Putrefaction in the pandemic: a comparative study of the frequency of advanced decomposition change in coronial autopsies since the start of the COVID-19 pandemic

AimsThe aim of this study is to evaluate whether there has been a significant change in the frequency of markedly decomposed bodies having coronial autopsies since the UK’s first COVID-19 lockdown.MethodsWe compared coronial autopsies (n=263) performed by one pathologist at a central London mortuary in the 1 year before and after 23 March 2020 by analysing their autopsy reports and coronial documentation.ResultsWe have shown that there has been a significant increase of 70.5% (p=0.001) in the frequency of markedly decomposed bodies having coronial autopsies since the first lockdown. This is associated with a 38% increase (p=0.0001) in the rate of those dying at home and a 52.4% decrease (p=0.00003) in the rate of those dying in hospital who go on to have a coronial autopsy in our facility. Our results suggest that the most significant factor behind the increased frequency in advanced decomposition change since the first lockdown is this increase in coronial autopsies for deaths at home relative to deaths in hospital.ConclusionOur results support the idea that perimortem social isolation will lead to an increased frequency of advanced decomposition changes seen at autopsy. We suggest that it could be possible to use the frequency of advanced postmortem decomposition change in a population as a surrogate marker for social isolation in future studies. Our study also illustrates a changing environment where the increasing prevalence of postmortem decomposition changes could affect the accuracy of autopsy reports and the medicolegal consequences thereof.

Characterisation of tuberculosis mortality in informal settlements in Nairobi, Kenya: analysis of data between 2002 and 2016

Background Tuberculosis (TB) remains one of the key public health problems in Africa. Due to multifaceted challenges, its burden is poorly described in informal settlements. We describe tuberculosis mortality in two informal settlements in Nairobi, Kenya. Methods This is a secondary analysis of 2002–2016 verbal autopsy data from informal settlements in the Nairobi Urban Health Demographic Surveillance System (NUHDSS). A descriptive analysis of deaths assigned as caused by TB was done. Pearson chi-square tests were used to determine differences between socio-demographic factors. Logistic regression was carried out to examine the risk of death from TB within the characteristics. Results There were 6218 deaths in the NUHDSS within the period of analysis, of which 930 (14.96%) were deaths from TB. The average number of TB deaths per year was 62(SD 23.9). There was a reduction in TB deaths from 21.2% in 2005 to 1.7% in 2016. Males had 1.39 higher odds of dying from TB than females (AOR 1.39; 95% CI 1.18–1.64; p-value < 0.001). Compared to those aged 30–39 years, the ≥50-year-olds had a 42% lower chance of dying from TB (AOR 0.57; 95% CI 0.47–0.73; p-value < 0.001). Those dying at home had 1.39 odds of dying from TB as compared to those who died in a health facility(AOR 1.93; 95% CI 1.17–1.64; p value< 0.001). Conclusion There was a reduction in TB deaths over the study period. Males had the highest risk of death. There is a need to strengthen TB surveillance and access to TB diagnosis and treatment within informal settlements to enhance early diagnosis and treatment.

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

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.

The ‘work’ of managing medications when someone is seriously ill and dying at home: A longitudinal qualitative case study of patient and family perspectives’

Background: Managing medications can impose difficulties for patients and families which may intensify towards the end of life. Family caregivers are often assumed to be willing and able to support patients with medications, yet little is known about the challenges they experience or how they cope with these. Aim: To explore patient and family caregivers’ views of managing medications when someone is seriously ill and dying at home. Design: A qualitative design underpinned by a social constructionist perspective involving interviews with bereaved family caregivers, patients and current family caregivers. A thematic analysis was undertaken. Setting/participants: Two English counties. Data reported in this paper were generated across two data sets using: (1) Interviews with bereaved family caregivers ( n = 21) of patients who had been cared for at home during the last 6 months of life. (2) Interviews ( n = 43) included within longitudinal family focused case studies ( n = 20) with patients and current family caregivers followed-up over 4 months. Results: The ‘work of managing medications’ was identified as a central theme across the two data sets, with further subthemes of practical, physical, emotional and knowledge-based work. These are discussed by drawing together ideas of illness work, and how the management of medications can substantially add to the burden placed on patients and families. Conclusions: It is essential to consider the limits of what it is reasonable to ask patients and families to do, especially when fatigued, distressed and under pressure. Focus should be on improving support via greater professional understanding of the work needed to manage medications at home.

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

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]