Implementation of the Mental Capacity Act: a national observational study of changes in place of death for older heart failure patients with or without comorbid dementia

2021 ◽  
Author(s):  
James M. Beattie ◽  
Irene J. Higginson ◽  
Theresa A. McDonagh ◽  
Wei Gao
Keyword(s):  
Heart Failure ◽  
Mental Capacity ◽  
Place Of Death ◽  
Care Homes ◽  
Appreciable Change ◽  
Heart Failure Patients ◽  
Comorbidity Burden ◽  
Dying At Home ◽  
Mental Capacity Act ◽  
At Home

Abstract Background: Heart failure is increasingly prevalent in the growing elderly population and commonly associated with cognitive impairment. This study compared trends in place of death (PoD) of heart failure patients with / without comorbid dementia over the period of implementation of the Mental Capacity Act (MCA) in October 2007, this legislation supporting patient-centred decision making for those with reduced agency.Methods: Analyses of death certification data for England between January 2001 and December 2018, describing the PoD and sociodemographic characteristics of all people ≥ 65 years registered with heart failure as the underlying cause of death, with / without a mention of comorbid dementia. Multiple Poisson regression modelling was used to determine the prevalence ratio (PR) of dying at home or in care homes compared to dying in hospital. Covariates included year of death, age, gender, marital status, comorbidity burden, index of multiple deprivation and urban / rural settings.Results:120,068 heart failure-related death records were included of which 8199 mentioned dementia as a contributory cause. The overall prevalence of dementia was 6.8%, the trend significantly increasing from 5.6% to 8.0% pre- and post-MCA (p<0.0001). Dementia was coded as unspecified (78.2%), Alzheimer’s disease (13.5%) and vascular (8.3%). Those with dementia were more commonly older, female, widowed, and had more comorbidities. Pre-MCA, PoD for heart failure patients without dementia was hospital 68.2%, care homes 20.2%, 10.7% dying at home. The corresponding figures for those with comorbid dementia were 47.6%, 48.0% and 4.2%, respectively. Following MCA enforcement, PoD for those without dementia shifted from hospital to home, PR: 1.026 [95%CI: 1.024-1.029]. This trend was not significant for those with dementia, PR: 1.001 [0.988-1.015], hospital deaths increasing. Care home deaths reduced for all, with or without dementia, PR: 0.959 [0.949-0.969], and PR: 0.996 [0.993-0.998], respectively. Hospice as PoD was rare for both groups (≤0.5%) with no appreciable change over the study period.Conclusions: Our analyses suggest the MCA did not materially affect the PoD of heart failure decedents with comorbid dementia, likely reflecting difficulties implementing this legislation in real-life clinical practice.

Palliative Care Consultation Affects How and Where Heart Failure Patients Die

2020 ◽  
pp. 104990912096356
Author(s):  
Richard Pham ◽  
Casey McQuade ◽  
Alex Somerfeld ◽  
Sandra Blakowski ◽  
Gavin W. Hickey
Keyword(s):  
Heart Failure ◽  
Palliative Care ◽  
Chi Square ◽  
Code Status ◽  
Heart Failure Patients ◽  
Palliative Care Consultation ◽  
Care Consultation ◽  
Dying At Home ◽  
The Impact ◽  
At Home

Objective: Determine the role of palliative care on terminal code status and setting of death for those with heart failure. Background: Although palliative care consultation (PCC) has increased for many conditions, PCC has not increased in those with cardiovascular disease. While it has been shown that the majority of those with heart failure die in medical facilities, the impact of PCC on terminal code status and setting of death requires further analysis. Methods: Patients admitted with heart failure between 2014-2015 at an academic VA Healthcare System were reviewed. Primary outcome was terminal code status. Secondary outcomes included setting of death, hospice utilization, and mortality scores. Student t-testing and Chi-square testing were performed where appropriate. Results: 334 patients were admitted with heart failure and had a median follow up time of 4.3 years. 196 patients died, with 122 (62%) receiving PCC and 74 (38%) without PCC. Patients were more likely to have terminal code statuses of comfort measures with PCC (OR = 4.6, p = 0.002), and less likely to be full code (OR = 0.09, p < 0.001). 146 patients had documented settings of death and were more likely to receive hospice services with PCC (OR 6.76, p < 0.001). A patient’s chance of dying at home was not increased with PCC (OR 0.49, p = 0.07), but they were more likely to die with inpatient hospice (OR = 17.03; p < 0.001). Conclusion: Heart failure patients who received PCC are more likely to die with more defined care preferences and with hospice services. This does not translate to dying at home.

scholarly journals CARE MANAGEMENT CHALLENGES AND PROGNOSTIC TOOLS FOR HEART FAILURE PATIENTS IN HOSPICE

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S791-S791
Author(s):  
Ruth Masterson Creber ◽  
Lizeyka Jordan ◽  
Dawon Baik ◽  
David Russell
Keyword(s):  
Heart Failure ◽  
End Of Life ◽  
Medical Devices ◽  
Care Management ◽  
Qualitative Interviews ◽  
Heart Failure Patients ◽  
Performance Scale ◽  
Worse Prognosis ◽  
Management Issues ◽  
At Home

Abstract Heart failure (HF) patients enroll in hospice at lower rates despite their worse prognosis. This multi-method study explores the characteristics and challenges associated with caring for HF patients. Data from qualitative interviews with hospice providers (n=32) and quantitative records (N=1,114) were used to identify care management issues and prognostic tools. Hospice providers described HF patients unique and often unpredictable symptomatology, their limited understanding and discordant hospice expectations, and difficulties managing symptoms at home. Providers also highlighted HF patients use of assistive medical devices and complex medication regimens. Palliative Performance Scale (PPSv2) scores at hospice enrollment were found to be strongly associated with hospice survival (AUC: 7 days=0.80; 14 days=0.77) and live discharge risk (PPSv2 50-70% AOR=5.68 [CI=3.66-8.79]). Findings underscore the need for specially-tailored trainings and protocols for providers to prevent unplanned discharges and support HF patients at end-of-life.

scholarly journals Predictors of Death at Home Among Cancer Patients in Israel: A Population-based Study

2020 ◽  
Author(s):  
Yakir Rottenberg ◽  
Gil Goldzweig ◽  
Adir Shaulov
Keyword(s):  
Cancer Patients ◽  
Binary Logistic Regression ◽  
Hematologic Malignancies ◽  
Population Based ◽  
Place Of Death ◽  
Personal Factors ◽  
Low Socioeconomic ◽  
Predictive Variables ◽  
Dying At Home ◽  
At Home

Abstract Background: Most cancer patients want to die at home; however, many die in hospital. The aim of the current study is to elucidate the correlation between dying at home and various personal factors in the Israeli population of cancer patients.Methods: Data on cancer incidence (2008-2015) and death (2008-2017) was provided by the Israeli Central Bureau of Statistics and the Israel National Cancer Registry. Binary logistic regression analyses were performed to assess odds ratios for death at home following cancer diagnosis while controlling for age, sex, ethnicity, years of education, residential socioeconomic score, and time from diagnosis. We also assessed the relation between place of death and specific cancer sites, as well as the time trend from 2008-2017.Results: About one quarter (26.7%) of the study population died at home. Death at home was most frequent among patients diagnosed with brain tumors (37.0%), while it was the lowest among patients with hematologic malignancies (lymphoma and leukemia, 20.3% and 20.0%, respectively). Rates of dying at home among patients with residential socioeconomic scores of 1, 2-9, and 10 were about 15%, 30%, and 42.9%, respectively. In patients from the 4th to the 7th decades of life, rates of death at home increased at a linear rate that increased exponentially from the 8th decade onwards. After controlling for potential confounders, predictive variables for death at home included age (HR=1.020 per year), male sex (HR=1.18), years of education (HR=1.029 per year), and time from diagnosis (HR=1.003 per month, all p<0.001). No trend was seen from 2008-2013, while from 2014-2017 a slight increase in the rate of death at home was seen each year.Conclusions: These results indicate that inequality exists among cancer patients in Israel regarding the opportunity to die at home. The present findings stress the importance of delivering efficient palliative care at home, mainly for patients with hematologic malignancies, younger patients, and patients of very low socioeconomic statuses. Understanding the complex mechanisms whereby patient preferences and the above variables may determine the preferred place of death remains an important research priority.

scholarly journals Disparities in place of death for patients with hematological malignancies, 1999 to 2015

2019 ◽  
Vol 3 (3) ◽  
pp. 333-338 ◽  
Author(s):  
Fumiko Chino ◽  
Arif H. Kamal ◽  
Junzo Chino ◽  
Thomas W. LeBlanc
Keyword(s):  
End Of Life Care ◽  
Multivariate Regression ◽  
Hematological Malignancies ◽  
Death Certificate ◽  
Multivariate Regression Analysis ◽  
Hematologic Malignancies ◽  
Place Of Death ◽  
Hospital Deaths ◽  
Dying At Home ◽  
At Home

Abstract Patients with hematologic malignancies (HMs) often receive aggressive end-of-life care and less frequently use hospice. Comprehensive longitudinal reporting on place of death, a key quality indicator, is lacking. Deidentified death certificate data were obtained via the National Center for Health Statistics for all HM deaths from 1999 to 2015. Multivariate regression analysis (MVA) was used to test for disparities in place of death associated with sociodemographic variables. During the study period, there were 951 435 HM deaths. Hospital deaths decreased from 54.6% in 1999 to 38.2% in 2015, whereas home (25.9% to 32.7%) and hospice facility deaths (0% to 12.1%) increased (all P &lt; .001). On MVA of all cancers, HM patients had the lowest odds of home or hospice facility death (odds ratio [OR], 0.55; 95% confidence interval, 0.54-0.55). Older age (40-64 years: OR, 1.34; ≥65 years: OR, 1.89), being married (OR, 1.62), and having myeloma (OR, 1.34) were associated with home or hospice facility death, whereas being black or African American (OR, 0.68), Asian (OR, 0.58), or Hispanic (OR, 0.84) or having chronic leukemia (OR, 0.83) had decreased odds of dying at home or hospice (all P &lt; .001). In conclusion, despite hospital deaths decreasing over time, patients with HMs remained more likely to die in the hospital than at home.

Medicaid patients more likely to die at home without hospice during the pandemic versus before, exacerbating disparities with commercially insured patients.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 6502-6502
Author(s):  
Laura Elizabeth Panattoni ◽  
Li Li ◽  
Qin Sun ◽  
Catherine R. Fedorenko ◽  
Hayley Sanchez ◽  
...  
Keyword(s):  
End Of Life ◽  
Cancer Patients ◽  
Low Income ◽  
Place Of Death ◽  
Cancer Type ◽  
Breast Cancer Patients ◽  
Patients Âgés ◽  
Dying At Home ◽  
Insured Patients ◽  
At Home

6502 Background: The COVID-19 pandemic dramatically reduced family access to hospitals and created new barriers to home hospice care, raising concerns about how the pandemic has impacted cancer patients’ place of death and end of life home hospice support. Hypothesizing that Medicaid-enrolled cancer patients may be at greater risk of disruptions in end-of-life care compared to commercially insured patients, we examined changes in place of death and home hospice support for Medicaid and Commercial enrollees following the pandemic. Methods: We linked WA State cancer registry records with claims from Medicaid and approximately 75% of commercially insured cancer patients in the state. Patients ages 18-64 with solid-tumor malignancies who died March-June 2020 (COVID) were compared to those who died March-June 2017-2019 (Pre-COVID). Place of death was categorized as hospital, home with hospice, and home without hospice; nursing home deaths were excluded. Given our sample size, we examined differences in the likelihood of place of death with Fisher’s exact tests and multinomial logistic regressions stratified by payer and by COVID period, controlling for age, gender, race, stage, cancer type, and census tract-level neighborhood deprivation. We report marginal effects. Results: In Fisher’s exact analyses, Medicaid but not commercial patients were significantly less like to die in hospital and more likely to die at home without hospice during COVID (Table). In pre-post adjusted analysis of Medicaid patients, the probability of dying in the hospital was 12.3% (p=0.03) percentage points lower during the pandemic versus before, while the probability of dying at home without hospice was 11.1% (p=0.04) greater. Place of death did not change significantly pre-post for commercial patients. In addition, Pre-COVID, the probability of dying in the hospital was 10.7% (p=0.03) greater for Medicaid than commercial patients. During COVID, the probability of dying at home without hospice was 15.8% (p=0.04) greater for Medicaid versus commercial patients but lower for women (ME=20.2%; p=0.01) and colorectal versus breast cancer patients (ME=39.2%; p=0.01). Conclusions: Following COVID, Medicaid patients place of death shifted from hospital to homes, but without an increase in the use of home hospice services. In contrast, place of death and hospice use among commercial patients did not significantly change. This widening disparity in home deaths without hospice services raises concerns that the pandemic disproportionately worsened end of life experience for low income patients with cancer.[Table: see text]

Reversal of the British trends in place of death: Time series analysis 2004–2010

2012 ◽  
Vol 26 (2) ◽  
pp. 102-107 ◽  
Author(s):  
Barbara Gomes ◽  
Natalia Calanzani ◽  
Irene J Higginson
Keyword(s):  
Descriptive Analysis ◽  
Age Groups ◽  
Place Of Death ◽  
Steady Increase ◽  
Death Time ◽  
Registration Data ◽  
The Usa ◽  
Dying At Home ◽  
National Trends ◽  
At Home

Background: Increased attention is being paid to the place where people die with a view to providing choice and adequately planning care for terminally ill patients. Secular trends towards an institutionalised dying have been reported in Britain and other developed world regions. Aim: This study aimed to examine British national trends in place of death from 2004 to 2010. Design and setting: Descriptive analysis of death registration data from the Office for National Statistics, representing all 3,525,564 decedents in England and Wales from 2004 to 2010. Results: There was a slow but steady increase in the proportion of deaths at home, from 18.3% in 2004 to 20.8% in 2010. Absolute numbers of home deaths increased by 9.1%, whilst overall numbers of deaths decreased by 3.8%. The rise in home deaths was more pronounced in cancer, happened for both genders and across all age groups, except for those younger than 14 years and for those aged 65–84, but only up to 2006. The rise was more evident when ageing was accounted for (age–gender standardised proportions of home deaths increased from 20.6% to 23.5%). Conclusions: Following trends in the USA and Canada, dying is also shifting to people’s homes in Britain. Home deaths increased for the first time since 1974 amongst people aged 85 years and over. There is an urgent need across nations for comparative evidence on the outcomes and the costs of dying at home.

Influences on place of death in Botswana

2010 ◽  
Vol 8 (2) ◽  
pp. 177-185 ◽  
Author(s):  
Mark Lazenby ◽  
Tony Ma ◽  
Howard J. Moffat ◽  
Marjorie Funk ◽  
M. Tish Knobf ◽  
...  
Keyword(s):  
Cause Of Death ◽  
Causes Of Death ◽  
Death Certificate ◽  
Female Gender ◽  
Place Of Death ◽  
Hospital Deaths ◽  
The Mean ◽  
Dying At Home ◽  
At Home

AbstractObjective:There is an emerging body of research aimed at understanding the determinants of place of death, as where people die may influence the quality of their death. However, little is known about place of death for people of Southern Africa. This study describes place of death (home or hospital) and potential influencing factors (cause of death, age, gender, occupation, and district of residence).Method:We collected the death records for years 2005 and 2006 for all adult non-traumatic deaths that occurred in Botswana, described them, and looked for associations using bivariate and multivariate analyses.Results:The evaluable sample consisted of 18,869 death records. Home deaths accounted for 36% of all deaths, and were predominantly listed with “unknown” cause (82.3%). Causes of death for hospital deaths were HIV/AIDS (49.7%), cardiovascular disease (13.8%), and cancer (6.6%). The mean age at the time of all deaths was 53.2 years (SD = 20.9); with 61 years (SD = 22.5) for home deaths and 48.8 years (SD = 18.6) for hospital deaths (p < .001). Logistic regression analysis revealed the following independent predictors of dying at home: unknown cause of death; female gender; >80 years of age; and residing in a city or rural area (p < .05).Significance of Results:A major limitation of this study was documentation of cause of death; the majority of people who died at home were listed with an unknown cause of death. This finding impeded the ability of the study to determine whether cause of death influenced dying at home. Future study is needed to determine whether verbal autopsies would increase death-certificate listings of causes of home deaths. These data would help direct end-of-life care for patients in the home.

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