Place of death and factors affecting it

1
Place of death and factors affecting it

• Evidence from different European countries

2
Introduction

• Why?
• Quality of end of life
• preference
• health care costs
• Specific patient populations
• cancer, older people, dementia,
• Cross-national comparisons?

3
Introduction

• What is already known?

USA
Hansen et al., J Pall Med 2002
4
Introduction

• What is already known?

Canada
Wilson et al., Soc Sci Med 2009
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Introduction

• What is already known?
• Factors affecting place of death in cancer,
  systematic review (Gomes Higginson, BMJ 2006)
• Main findings High strength evidence for the
  effect of 17 factors
• six best enablers of home deaths
• Patients low functional status (ORs range
  2.29-11.1)
• Patients preferences (2.19-8.38)
• Home care use (1.37-5.1)
• Home care intensity (1.06-8.65)
• Living with relatives (1.78-7.85)
• Extended family support (2.28-5.47)

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(Gomes Higginson, BMJ 2006)

Illness-related factors
Environmental factors
Individual factors
Healthcare support Beds availability and
hospitalisation HOSPITAL Use and
intensity of home care
HOME Rural environment
HOME Area of residence
Demographic variables Good social conditions
HOME Ethnic minorities HOSPITAL
Non-solid tumours HOSP Long disease
HOME Functional loss HOME
Personal variables Patients preferences
HOME
Social support Marital status married
HOME Living with relatives
HOME Extended family support
HOME Caregivers preferences
HOME
Macrosocial factors Historical trends
HOME
Place of death
7
Introduction

• Focus on
• cancer patients ? home
• older people
• care home residents? care home

JP 82.3
AU 81.4
CA 80.4
BE 79.2
US 77.9
RU 65.3
Source www.mortality.org
8
Introduction

• Focus on
• cancer patients ? home
• older people
• Care home residents? care home

Iceland
Belgium
Canada
RU 65.3
Source www.mortality.org
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Introduction

• Focus on
• cancer patients ? home
• older people
• Care home residents? care home

But numbers going up
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Introduction

• Research questions
• Cross-national comparison of
• Dying at home factors
• Care home residents dying in care home factors

11
Methods

• Methodologies
• Linked death certificate data
• Post mortem registration through sentinel network
  of GPs

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Where do patients with cancer die in Europe?
13
Home deaths in 6 countries
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What factors influence the chance of dying at home
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Factors influencing home deaths
Solid cancer vs hematologic
16
Factors influencing home deaths
Marital status (vs. divorced)
17
Factors influencing home deaths
Age (vs. 90 years and more)
0-49 1.53 (1.18-1.98) 0.49 (0.40-0.58) 4.96 (4.30-5.72) 2.56 (1.74-3.78) 2.60 (2.38-2.84) 2.85 (2.03-4.02)
50-59 1.26 (1.00-1.60) 0.51 (0.45-0.59) 3.96 (3.49-4.51) 2.35 (1.66-3.31) 2.90 (2.68-3.13) 3.05 (2.25-4.13)
60-69 1.28 (1.03-1.58) 0.64 (0.57-0.72) 3.35 (2.97-3.79) 1.76 (1.26-2.45) 2.82 (2.61-3.03) 2.43 (1.82-3.23)
70-79 1.21 (0.99-1.48) 0.72 (0.65-0.81) 2.50 (2.22-2.81) 1.57 (1.14-2.16) 2.18 (2.03-2.35) 2.17 (1.64-2.87)
80-89 1.11 (0.90-1.36) 0.84 (0.76-0.94) 1.59 (1.41-1.80) 1.27 (0.93-1.75) 1.63 (1.51-1.76) 1.51 (1.13-2.01)
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Factors influencing home deaths
Educational attainment (vs. elementary or less)
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Trends in home deaths
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Trends
Hospital
home
Care home
other
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Trends
Living alone
In household
Hospital
Home
In household
Living alone
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Palliative care services and dying at home
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Dying at home in relation to palliative care
services use
Use of PC services in people dying non-suddenly
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Dying at home in relation to palliative care
services use
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Dying at home in relation to palliative care
services use
Factors associated with Home Death (Relative to
Hospital Death) in Patients Residing at Home
(N750)
Involvement of Multidisciplinary Palliative
Home Care Team (vs. No Involvement)
Frequent Involvement of Informal Care (vs.
Infrequent or No Involvement)
Average Availability of Hospital Beds in Health
Care Region
Preference for Home Death Known to the GP (vs.
Other Preference or Preference Not Known)
26
Who dies in nursing homes?
27
Nursing home death in Europe
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Nursing home death in USA
Weitzen S, et al. 2003 Mitchell S, et al. 2005
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Dementia patients
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POD of Dementia Patients (65) in Europe
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Country Variation in POD Dementia
Home vs. Hospital death
Nursing Home vs. Hospital death
Home vs. Nursing Home Death
Relative to England (Reference category)
Belgium
Netherlands
Wales
Scotland
Country variation of care home death was
adjusted partially by available hospital and
nursing home beds.
32
Place of Death from Dementia in USA
Mitchell S, et al, 2005
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Risk Factors of Hospital Death of Nursing Home
Residents
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Risk factors of hospital death of care home
residents

• Patient Factors
• Cancer
• Younger age
• Male
• Ethnic Minority
• Preference POD unknown
• No ADL-limits
• No or moderate decline

• Environmental Factors
• Country or Region of Residence
• Metropolitan Region
• Less affluent Place
• Regions with more hospital beds
• Regions with less nursing home beds
• No Involvement of Palliative care
• Had Care Giver

Risk of Hospital Death
Based on own research Weitzen S, et al 2003
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Metropolitan- Non-Metropolitan Variation in POD
M
NM
M
M
NM
NM
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Trends in nursing home death
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Trends in Nursing Home death
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Trends in Nursing Home Death
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Trends in Nursing Home Death
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Trends in Nursing Home Death
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Trends in Nursing Home Death
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Trends in Nursing Home Death
Odds ratios adjusted for age, sex, educational
attainment, urbanization level, underlying cause
of death, available residential beds and skilled
nursing beds in nursing homes, and available
hospital beds.
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Palliative care services in nursing homes and
place of death
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Factors Associated with Care Home Death (Relative
to Hospital Death) in Patients Residing in Care
Home (N443)
Involvement of Palliative Care Reference Persons
of Care Home (vs. No Involvement)
Preference for Care Home Death Known to the
GP (vs. Other Preference or Preference Not Known)
Patient was Female (vs. Male)
Patient Died of Cancer (vs. Other Chronic
Life- Limiting Condition)
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Conclusions
48
Conclusions

• Important country variation
• Reasons?
• health care resources
• Nursing home beds, hospice beds
• health care models
• Dutch model
• Different approach end-of-life care
• Cultural differences
• Patient caregiver relations

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Conclusions

• Important factors
• Condition
• Social and demographic characteristics
• Preferences
• Environmental factors
• Available health care resources

50
Conclusions

• Trends in place of death
• nursing home deaths ?
• home deaths ?
• hospital deaths ?
• Explanations
• Social-demographic changes
• Policies

51
Conclusions

• Palliative care services reduce risk of hospital
  death.

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Policy implications

• long term care facilities for end-of-life care
• palliative care approach and services
• Examine models and provide resources
• vulnerable patient groups