Examining proximity to death and health care expenditure by disease: a Bayesian-based descriptive statistical analysis from the National Health Insurance database in Japan

Background Japan is one of the Organization for Economic Co-operation and Development (OECD) countries where population aging and increasing health care expenditures (HCE) are urgent issues. Recent studies have identified factors other than age, such as proximity to death and morbidity, as contributing factors to the increase in medical costs. It is important to assess HCE by disease and analyze their factors to estimate and improve future HCE. Methods We extracted individual records spanning approximately 2 years prior to the death of persons aged 65 to 95 years from the National Health Insurance data in Japan, and used a Bayesian approach to decompose monthly HCE into five disease groups (circulatory, chronic kidney disease, neoplasms, respiratory, and others). The relationship between the proximity to death and the average HCE in each disease group was stratified by sex and age and analyzed using a descriptive statistical method similar to the two-part model. Results The average HCE increased rapidly as death approached in most disease groups, but the increase-pattern differed greatly among disease groups, sex, and age groups. The effect of proximity to death on average HCE was small for chronic diseases, but large for lethal diseases. When stratified by age and sex, younger and male decedents tended to have higher average HCE, but the extent of this varied by disease group. The two-year cumulative average HCE for neoplasms in the 65–75 years age group was about six times larger than those in the 85–95 years age group. Conclusions In Japan, it was suggested that disease, proximity to death, age, and sex may contribute to HCE. However, these factors interact in a complex manner, and it is important to analyze HCE by disease. In addition, preventing or delaying the severity of diseases with high medical burdens in younger people may be effective in reducing future terminal care costs. These findings have important implications for future projections and improvements of HCE.

Processing Intensive Care Unit Treatment Experiences: A Thematic Analysis of a Diary Intervention

Survivors of the intensive care unit (ICU) report an aggregate of burdensome memories. ICU diaries have been proposed to address the psychological impact of ICU treatment. Twenty-six participants wrote about their ICU experiences in three successive sessions, while in the second session, they were presented with a dairy derived from their medical records. Using inductive thematic analysis in the first and third narratives, we explore how participants initially describe their ICU experience and how they process it after the intervention. Participants described a martyrdom experience, including being emotionally distressed, disorientated, and physically trapped that provoked a quest for any available interpersonal support. A vacuum-like state permeated their existence, impacted their sense-making ability, and the proximity to death uniquely characterized this experience. After intervention, participants made small but significant changes in their written narratives. They appeared to reorganize their recollections, reestablish self-continuity by integrating their ICU experiences, and authored restitution narratives.

Hospitalizations and emergency department visits trends among elderly individuals in proximity to death: a retrospective population-based study

Acute healthcare services are extremely important, particularly during the COVID-19 pandemic, as healthcare demand has rapidly intensified, and resources have become insufficient. Studies on specific prepandemic hospitalization and emergency department visit (EDV) trends in proximity to death are limited. We examined time-trend specificities based on sex, age, and cause of death in the last 2 years of life. Datasets containing all hospitalizations and EDVs of elderly residents in Friuli-Venezia Giulia, Italy (N = 411,812), who died between 2002 and 2014 at ≥ 65 years, have been collected. We performed subgroup change-point analysis of monthly trends in the 2 years preceding death according to sex, age at death (65–74, 75–84, 85–94, and ≥ 95 years), and main cause of death (cancer, cardiovascular, or respiratory disease). The proportion of decedents (N = 142,834) accessing acute healthcare services increased exponentially in proximity to death (hospitalizations = 4.7, EDVs = 3.9 months before death). This was inversely related to age, with changes among the youngest and eldest decedents at 6.6 and 3.5 months for hospitalizations and at 4.6 and 3.3 months for EDVs, respectively. Healthcare use among cancer patients intensified earlier in life (hospitalizations = 6.8, EDVs = 5.8 months before death). Decedents from respiratory diseases were most likely to access hospital-based services during the last month of life. No sex-based differences were found. The greater use of acute healthcare services among younger decedents and cancer patients suggests that policies potentiating primary care support targeting these at-risk groups may reduce pressure on hospital-based services.

Divergent patterns of confrontation with death using the Anticipated Farewell to Existence Questionnaire (AFEQT): a cross-sectional comparative study of four samples with increasing proximity to death

Background Based on the concept of “Daseinsverabschiedung”, an anthropological theory of “Anticipated Farewell to Existence” (AFE) was suggested on the basis of six grounding dimensions: selfhood, interpersonality, temporality, corporeality, worldliness, and transcendence, which are activated in a genuine manner facing death. The purpose of the study is to quantitatively compare the extent of confrontation with death between dying people in palliative care and those in other stages of life by means of the Anticipated Farewell to Existence Questionnaire” (AFEQT), based on these dimensions. Methods The sample (N = 485) consists of dying individuals in palliative wards and hospices (n = 121); old people living in nursing homes not suffering from a mortal disease (n = 62); young adults (n = 152), and middle-aged adults (n = 150). The design is cross-sectional and analytical. The relevance of anticipated farewell to existence was measured by means of the AFEQT. The internal consistency of the AFEQT was assessed using Cronbach’s alpha and convergent validity by means of dimensions of the Life Attitude Profile-Revised (LAP-R). Differences between groups and associations with control variables were estimated by means of multiple regression models, including propensity scores. Results Cronbach’s alpha for AFEQT was > 0.80 for the whole test and all subsamples, but < 0.70 for most dimensions in dying people. Correlations between each dimension and corresponding two factors was almost overall r > 0.80, p < 0.001. Good convergent validity between dimensions of AFEQT and of Life Attitude Profile-Revised in young and middle-aged participants showed correlations for superordinate indices between -0.23 and 0.72, and an overall p < 0.001. Dying people scored significantly higher for all dimensions, especially “altruistic preoccupation” and “reconciliation with existence” than people in other life stages (p < 0.01- < 0.001). Personality traits of “openness” and “agreeableness” are positively associated with higher scoring of AFEQT dimensions. About 77% of dying participants reported a personal benefit through the interview questions. Conclusions With proximity to death, the anthropological dimensions proposed scored significant higher than in other stages of life, reflecting a stronger awareness, confrontation and reconciliation with the end of their own life. These dimensions, especially preoccupation for related persons and coexistence of acceptance and struggle with death have to be taken into account in a sensitive way by supporting dialogues with dying people and their relatives. Trial registration Observational cross-sectional study.

Health economics for palliative care

Healthcare costs are escalating due to public demand for, and the increasing availability of, treatment. National frameworks that use economic evaluation as a basis for health technology assessment have been successful at constraining expenditure on low-value treatments primarily by explicitly considering the opportunity cost of new technology adoption or service redesign. At the end of life and in palliative contexts, such methods have not been widely applied and are underdeveloped despite evidence that healthcare costs typically increase with proximity to death. There may be a requirement for the adaptation of standard methods for healthcare resource allocation in this setting, where the goals of care may differ from a curative or preventative context. Health service and financing models may be complex and specific to this setting, with a greater consideration for third-sector provision and informal care. This chapter outlines the core concepts in health economics that are relevant in the planning of palliative services, with specific considerations in the developed and developing world contexts.

Analysis of Experiences and Psychological Perceptions of Recovered COVID-19 Patients

Aim: The aim of this study was to analyze the experiences and psychological perceptions of recovered COVID-19 patients. Methods: This research was conducted using qualitative approach of phenomenology type. The population of this study included the patients recovered from Corona virus in Tehran province. Sampling was performed purposefully. The research was conducted through semi-structured interviews. Collaizi’s seven-step method was applied for analyzing the data. Findings: After coding the interviews and categorizing the topics, the following nine main themes were obtained: initial reaction of loneliness and the need for receiving compassion, negative consequences, proximity to death and the reaction of individuals toward it, effective coping activities, mutual transmission of mental status of the patient, caregivers and medical staff, the effect of illness on meaning and style of life, preoccupation with duties and responsibilities. Conclusion: The present study showed that the experiences of Covid-19 patients have similarities and differences and being ware of these experiences may help the experts and policymakers to prevent the psychological crisis in the post-corona period and prepare the people psychologically in the society to face the epidemics.

Sandra Bland at the cross: A womanist reading of Mark 15:40-47

How do women who lack power and privilege experience the cross? How do women who lack power and privilege view privileged men at the cross? How do such questions probe issues of Jesus’s death in the Markan passion narrative? This article employs a womanist hermeneutic of “gazing” to interpret differently the complexity of women in close proximity to death while interrogating one particular woman’s close proximity to death in contemporary memory: Sandra Bland. Particularly, a womanist hermeneutic of gazing coupled with a womanist hermeneutic of suspicion provides a liberating space for nuanced engagement with the women who gaze upon Jesus’s crucifixion from afar. Recognizing specifically that the Gospel of Mark uses the Greek word βλέπω ( blepō) to identify “seeing” as a metaphor for belief, how does a womanist understanding of the Greek term θεωρέω ( theōreō, which the gospel writer uses sparingly) crack open the text for contemporary audiences? Engaging issues of power, privilege, and death in relationship to the “gaze” of Mark 15:40-47, this article highlights that the women who attempt to anoint Jesus’s body in the Markan narrative, because of their gender in the highly charged testosterone environment of a militarized imperial execution, have more “skin in the game,” different from the privileged position of men in the text. What happens when women are confronted with men who exhibit high levels of masculine testosterone and masculine identity? Like Sandra Bland, they are closer to death. Accordingly, thinking through the women who go to anoint Jesus with contemporary women today means that women who are often closer to death must continue the analytical work of “gazing”, as found in Mark 15:47 to the point that returning the “gaze” produces change for those closest to death (e.g., black and brown bodies close to militarized imperial violence).

Healthcare trajectories and costs in the last year of life: a retrospective primary care and hospital analysis

ObjectivesTo analyse healthcare utilisation and costs in the last year of life in England, and to study variation by cause of death, region of patient residence and socioeconomic status.MethodsThis is a retrospective cohort study. Individuals aged 60 years and over (N=108 510) who died in England between 2010 and 2017 were included in the study.ResultsHealthcare utilisation and costs in the last year of life increased with proximity to death, particularly in the last month of life. The mean total costs were higher among males (£8089) compared with females (£6898) and declined with age at death (£9164 at age 60–69 to £5228 at age 90+) with inpatient care accounting for over 60% of total costs. Costs decline with age at death (0.92, 95% CI 0.88 to 0.95, p<0.0001 for age group 90+ compared with to the reference category age group 60–69) and were lower among females (0.91, 95% CI 0.90 to 0.92, p<0.0001 compared with males). Costs were higher (1.09, 95% CI 1.01 to 1.14, p<0.0001) in London compared with other regions.ConclusionsHealthcare utilisation and costs in the last year of life increase with proximity to death, particularly in the last month of life. Finer geographical data and information on healthcare supply would allow further investigating whether people receiving more planned care by primary care and or specialist palliative care towards the end of life require less acute care.

Health care and long-term care costs by age and proximity to death in a publicly funded universal system: A descriptive study of population data

Trends in population ageing parallel concerns with escalating health care expenditures. The purposes of this study are to (1) estimate the distribution of health care and long-term care costs to ascertain the relative importance of age vs. proximity to death as the main driver of costs; (2) explore the relative importance of user rates and costs per user as the primary driver of per capita costs of selected services for survivors and decedents, respectively; and (3) provide projections of future costs. We use data on service use for the entire Norwegian population from four national registers linked with the Cause of Death Registry to calculate costs per decedent in the last 365 days of life and the average one-year costs of people surviving at least two years. Future costs were calculated using projections on population and probability of death from Statistics Norway. We find that the substantial increase in costs at older ages among both decedents and survivors relates to higher long-term care costs. Health care costs peak in the late 50s among decedents and in the early 80s among survivors and then decrease with age. While costs in the last year of life for each decedent are 19 times the average costs of survivors, the decedent/survivor cost ratio decreases with age to less than double among those aged ³95 years. Expenditure projections indicate an increase in spending due to population ageing, especially in long-term care expenditures. For somatic hospital costs, proximity to death has a greater impact on costs than age; the age effect is more important for long-term care, implying that the “red herring” effect is larger for acute health care than for long-term care. Adjusting for costs during the last year of life reduces the projected increase in expenditures, but only to a limited extent.