Place of death and factors affecting it

1. Place of death and factors affecting it Evidence from different European countries Edmonton Conference

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

3. What is already known? Introduction USA Hansen et al., J Pall Med 2002 Edmonton Conference

4. Introduction • What is already known? Canada Wilson et al., Soc Sci Med 2009 Edmonton Conference

5. 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 (OR’s 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) Introduction Edmonton Conference

6. (Gomes & Higginson, BMJ 2006) Illness-related factors Individual factors Environmental 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 Edmonton Conference

7. Focus on cancer patients  home older people care home residents care home Introduction JP: 82.3 AU: 81.4 CA: 80.4 BE: 79.2 US: 77.9 RU: 65.3 Source: www.mortality.org Edmonton Conference

8. Focus on cancer patients  home older people Care home residents care home Introduction Iceland Belgium Canada RU: 65.3 Source: www.mortality.org Edmonton Conference

9. Focus on cancer patients  home older people Care home residents care home Introduction But numbers going up Edmonton Conference

10. Research questions: Cross-national comparison of: Dying at home + factors Care home residents dying in care home + factors Introduction Edmonton Conference

11. Methodologies: Linked death certificate data Post mortem registration through sentinel network of GPs Methods Edmonton Conference

12. Where do patients with cancer die in Europe? Edmonton Conference

13. Home deaths in 6 countries Edmonton Conference

14. What factors influence the chance of dying at home Edmonton Conference

15. Factors influencing home deaths Solid cancer vs hematologic Edmonton Conference

16. Factors influencing home deaths Marital status (vs. divorced) Edmonton Conference

17. Factors influencing home deaths Age (vs. 90 years and more) Edmonton Conference

18. Factors influencing home deaths Educational attainment (vs. elementary or less) Edmonton Conference

19. Trends in home deaths Edmonton Conference

20. Trends Hospital home Care home other Edmonton Conference

21. Trends Living alone In household Hospital Home In household Livingalone Edmonton Conference

22. Palliative care services and dying at home Edmonton Conference

23. Dying at home in relation to palliative care services use Use of PC services in people dying non-suddenly Edmonton Conference

24. Dying at home in relation to palliative care services use Edmonton Conference

25. Dying at home in relation to palliative care services use Factors associated with Home Death (Relative to Hospital Death) in Patients Residing at Home (N=750) 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) Edmonton Conference

26. Who dies in nursing homes? Edmonton Conference

27. Nursing home death in Europe Edmonton Conference

28. Nursing home death in USA Weitzen S, et al. 2003 Mitchell S, et al. 2005 Edmonton Conference

29. Dementia patients Edmonton Conference

30. POD of Dementia Patients (≥65) in Europe Edmonton Conference

31. 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. Edmonton Conference

32. Place of Death from Dementia in USA Mitchell S, et al, 2005 Edmonton Conference

33. Risk Factors of Hospital Death of Nursing Home Residents Edmonton Conference

34. 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 Edmonton Conference

35. Metropolitan- Non-Metropolitan Variation in POD M NM M NM M NM Edmonton Conference

36. Trends in nursing home death Edmonton Conference

37. Trends in Nursing Home death Edmonton Conference

38. Trends in Nursing Home Death Edmonton Conference

39. Trends in Nursing Home Death Edmonton Conference

40. 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. Edmonton Conference

41. Palliative care services in nursing homes and place of death Edmonton Conference

42. Edmonton Conference

43. Edmonton Conference

44. Factors Associated with Care Home Death (Relative to Hospital Death) in Patients Residing in Care Home (N=443) 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) Edmonton Conference

45. Conclusions Edmonton Conference

46. 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 Edmonton Conference

47. Conclusions • Important factors • Condition • Social and demographic characteristics • Preferences • Environmental factors • Available health care resources Edmonton Conference

48. Conclusions • Trends in place of death • nursing home deaths:  • home deaths:  • hospital deaths:  • Explanations • Social-demographic changes • Policies Edmonton Conference

49. Conclusions • Palliative care services reduce risk of hospital death. Edmonton Conference

50. Policy implications • long term care facilities for end-of-life care • palliative care approach and services • Examine models and provide resources • vulnerable patient groups Edmonton Conference