The Last Year of Life in Cologne: Comparison of health care provision for terminally ill cancer and non-cancer patients

Liegt eine schwere lebenslimitierende Erkrankung vor, kommt es häufig zu einer zunehmenden Inanspruchnahme von Gesundheitsleistungen, die sich über das gesamte Gesundheits- und Sozialversorgungssystem erstreckt. Eine dezidierte Betrachtung der Versorgungsverläufe ist erforderlich, um Optimierungspotenziale für die Betroffenen und ihre Nahestehenden aufzudecken. Mit dem Ziel, das letzte Lebensjahr der Patientinnen und Patienten zu rekonstruieren, werden im Rahmen dieser Arbeit diagnosespezifische Unterschiede entlang der sog. Transitionen dargestellt. Transitionen sind definiert als Wechsel zwischen einzelnen Modalitäten und Settings: I) Transition: „Eintritt“ in das letzte Lebensjahr II) Transitionen innerhalb des letzten Lebensjahres und III) Transition: „Austritt“ aus dem letzten Lebensjahr (Sterbephase). Die Daten entstammen einem Mixed-Methods Forschungsprojekt „Last Year of Life in Cologne“, einem Teilprojekt des „Cologne Research and Development-Networks“. Die vorliegende Dissertationsschrift basiert auf drei Publikationen: Publikation 1 (P1): Qualitative Exploration von Faktoren für vermeidbare Übergänge zwischen Versorgungssettings im letzten Lebensjahr in Köln aus der Perspektive von Versorgenden. Publikation 2 (P2): Quantitative Analyse von Unterschieden in der Versorgung im letzten Lebensjahr in Köln aus der Perspektive von Hinterbliebenen von Patientinnen und Patienten mit einer onkologischen und nicht-onkologischen Erkrankung. Publikation 3 (P3): Quantitative Analyse von Unterschieden in der Versorgung im Krankenhaus in der Sterbephase in Köln aus der Perspektive von Hinterbliebenen von Patientinnen und Patienten mit einer onkologischen und nicht-onkologischen Erkrankung. Die zentralen Ergebnisse beleuchten neben Faktoren und Ansätzen zur Prävention vermeidbarer Transitionen innerhalb des letzten Lebensjahres diagnosespezifische Unterschiede in der Versorgung im letzten Lebensjahr mit einer ausgeprägten Benachteiligung der Patientinnen und Patienten mit einer nicht-onkologischen Grunderkrankung. Hinsichtlich der Kommunikation über die Unheilbarkeit einer Erkrankung, der Integration von Palliativ- und Hospizversorgung sowie der wahrgenommenen Versorgungsqualität und Begleitung in der Sterbephase sind Menschen, die an anderen somatischen Ursachen versterben als Krebs, im Nachteil. Die Ergebnisse werden anhand einzelner Publikationen synthetisiert und diskutiert

The last year of life for patients dying from cancer vs. non-cancer causes: a retrospective cross-sectional survey of bereaved relatives

Purpose To compare health care experiences of patients with cancer or non-cancer diseases in their last year of life. Methods A cross-sectional post-bereavement survey was conducted using an adapted German version of the VOICES questionnaire (VOICES-LYOL-Cologne). Differences in the reported experiences were assessed using a two-sided Pearson's chi-square test and Mann-Whitney U test. Results We collected data from 351 bereaved relatives. More than half of non-cancer patients were not informed that their disease could lead to death (p < 0.001). When this was communicated, in 46.7% of non-cancer and 64.5% of cancer patients, it was reported by the hospital doctor (p = 0.050). In all, 66.9% of non-cancer and 41.6% of cancer patients were not informed about death being imminent (p < 0.001). On average, non-cancer patients had significantly fewer transitions and hospital stays in their last year of life (p = 0.014; p = 0.008, respectively). Non-cancer patients were treated more often by general practitioners, and cancer patients were treated more often by specialists (p = 0.002; p = 0.002, respectively). A substantially lower proportion of non-cancer patients were treated by at least one member of or in the setting of general or specialized palliative care (p < 0.001). Conclusions Non-cancer patients experience disadvantages in communication regarding their care and in access to specialized palliative care in their last year of life compared to cancer patients. Regarding the assessment of palliative care needs and the lack of communication of an incurable disease, non-cancer patients are underserved. An early identification of patients requiring palliative care is a major public health concern and should be addressed irrespective of diagnosis

Unsolved problems and unwanted decision-making in the last year of life: A qualitative analysis of comments from bereaved caregivers

Objectives Patients in their last year of life, as well as their relatives, often feel that existent care structures of the healthcare system do not adequately address their individual needs and challenges. This study analyzes unmet needs in terms of unsolved problems and unwanted decision-making in the health and social care of patients in their last year of life from the perspective of bereaved caregivers. Methods This qualitative study is based on free-text comments from informal caregivers of deceased patients collected as part of the Last-Year-of-Life-Study-Cologne (LYOL-C) using a postal survey. With qualitative content analysis, a category system with main and subcategories was developed in a multi-step process. Results Free-text commentaries and demographic data were collected from 240 bereaved caregivers. Particularly outside of hospice and palliative care services, study participants addressed the following unsolved problems: poor communication with medical and nursing staff, insufficient professional support for informal caregivers, inadequate psycho-social support for patients, and poor management of pain and other symptoms. Respondents often stated that their relative had to be cared for and die outside their own home, which the relative did not want. Significance of results Our findings suggest the necessity for greater awareness of patients' and their relatives' needs in the last year of life. Addressing individual needs, integrating palliative and hospice care in acute hospitals and other healthcare structures, and identifying patients in their last year of life and their caregivers could help to achieve more targeted interventions and optimization of care

Dying in hospital is worse for non-cancer patients. A regional cross-sectional survey of bereaved relatives' views

Objective The aim of the study is to examine differences in hospital care between patients with cancer and non-cancer conditions in their dying phase, perceived by bereaved relatives. Methods A retrospective cross-sectional post-bereavement survey, with the total population of 351 deceased, 91 cancer patients and 46 non-cancer patients, who spent their last 2 days of life in hospital. A validated German version of the VOICES-questionnaire ('VOICES-LYOL-Cologne') was used. Results There were substantial differences between the two groups in the rating of sufficient practical care such as pain relief or support to eat or drink (p = 0.005) and sufficient emotional care needs (p = 0.006) and in the quality of communication with healthcare professionals (p < 0.001), with non-cancer patients scoring lowest in all these dimensions. Conclusion In all surveyed dimensions on the quality of care in the dying phase, non-cancer patients' relatives rated the provided care worse than those of cancer patients. To compensate any differences in care in the dying phase between diagnosis groups, hospital care should be provided as needs-oriented and non-indication-specific

What are the risk factors for avoidable transitions in the last year of life? A qualitative exploration of professionals' perspectives for improving care in Germany

BackgroundLittle is known about the nature of patients' transitions between healthcare settings in the last year of life (LYOL) in Germany. Patients often experience transitions between different healthcare settings, such as hospitals and long-term facilities including nursing homes and hospices. The perspective of healthcare professionals can therefore provide information on transitions in the LYOL that are avoidable from a medical perspective. This study aims to explore factors influencing avoidable transitions across healthcare settings in the LYOL and to disclose how these could be prevented.MethodsTwo focus groups (n=11) and five individual interviews were conducted with healthcare professionals working in hospitals, hospices and nursing services from Cologne, Germany. They were asked to share their observations about avoidable transitions in the LYOL. The data collection continued until the point of information power was reached and were audio recorded and analysed using qualitative content analysis.ResultsFour factors for potentially avoidable transitions between care settings in the LYOL were identified: healthcare system, organization, healthcare professional, patient and relatives. According to the participants, the most relevant aspects that can aid in reducing unnecessary transitions include timely identification and communication of the LYOL; consideration of palliative care options; availability and accessibility of care services; and having a healthcare professional taking main responsibility for care planning.ConclusionsPreventing avoidable transitions by considering the multicomponent factors related to them not only immediately before death but also in the LYOL could help to provide more value-based care for patients and improving their quality of life

Last Year of Life Study-Cologne (LYOL-C) (Part II): study protocol of a prospective interventional mixed-methods study in acute hospitals to analyse the implementation of a trigger question and patient question prompt sheets to optimise patient-centred care

Introduction The Last Year of Life Study-Cologne Part I (LYOL-C I) has identified general hospital units as the most important checkpoints for transitions in the last year of life of patients. Yet, satisfaction with hospitals, as reported by bereaved relatives, is the lowest of all health service providers. Thus, the LYOL-C Part II (LYOL-C II) focuses on optimising patient-centred care in acute hospitals for patients identified to be in their last year of life. LYOL-C II aims to test an intervention for hospitals by using a two-sided (healthcare professionals (HCPs) and patients) trigger question-based intervention to 'shake' the system in a minimally invasive manner. Methods and analysis Prospective interventional mixed-methods study following a two-phase approach: phase I, individual interviews with HCPs and patient representatives to design the intervention to maximise ease of implementation and phase II, exploratory study with two arms and a prepost design with patients in their last year of life. The intervention will consist of the Surprise Question and the German version of the Supportive and Palliative Care Indicators Tool (SPICT-DE) for HCPs to identify patients and provide patient-centred care, plus question prompt sheets for patients, encouraging them to initiate discussions with their HCPs. Data on transitions, changes in therapy, quality of care, palliative care integration and death of patients will be analysed. Furthermore, a staff survey (pre/post) and guided interviews with staff, patients and relatives (post) will be conducted. Finally, a formative socioeconomic impact assessment to provide evidence regarding the sustainability of the intervention will be performed. Ethics and dissemination The study was approved by the Ethics Committee of the Faculty of Medicine of the University of Cologne (#20-1431). Results will be published in peer-reviewed journals and presented at national and international conferences

What are the risk factors for avoidable transitions in the last year of life? A qualitative exploration of professionals’ perspectives for improving care in Germany

Background!#!Little is known about the nature of patients' transitions between healthcare settings in the last year of life (LYOL) in Germany. Patients often experience transitions between different healthcare settings, such as hospitals and long-term facilities including nursing homes and hospices. The perspective of healthcare professionals can therefore provide information on transitions in the LYOL that are avoidable from a medical perspective. This study aims to explore factors influencing avoidable transitions across healthcare settings in the LYOL and to disclose how these could be prevented.!##!Methods!#!Two focus groups (n = 11) and five individual interviews were conducted with healthcare professionals working in hospitals, hospices and nursing services from Cologne, Germany. They were asked to share their observations about avoidable transitions in the LYOL. The data collection continued until the point of information power was reached and were audio recorded and analysed using qualitative content analysis.!##!Results!#!Four factors for potentially avoidable transitions between care settings in the LYOL were identified: healthcare system, organization, healthcare professional, patient and relatives. According to the participants, the most relevant aspects that can aid in reducing unnecessary transitions include timely identification and communication of the LYOL; consideration of palliative care options; availability and accessibility of care services; and having a healthcare professional taking main responsibility for care planning.!##!Conclusions!#!Preventing avoidable transitions by considering the multicomponent factors related to them not only immediately before death but also in the LYOL could help to provide more value-based care for patients and improving their quality of life