Change in End-of-Life Care for Medicare Beneficiaries Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009
ABSTRACT Importance A recent Centers for Disease Control and Prevention report found that more persons die at home. This has been cited as evidence that persons dying in the United States are using more supportive care. Objective To describe changes in site of death, place of care, and health care transitions between 2000, 2005, and 2009. Design, Setting, and Patients Retrospective cohort study of a random 20% sample of fee-for-service Medicare beneficiaries, aged 66 years and older, who died in 2000 (n=270 202), 2005 (n=291 819), or 2009 (n=286 282). A multivariable regression model examined outcomes in 2000 and 2009 after adjustment for sociodemographic characteristics. Based on billing data, patients were classified as having a medical diagnosis of cancer, chronic obstructive pulmonary disease, or dementia in the last 180 days of life. Main Outcome Measures Site of death, place of care, rates of health care transitions, and potentially burdensome transitions (eg, health care transitions in the last 3 days of life). Results Comparing 2000, 2005, and 2009 shows a decrease in deaths in acute care hospitals and increases in intensive care unit (ICU) use in the last 30 days, hospice use at the time of death, and health care transitions at the end of the life (test of trend P < .001 for each). [GRAPHICS] In 2009, 28.4% (95% CI, 27.9%-28.5%) of hospice use at the time of death was for 3 days or less. Of these late hospice referrals, 40.3% (95% CI, 39.7%-40.8%) were preceded by hospitalization with an ICU stay. Conclusion and Relevance Among Medicare beneficiaries who died in 2009 and 2005 compared with 2000, a lower proportion died in an acute care hospital, although both ICU use and the rate of health care transitions increased in the last month of life. JAMA. 2013; 309(5): 470-477 www.jama.
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ABSTRACT: Background Alzheimer's disease (AD) profoundly affects the end-of-life experience. Yet, counts of deaths attributable to AD understate this burden of AD in the population. Therefore, we estimated the annual number of deaths in the United States among older adults with AD from 2010 to 2050. Methods We calculated probabilities of AD incidence and mortality from a longitudinal population-based study of 10,802 participants. From this population, 1913 previously disease-free individuals, selected via stratified random sampling, underwent 2577 detailed clinical evaluations. Over the course of follow-up, 990 participants died. We computed age-, sex-, race-, and education-specific AD incidences and education-adjusted AD mortality proportions specific to age, sex, and race group. We then combined these probabilities with US-wide census, education, and mortality data. Results In 2010, approximately 600,000 deaths occurred among individuals aged 65 years or older with AD, comprising 32% of all older adult deaths. By 2050, this number is projected to be 1.6 million, 43% of all older adult deaths. Conclusion Individuals with AD comprise a substantial number of older adult deaths in the United States, a number expected to rise considerably in coming decades.Alzheimer's & dementia: the journal of the Alzheimer's Association 03/2014; 10(2):e40–e46. DOI:10.1016/j.jalz.2014.01.004 · 17.47 Impact Factor
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ABSTRACT: We developed and assessed feasibility of an Ethics Screening and Early Intervention Tool that identifies at-risk clinical situations and prompts early actions to mitigate conflict and moral distress. Despite intensive care unit and oncology nurses' reports of tool benefits, they noted some risk to themselves when initiating follow-up actions. The riskiest actions were discussing ethical concerns with physicians, calling for ethics consultation, and initiating patient conversations. When discussing why initiating action was risky, participants revealed themes such as "being the troublemaker" and "questioning myself." To improve patient care and teamwork, all members of the health care team need to feel safe in raising ethics-related questions.ANS. Advances in nursing science 36(4):304-19. DOI:10.1097/ANS.0000000000000004 · 0.87 Impact Factor
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ABSTRACT: Background Living will (LW) documents have been suggested to act in patients’ best interests in end-of-life care. It is unclear, however, whether the LWs influence medical decisions when death is impending. Aim To explore, whether a LW among the community-dwelling older people has an influence on intensity of end-of-life treatment, place of death, or length of the dying process. Design A 10-year follow-up; data concerning place and cause of death, event history, intensity of care, decision-making process, and length of the dying process were collected from the death certificates. Setting/Participants In a community-based longitudinal cardiovascular prevention trial (DEBATE) in Helsinki, home-dwelling older people with an atherosclerotic disease (n = 378, mean age 80.2 years) were questioned about the pre-existence of a written LW at baseline (n = 44) in 2000. In 2010, all death certificates (n = 207) were analysed, comparing people with a LW (n = 30) at baseline with those without (n = 177). Results Of the deceased, 77% died in hospital. Intensity of end-of-life treatment or cause of death did not differ between the groups. However, dying at home was more common among persons with a LW at baseline (16.7% vs. 5.6%, P = 0.031), and length of the dying process was shorter in this group (< 1 week in 50.0% vs. 27.1%, P = 0.013). Conclusions Length of the dying process was often shorter and home death more common among those with a LW at the beginning of the follow-up. More insight into the dying process is required to ensure that the decision-making process better accommodates the preferences of older people.European geriatric medicine 01/2013; 5(1). DOI:10.1016/j.eurger.2013.09.009 · 0.55 Impact Factor