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Low socioeconomic position (SEP) is recognized as a risk factor for worse health outcomes. How socioeconomic factors influence end-of-life care, and the magnitude of their effect, is not understood. This review aimed to synthesise and quantify the associations between measures of SEP and use of healthcare in the last year of life. MEDLINE, EMBASE, PsycINFO, CINAHL, and ASSIA databases were searched without language restrictions from inception to 1 February 2019. We included empirical observational studies from high-income countries reporting an association between SEP (e.g., income, education, occupation, private medical insurance status, housing tenure, housing quality, or area-based deprivation) and place of death, plus use of acute care, specialist and nonspecialist end-of-life care, advance care planning, and quality of care in the last year of life. Methodological quality was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS). The overall strength and direction of associations was summarised, and where sufficient comparable data were available, adjusted odds ratios (ORs) were pooled and dose-response meta-regression performed. A total of 209 studies were included (mean NOS quality score of 4.8); 112 high- to medium-quality observational studies were used in the meta-synthesis and meta-analysis (53.5% from North America, 31.0% from Europe, 8.5% from Australia, and 7.0% from Asia). Compared to people living in the least deprived neighbourhoods, people living in the most deprived neighbourhoods were more likely to die in hospital versus home (OR 1.30, 95% CI 1.23-1.38, p < 0.001), to receive acute hospital-based care in the last 3 months of life (OR 1.16, 95% CI 1.08-1.25, p < 0.001), and to not receive specialist palliative care (OR 1.13, 95% CI 1.07-1.19, p < 0.001). For every quintile increase in area deprivation, hospital versus home death was more likely (OR 1.07, 95% CI 1.05-1.08, p < 0.001), and not receiving specialist palliative care was more likely (OR 1.03, 95% CI 1.02-1.05, p < 0.001). Compared to the most educated (qualifications or years of education completed), the least educated people were more likely to not receive specialist palliative care (OR 1.26, 95% CI 1.07-1.49, p = 0.005). The observational nature of the studies included and the focus on high-income countries limit the conclusions of this review. In high-income countries, low SEP is a risk factor for hospital death as well as other indicators of potentially poor-quality end-of-life care, with evidence of a dose response indicating that inequality persists across the social stratum. These findings should stimulate widespread efforts to reduce socioeconomic inequality towards the end of life.

Background Providing individualised healthcare in line with patient wishes is a particular challenge for emergency healthcare professionals. Documentation of patient wishes (DPW), e.g. as advance directives, can guide clinicians in making end-of-life decisions that respect the patient’s wishes and autonomy. However, patient centered decisions are hindered by limited availability of DPWs in emergency settings. Objective This systematic review aims to congregate present data on recorded rates for DPW existence and availability in the emergency department (ED) as well as contributing factors for these rates. Methods We searched MEDLINE, Google Scholar, Embase and Web of Science databases in September 2023. Publications providing primary quantitative data on DPW in the ED were assessed. Publications referring only to a subset of ED patients (other than geriatric) and investigating DPW issued after admission were excluded. Results A total of 22 studies from 1996 to 2021 were included in the analysis. Most were from the US ( n  = 12), followed by Australia ( n  = 4), Canada ( n  = 2), South Korea, Germany, the United Kingdom and Switzerland ( n  = 1 each). In the general adult population presenting to the ED, 19.9–27.8% of patients reported having some form of DPW, but only in 6.8% or less it was available on presentation. In the geriatric population, DPW rates (2.6–79%) as well as their availability (1.1–48.8%) varied widely. The following variables were identified as positive predictors of having DPW, among others: higher age, poorer overall health, as well as sociodemographic factors, such as female gender, having children, being in a relationship, higher level of education or a recent previous presentation to hospital. Conclusions Existence and availability of a recorded DPW among ED patients was low in general and even in geriatric populations mostly well below 50%. While we were able to gather data on prevalence and predictors, this was limited by heterogeneous data. We believe further research is needed to explore the quality of DPW and measures to increase both rates of existence and availability of DPW in the ED.

Context Specialized outpatient palliative care (SOPC) aims at relieving symptoms and providing psychosocial aid in the outpatient setting. SOPC also supports patients in setting up advance directives so that their will is respected in emergency situations. Objectives The aim of this study is to analyze the impact of SOPC on the completion of advance care directives with the focus on medical emergency identification (ID) cards (= living will in a credit card format on yellow paper) and their impact on hospital admissions. Methods All adult patients who were admitted to the SOPC service at a tertiary care center in Germany between 07/2022 and 06/2023 were included in this retrospective cohort study. Demographic data, level of care, information on advance care directives, hospitalizations, adherence to patient wishes, and tumor specific treatments were collected. The data were analyzed using descriptive and inferential measures. Results During the study period, 359 patients were included (52.0% female, mean age 74 ± 13 years). A medical emergency ID card was set up by 32.6% ( n  = 117/359). It was significantly more likely to be created during SOPC than prior to SOPC involvement (before: 20%, after: 80%; p  < 0.05). Patients who expressed not wanting to be admitted to hospital in their medical emergency ID card saw significantly less hospital admissions ( p  < 0.05). Conclusion SOPC supports patients in setting up medical emergency ID cards. These help in respecting patients’ wishes and prevent unwanted admissions to hospitals, thereby reducing strain on emergency services and emergency departments.

Measuring changes in the appropriateness of end-of-life care provided to patients with advanced illness such as cancer, COPD or dementia can help governments and practitioners improve service delivery and quality of life. However, an assessment of a possible shift in appropriateness of end-of-life care across the population is lacking. Measuring quality indicators with routinely collected population-level data, this study aims to evaluate the appropriateness of end-of-life care for people with cancer, COPD or dementia in Belgium. A population-level decedent cohort study, using data from eight population-level databases, including death certificate and health claims data. We measured validated sets of quality indicators for appropriateness of end-of-life care. All people who died from cancer or COPD or with dementia between 1st January 2010 and 1st January 2016 in Belgium. We identified three main trends over time across the three disease groups of increasing use of: family physicians in the last 30 days of life (+21.7% in cancer, +33.7% in COPD and +89.4% in dementia); specialist palliative care in the last 14 days of life (+4.6% in cancer, +36.9% in COPD, +17.8% in dementia); and emergency department in the last 30 days of life (+7.0% in cancer, +4.4% in COPD and +8.2% in dementia). Although we found an increase of both specialized palliative care and generalist palliative care use, we also found an increase in potentially inappropriate care, including ED and ICU admissions. To increase the quality of end-of-life care, both timely initiating (generalist and specialist) palliative care and avoiding potentially inappropriate care transitions, treatments and medications need to be quality performance targets.

Psychiatric advance directives (PAD), also known as advance statements or advance choice documents, are legal documents that enable people with mental health conditions to specify their treatment preferences in advance for possible future crises. Subtypes of PADs include crisis cards, joint crisis plans, and self-binding directives (also known as Ulysses contracts). These instruments are intended to improve service user involvement and need orientation in the care of mental crises and to avoid traumatization through unwanted treatment. The existing evidence suggests that people who complete a PAD tend to work more cooperatively with their clinician and experience fewer involuntary hospital admissions. Nevertheless, PADs have not been successfully mainstreamed into care due to multiple barriers to the implementation of PADs, mainly around the completion of PADs and their accessibility and use in crises. The reasons for this include the lack of support in the completion process and acceptance problems, especially on the part of professionals. The research to date primarily recommends support for service users from facilitators, such as peer support workers, and training for all stakeholders. In this article, we argue that while these approaches can help to solve completion and acceptance challenges, they are not sufficient to ensure access to PADs in crises. To ensure accessibility, we propose digital PADs, which offer considerable potential for overcoming these aforementioned barriers. Embedded in national health data infrastructures, PADs could be completed and accessed by service users themselves, possibly with the support of facilitators, and retrieved by any clinic in an emergency. We highlight the strengths and limitations of digital PADs and point out that the proposed solutions must be developed collaboratively and take into account digital inequalities to be effective support for people with serious mental health conditions.

Background Pediatric palliative care supports children and young adults with life-limiting conditions and their families, seeking to minimize suffering and enhance quality of life. This study evaluates the impact of specialized palliative care (SPC) on advance care planning (ACP) and patterns of end-of-life care for patients who died in the hospital. Methods This is a retrospective cohort study of medical records extracted from a clinical data warehouse, covering patients who died aged 0–24 in an academic tertiary children’s hospital in South Korea. Participants were categorized into before (2011–2013; pre-period) and after (2017–2019; post-period) the introduction of an SPC service. Within the post-period, patients were further categorized into SPC recipients and non-recipients. Results We identified 274 and 205 patients in the pre-period and post-period, respectively. ACP was conducted more and earlier in the post-period than in the pre-period, and in patients who received palliative care than in those who did not. Patients who received SPC were likely to receive less mechanical ventilation or cardiopulmonary resuscitation and more opioids. A multivariable regression model showed that earlier ACP was associated with not being an infant, receiving SPC, and having a neurological or neuromuscular disease. Conclusions SPC involvement was associated with more and earlier ACP and less intense end-of-life care for children and young adults who died in the hospital. Integrating palliative care into routine care can improve the quality of end-of-life care by reflecting patients’ and their families’ values and preferences.

Embracing Our Mortality captures medical and ethical decision-making in action at the end of life-- the context in which individual physicians'and patients' decisions about care and perhaps most heightened. The author, an internist and biomedical ethicist recognized for his seminal work on medical futiliity and living wills, blends vivid case studies from his practice with evidence-based insights from the medical literature and intuitive lessons from literary classics to show how the persistent denial of death in both our culture at large and the high-tech culture of medicine interfered with providing the best possible care for people near the end of life. The book is of interest to biomedical ethicists, physicians caring for patients at the end of life, residents and fellows in palliative medicine, and medical and advanced undergraduate students in courses on Biomedical Ethics and Death & Dying. The book, written in a lively, accessible style, also attracts readers among laypeople.

Purpose Several studies demonstrated that cancer patients visited the emergency department (ED) frequently. This indicates unmet needs and poor-quality palliative care. We aimed to investigate the factors that contribute to ED visits among patients with advanced cancer in order to identify strategies for reducing unnecessary ED visits among these patients. Methods A retrospective study was conducted between January and December, 2019. Eligible patients were previously enrolled in the comprehensive palliative care program prior to their ED visit. All patients older than 18 were included. Patients were excluded if they had died at the initial consultation, were referred to other programs at the initial consultation, or had an incomplete record. The trial ended when the patients died, were referred to other palliative programs, or the study ended. The time between the initial palliative consultation and study endpoints was categorized into three groups: 16 days, 16–100 days, and > 100 days, based on the literature review. To investigate the factors associated with ED visits, a logistic regression analysis was conducted. The variables with a P value < 0.15 from the univariate logistic regression analysis were included in the multiple logistic regression analysis. Results Among a total of 227 patients, 93 visited the ED and 134 did not. Mean age was 65.5 years. Most prevalent cancers were colorectal (18.5%), lung (16.3%), and hepatobiliary (11.9%). At the end, 146 patients died, 45 were alive, nine were referred to other programs, and 27 were lost to follow-up. In univariate logistic regression analysis, patients with > 100 days from palliative consultation (OR 0.23; 95%CI 0.08, 0.66; p -value 0.01) were less likely to attend the ED. In contrast, PPS 50–90% (OR 2.02; 95%CI 1.18, 3.47; p -value 0.01) increased the ED visits. In the multiple logistic regression analysis, these two factors remained associated with ED visits:> 100 days from the palliative consultation (OR 0.18; 95%CI 0.06, 0.55; p -value 0.01) and PPS 50–90% (OR 2.62; 95%CI 1.44, 4.79; p -value 0.01). Conclusions There was reduced ED utilization among cancer patients with > 100 days of palliative care. Patients having a lower PPS were associated with a lower risk of ED visits.

Introduction Immune checkpoint inhibitors (ICI) have revolutionized treatment for advanced hepatocellular carcinoma (HCC). However, end‐of‐life (EOL) outcomes and healthcare utilization patterns prior to death for patients who receive ICI compared to non‐ICI as their last therapy are unknown. Methods Patients with advanced HCC evaluated from January 1, 2020, and who died by March 29, 2024, were included for analysis. Primary EOL outcomes include: advance directives, goals of care conversations, location of death, palliative care referral, hospice referral, and hospice duration. Secondary healthcare utilization outcomes include systemic therapy receipt, emergency department visits, hospitalizations, and intensive care unit admissions within 14, 30, and 90 days of death. Outcomes were stratified by ICI or non‐ICI as the last therapy received, and p values were derived using Pearson's chi‐square test for equality of proportions. Results We identified 71 patients for our retrospective cohort: mean age 64.1 years; 70.8% male; Child Pugh (CP) status at last treatment: 51.1% CPA, 40.0% CPB, 8.9% CPC. No differences in EOL outcomes were detected between groups; median days enrolled in hospice did not differ (24.5 days [non‐ICI] vs. 10 days [ICI]; p = 0.39). Yet, a higher proportion of patients who received ICI as the last therapy had increased healthcare utilization across secondary outcomes. Conclusions Patients with advanced HCC receiving ICI as their last treatment before death, compared to those receiving non‐ICI, had similar EOL outcomes but higher healthcare utilization. Further investigation into risk stratification to predict high healthcare utilizers could guide decision‐making around the ongoing use of ICI near the EOL. Patients with hepatocellular carcinoma received more immune checkpoint inhibitors (ICI) closer to death than patients treated with non‐ICI therapy. Patients who received ICI as their last therapy had higher healthcare utilization at the end of life.

Introduction Advance Care Planning (ACP) refers to a process that includes Advance Care Directives (ACD) and Goals of Care (GOC), a practice widely used for over three decades. Following the findings of an audit and a cross-sectional study in 2019 and 2021 respectively, we implemented several educational and other interventional strategies aimed at enhancing staff awareness and emphasizing the importance of recognizing and documenting of ACD/GOC. The aim of this study was to evaluate the acknowledgement and use of ACD and GOC by Emergency Department (ED) staff following these interventions. Method We used a mixed methods approach, incorporating both observational and cross-sectional designs with reflexive thematic analysis. Data extraction for the observational study took place between 1st April and 30th June 2023 focusing on a target population of randomly sampled adults aged ≥ 65 years. Demographics and other ACD and GOC related patients’ clinical data were collected. Data collection for the cross-sectional study occurred between 19th July and 13th September 2023 targeting all ED staff. Information gathered included demographics, awareness about ACD and GOC, including storage location and implementation, as well as knowledge of Medical Treatment decision Makers (MTDM), a jurisdictional term identifying a person legally appointed to make healthcare decisions on behalf of someone who lacks decision-making capacity and other Victorian State legislative requirements were collected. Results In the observational period, 22,335 patients attended the ED and 19% ( n  = 6546) qualified for inclusion from which a sample of 308 patients were randomly extracted. We found ACD documents were noted in the medical records of 6.5% of the sample, fewer than 8% identified in our previous study. There was no correlation between ACD record availability and age ( p  = 0.054; CI ranging from − 0.065 to 7.768). The response rate for the cross-sectional survey was 12% ( n  = 340) in contrast to earlier study with 28% ( n  = 476) respondents. Staff knowledge and familiarity with ACD was 25% and GOC 45%. Conclusion After implementing interventions in staff education and ACP awareness, we found that ACD documentation did not improve. However, GOC documentation increased in the context of heightened institutional awareness and integration into the Electronic Medical Records (EMR).