident caregivers were disadvantaged in several respects (i.e., health, income, assistance from other carers) compared to nonresident caregivers, interventions by formal caregivers should also be directed towards these persons, enabling them to bear the burden of end-of-life care. Palliative Medicine 2004; 18: 468-477

BackgroundIt is well-known that the use of care services is most intensive in the last phase of life. However, so far only a few determinants of end-of-life care utilization are known. The aims of this study were to describe the utilization of acute and long-term care among older adults in their last year of life as compared to those not in their last year of life, and to examine which of a broad range of determinants can account for observed differences in care utilization.MethodsData were used from the Longitudinal Aging Study Amsterdam (LASA). In a random, age and sex stratified population-based cohort of 3107 persons aged 55 – 85 years at baseline and representative of the Netherlands, follow-up cycles took place at 3, 6 and 9 years. Those who died within one year directly after a cycle were defined as the "end-of-life group" (n = 262), and those who survived at least three years after a cycle were defined as the "survivors". Utilization of acute and long-term care services, including professional and informal care, were recorded at each cycle, as well as a broad range of health-related and psychosocial variables.ResultsThe end-of-life group used more care than the survivors. In the younger-old this difference was most pronounced for acute care, and in the older-old, for long-term care. Use of both acute and long-term home care in the last year of life was fully accounted for by health problems. Use of institutional care at the end of life was partly accounted for by health problems, but was not fully explained by the determinants included.ConclusionThis study shows that severity of health problems are decisive in the explanation of the increase in use of care services towards the end-of-life. This information is essential for an appropriate allocation of professional health care to the benefit of older persons themselves and their informal caregivers.

Alternative treatment, such as homoeopathy, acupuncture and spiritual healing, are popular among patients with rheumatic diseases. Rheumatologists are therefore likely to be confronted with patients who make use of less orthodox health care. Patients' and rheumatologists' views on the subject and on the rheumatologists' role, however, have not yet been assessed. A questionnaire on alternative medicine was sent to all 101 practising Dutch rheumatologists (response rate: 70%). After the results had been analysed 17 rheumatologists, seven rejecting alternative medicine and ten accepting it, handed out a questionnaire to a sample of their patients: 1466 patient questionnaires were distributed (response rate: 80%). Of the respondents 43% had visited an alternative practitioner at least once for their rheumatism and 26% in the year before the survey was held. Hand healers, homoeopaths and acupuncturists were most often visited. Rheumatologists, on their part, were not too enthusiastic about these visits. Only patients' visits to spa treatment centres were welcomed by a majority of them; visits of their patients to manipulative therapists, acupuncturists and homoeopaths were judged positively by a large minority, whereas other therapies were strongly disapproved. Nevertheless, most patients informed their rheumatologist about their visiting an alternative practitioner. A surprisingly low percentage of these patients noticed that the rheumatologist did not sympathize with it. Although many patients paid a visit to an alternative practitioner because regular care did not really help them, their satisfaction with the alternative treatment turned out to be less than their satisfaction with the rheumatologists' help.(ABSTRACT TRUNCATED AT 250 WORDS)

A questionnaire on alternative medicine was sent to 600 general practitioners in the Netherlands. Most of the 360 (60%) GPs who replied expressed on interest in alternative practice; and 47% revealed that they used one or more alternative methods themselves, most often homoeopathy. However, the number of patients given alternative treatment by each doctor was small. Almost all (90%) of the GPs referred patients to alternative practitioners. There is no reason to assume that GPs make use of alternative methods just to meet their patients' wishes. A majority of the respondents thought that these therapies included ideas and methods from which the regular methods might benefit. Actual contacts with alternative practitioners are mostly limited to those practicing acupuncture, homeopathy and manipulative medicine with a regular medical or paramedical education. The integration of alternative medicine within the medical system goes hand in hand with its acceptance by general practitioners. Contact with medically or paramedically qualified practitioners has hardly any legal implications for individual general practitioners.