Predictors of the final place of care of patients with advanced cancer receiving integrated home-based palliative care: a retrospective cohort study

Abstract

Background Meeting patients’ preferences for place of care at the end-of-life is an indicator of quality palliative care. Understanding the key elements required for terminal care within an integrated model may inform policy and practice, and consequently increase the likelihood of meeting patients’ preferences. Hence, this study aimed to identify factors associated with the final place of care in patients with advanced cancer receiving integrated, home-based palliative care. Methods This retrospective cohort study included deceased adult patients with advanced cancer who were enrolled in the home-based palliative care service between January 2016 and December 2018. Patients with < 2 weeks’ enrollment in the home-based service, or ≤ 1-week duration at the final place of care, were excluded. The following information were retrieved from patients’ electronic medical records: patients’ and their families’ characteristics, care preferences, healthcare utilization, functional status (measured by the Palliative Performance Scale (PPSv2)), and symptom severity (measured by the Edmonton Symptom Assessment System). Multivariate logistic regression was employed to identify independent predictors of the final place of care. Kappa value was calculated to estimate the concordance between actual and preferred place of death. Results A total of 359 patients were included in the study. Home was the most common (58.2%) final place of care, followed by inpatient hospice (23.7%), and hospital (16.7%). Patients who were single or divorced (OR: 5.5; 95% CI: 1.1–27.8), or had older family caregivers (OR: 3.1; 95% CI: 1.1–8.8), PPSv2 score ≥ 40% (OR: 9.1; 95% CI: 3.3–24.8), pain score ≥ 2 (OR: 3.6; 95% CI: 1.3–9.8), and non-home death preference (OR: 23.8; 95% CI: 5.4–105.1), were more likely to receive terminal care in the inpatient hospice. Patients who were male (OR: 3.2; 95% CI: 1.0–9.9), or had PPSv2 score ≥ 40% (OR: 8.6; 95% CI: 2.9–26.0), pain score ≥ 2 (OR: 3.5; 95% CI: 1.2–10.3), and non-home death preference (OR: 9.8; 95% CI: 2.1–46.3), were more likely to be hospitalized. Goal-concordance was fair (72.6%, kappa = 0.39). Conclusions Higher functional status, greater pain intensity, and non-home death preference predicted institutionalization as the final place of care. Additionally, single or divorced patients with older family caregivers were more likely to receive terminal care in the inpatient hospice, while males were more likely to be hospitalized. Despite being part of an integrated care model, goal-concordance was sub-optimal. More comprehensive community networks and resources, enhanced pain control, and personalized care planning discussions, are recommended to better meet patients’ preferences for their final place of care. Future research could similarly examine factors associated with the final place of care in patients with advanced non-cancer conditions.

Illnesses and Symptoms in Older Adults at the End of Life at Different Places of Death in Korea

“…Rather, older adults who died at hospitals had a higher likelihood of experiencing ADL limitation (1.14 times) and several debilitating symptoms (2.02–4.43 times) than those who died at home. This finding was not in line with the previous studies, which suggested that patients with advanced cancer who had higher functional status and greater pain intensity were more likely to be hospitalized at the end of life [ 12 ]. Our results also suggest that older adults who are in their end of life and admitted to hospitals in Korea need more attention regarding a progressive functional decline and debilitating symptoms, including anorexia, depression, weakness, dyspnea, and confusion, from comorbid chronic illnesses.…”

“…In a systematic review about terminally ill patients with cancer, death at home was associated with a long duration of disease and low functional status, while disease symptoms and pain were not associated with the place of death [ 10 ]. Another study reported that higher functional status and greater pain intensity predicted institutionalization as the final place of care in older adults with cancer enrolled in home-based palliative care service [ 12 ]. A study involving geriatric outpatients in Turkey stated that the prevalence of death was higher for in-hospital older patients with chronic renal failure, but no other comorbid condition was associated with the place of death [ 6 ].…”

“…Although most older adults suffer from multiple illnesses and symptoms at the end of life, there is limited data regarding the prevalence of symptoms and illnesses in older adults with multiple comorbidities at death in common care settings [ 6 , 9 ]. Previous studies analyzing the determinants for the place of death among older adults have mostly been conducted for single diseases, such as cancer [ 12 , 13 , 14 ], dementia [ 15 , 16 , 17 ], and lung, kidney, or liver diseases [ 18 , 19 , 20 ], with most data available as demographic and clinical characteristics. As palliative services need to be tailored as per the patient’s illness and symptoms, which might differ from each place of end-of-life care, more information is needed to identify the reported illnesses and symptoms at various places of care for older adults at the end of life in Korea.…”

Longitudinal patterns and predictors of healthcare utilization among cancer patients on home-based palliative care in Singapore: a group-based multi-trajectory analysis

“…Within literature, predictive factors for higher utilization among HPC patients included younger age [ 14 – 16 ], male gender [ 14 , 15 , 17 ], more comorbidities [ 14 , 16 ], better function [ 17 ], and reduced hospice capacity [ 14 , 15 , 18 ]. Preference to die at home, having an involved decision-maker, and an advanced care plan (ACP) protect against hospitalizations [ 17 , 19 , 20 ]. These studies typically measured healthcare utilization as an aggregated single composite index over a cross-sectional period (e.g.…”

Supporting the Heterogeneous and Evolving Treatment Preferences of Patients With Heart Failure Through Collaborative Home‐Based Palliative Care

“…Prior studies have demonstrated that home‐based models of palliative care may align patients' actual locations of care and death with their preferences. 10 , 11 , 12 , 13 However, these studies were not specifically for patients with HF, where prognosticating death is particularly difficult. 3 There is therefore a gap in knowledge regarding the ability to support potentially heterogeneous treatment care preferences for patients with HF.…”