INTRODUCTION: The Covid-19 pandemic has caused significant increases in mortality in the United States, and nursing homes were particularly impacted early in the pandemic. With questions around underreporting, limited testing, and indirect effects, it is difficult to understand the true impact of the pandemic on US mortality while only examining the deaths attributed to Covid-19. Prior analyses have looked at excess mortality, the increase in mortality over what would have been expected in 2020 if the Covid-19 pandemic had not occurred, focusing on temporal and spatial relationships between excess mortality and direct Covid-19 attributed mortality. The true impact of Covid-19 by place of death remains to be understood. Recent historical trends in mortality by place of death have shown a decreasing share of deaths occurring in hospitals while deaths in homes have increased and deaths in nursing homes have not changed significantly. OBJECTIVE: This observational study aims to characterize the impact of the Covid-19 pandemic on nursing homes in the US by examining direct Covid-19 mortality, excess mortality, and the relationship between direct and excess mortality by place of death at a state level. METHODS: Vital statistics data around mortality by place of death from CDC WONDER and the NVSS Provisional Covid-19 Deaths dataset were used along with US Census data to create a time series for US mortality by place of death from 2013 to 2020. The analysis was restricted to individuals above the age of 65 to limit fields with missing or suppressed data and stratified by 10-year age category. 2020 mortality in the absence of Covid-19 was estimated using the historical average mortality and the simple linear extrapolation of historical mortality within each age group, place of death, and state. Excess deaths were divided into those assigned to Covid-19 and those not assigned to Covid-19 and compared by place of death, age category, and state. RESULTS: 26.2% of direct Covid-19 deaths were found to occur in nursing homes, while 63.1% of Covid-19 deaths occurred in hospitals and 5.3% occurred at home. The excess mortality rate was found to be the highest at home, with 1.78 more deaths per thousand person-years occurring in 2020 in the US than would have been expected in the absence of Covid-19, despite a low direct Covid-19 mortality rate of only 0.162 deaths per thousand person-years. Excess mortality rates in nursing homes across the US were relatively low at 0.296 deaths per thousand person-years, with a direct Covid-19 mortality rate (1.29 deaths per thousand person-years) that was higher than the estimated excess mortality. Despite the high direct Covid-19 mortality compared to excess mortality in nursing homes, a regression model examining the extent to which Covid-19 mortality and historical mortality predicted 2020 mortality in nursing homes suggested that for every 100 deaths assigned to Covid-19, there were 107 more all-cause deaths in 2020. Nursing home excess mortality was found to be highest in Utah, and lowest in North Carolina and New York. CONCLUSION: This work suggests that direct Covid-19 mortality captures most of the impact of Covid-19 on mortality in US nursing homes in individuals over the age of 65. A significant difference was discovered between direct Covid-19 mortality and excess mortality in decedent’s homes, which warrants additional study. / 2022-11-23T00:00:00Z

<p>Only 12% of the patients died at home. When the period between diagnosis and death was less than one month, every patient died in an institution. Younger patients, married</p><p>patients, and those living within the 40 km radius of the hospital utilized more hospital days. The "length of terminal hospitalisation" and the "proportion of days at home/ total inclusion days" seemed to be feasible outcome varibles when evaluating a palliative support service. The hospital-based palliative support service in this study defrayed its own costs due to a median saving of 10 hospital days/patient, compared with matched historical controls.</p><p>A 19-item quality of life questionnaire (AQEL) was developed which evidenced good signs of reliability and validity. The item most closely correlated to global quality of life was the sense of meaningfulness. This was true for both patients and their spouses. Patients´ levels of pain and anxiety did not increase at the end of life. In this study we could not find convincing evidence for an additive analgesic effect of paracetamol in morphine therapy of pain in cancer patients.</p>

Only 12% of the patients died at home. When the period between diagnosis and death was less than one month, every patient died in an institution. Younger patients, married patients, and those living within the 40 km radius of the hospital utilized more hospital days. The "length of terminal hospitalisation" and the "proportion of days at home/ total inclusion days" seemed to be feasible outcome varibles when evaluating a palliative support service. The hospital-based palliative support service in this study defrayed its own costs due to a median saving of 10 hospital days/patient, compared with matched historical controls. A 19-item quality of life questionnaire (AQEL) was developed which evidenced good signs of reliability and validity. The item most closely correlated to global quality of life was the sense of meaningfulness. This was true for both patients and their spouses. Patients´ levels of pain and anxiety did not increase at the end of life. In this study we could not find convincing evidence for an additive analgesic effect of paracetamol in morphine therapy of pain in cancer patients.

This research investigated the racial/ethnic differences in hospice utilization and the effect of hospice in reducing the risk of hospital death at the end of life among non-Hispanic Black and non-Hispanic White dual-eligible (Medicare and Medicaid) older adults residing in a nursing home setting. The final study population included 30,765 non-Hispanic Black and non-Hispanic White nursing home residents who died between state fiscal years 2000-2002 in Florida.The behavioral model of health services use successfully predicted group membership in hospice use. In the full model, seven variables - female gender, non-Hispanic White race/ethnicity, being married, urban area of residence, and cancer and dementia/Alzheimer's disease as causes of death -- predicted increased likelihood of hospice use. This study also found that race/ethnicity moderates the strength of the effect of the illness on the likelihood of using hospice. Among residents who died of cancer, no difference in hospice use was found between the two racial/ethnic groups while hospice utilization rate among non-cancer residents was lower for non-Hispanic Blacks than non-Hispanic Whites.The same predisposing, enabling and need factors tested in predicting hospice use were examined for association with the probability of survival time since hospice admission. The poor model fit and the small number of factors found to significantly affect the probability of survival time from the initial hospice enrollment suggest that the survival time might be influenced by external factors other than covariates examined in this study.This study found hospice to be a powerful predictor of place of death among nursing home residents. After controlling for other factors, hospice nurs ing home residents were 91 percent less likely to die in a hospital. At the same time, non-Hispanic Black residents were still 76 percent more likely to die in a hospital even after adjusting for the effect of hospice use and other variables.

Bakgrund: De flesta i livets slut önskar dö hemma. Ändå visar forskning att långt ifrån alla får önskemålet uppfyllt. Döden och önskemål i livets slut ser olika ut och därför är en personcentrerad utgångspunkt avgörande för att vården ska kunna utgå ifrån patient och närståendes behov. Frihet från svåra symtom och att få dö på den plats man önskar är ofta förknippat med en god död. Syfte: Syftet med studien var att beskriva hinder och möjligheter för patienter i livets slutskede att dö hemma. Metod: En litteraturöversikt med induktiv ansats. Artiklar med kvantitativ och kvalitativ ansats samt mixad metod inkluderades utifrån både patient- närstående- och vårdpersonalens perspektiv. Resultatet har diskuterats utifrån det teoretiska ramverket de 6S:en. Resultat: En palliativ vårdplan, advance care plan (ACP), med personcentrerad utgångspunkt tydliggjorde patient och närståendes behov sista tiden och ökade möjligen att dö hemma. En ömsesidig önskan hos patient och närstående att tillbringa sista tiden i hemmet ökade möjligheten att dö hemma och att det samtidigt fanns stöd från ett specialiserat palliativt team. God kommunikation mellan närstående, patient och vårdgivare, adekvat symtomlindring och hjälp med grundläggande behov var viktiga delar för att öka möjligheten att kunna vårdas hemma till livets slut. Vårdpersonal kunde både utgöra hinder och möjligheter för en patient i livets slut att dö hemma. Slutsats: En personcentrerad palliativ vårdplan ökar möjligheten för människor i livets slut att dö hemma. Närstående är oftast en förutsättning för att kunna dö hemma. Sjukvårdspersonalens förhållningssätt kan både vara ett hinder och en möjlighet för patienter i livets slut att dö kunna hemma.

Cancer is a disease caused by uncontrolled growth of abnormal cells. Cancer is often related to a need for palliative care. Palliative care is an approach and treatment provided to improve quality of life for patients with life threatening illness, such as cancer. Dying patients at the end of their life may lose their autonomy towards themselves especially related to their desires and preference. Patients’ preference towards place of death may be influenced by many factors. Patients with cancer require support from their family members as well as health care professionals, especially nurses, they are the one who frequently keep in touch with patients. Therefore, through the support given, patients’ might be able to express their desires.  The purpose of this study was to describe factors associated with preferential place of death for cancer patients receiving palliative care. This study also described how patients’ autonomy affect patients’ decision making related to preferential place of death and how nurses provide support in patients decision making with regards of preferential place of death.  A literature review of 17 scientific articles that met the inclusion criteria was carried out. The articles were collected using two electronic database searches: PubMed and CINAHL. Moreover, four of articles were identified through manual search.  Majority of cancer patients preferred their home as their place of death. Demographic factors such as, gender, age, marital status, economic status, country of birth and place of residence were found to be the most influential factors regarding the preference of home as place of death. The wishes related to place of death of both patients and family caregivers were expected to be recorded in the first meeting. Nurses in providing support for patients with cancer should have to empower patients express their desires.  In conclusion, this literature review showed that promoting autonomy and decision making are challenging for nurses. Nurses can help patients express their preferences or desires by providing decision making support. There are many factors that contribute to the decision of location of death. Therefore, it is important for nurses to empower patients’ autonomy and to respect their values in order to provide support for patients with cancer in making decision related to place of death

Bakgrund: De flesta i livets slut önskar dö hemma. Ändå visar forskning att långt ifrån alla får önskemålet uppfyllt. Döden och önskemål i livets slut ser olika ut och därför är en personcentrerad utgångspunkt avgörande för att vården ska kunna utgå ifrån patient och närståendes behov. Frihet från svåra symtom och att få dö på den plats man önskar är ofta förknippat med en god död. Syfte: Syftet med studien var att beskriva hinder och möjligheter för patienter i livets slutskede att dö hemma. Metod: En litteraturöversikt med induktiv ansats. Artiklar med kvantitativ och kvalitativ ansats samt mixad metod inkluderades utifrån både patient- närstående- och vårdpersonalens perspektiv. Resultatet har diskuterats utifrån det teoretiska ramverket de 6S:en. Resultat: En palliativ vårdplan, advance care plan (ACP), med personcentrerad utgångspunkt tydliggjorde patient och närståendes behov sista tiden och ökade möjligen att dö hemma. En ömsesidig önskan hos patient och närstående att tillbringa sista tiden i hemmet ökade möjligheten att dö hemma och att det samtidigt fanns stöd från ett specialiserat palliativt team. God kommunikation mellan närstående, patient och vårdgivare, adekvat symtomlindring och hjälp med grundläggande behov var viktiga delar för att öka möjligheten att kunna vårdas hemma till livets slut. Vårdpersonal kunde både utgöra hinder och möjligheter för en patient i livets slut att dö hemma. Slutsats: En personcentrerad palliativ vårdplan ökar möjligheten för människor i livets slut att dö hemma. Närstående är oftast en förutsättning för att kunna dö hemma. Sjukvårdspersonalens förhållningssätt kan både vara ett hinder och en möjlighet för patienter i livets slut att dö kunna hemma.

Hospital admissions for patients close to the end of life are considered ‘inappropriate’ in contemporary English health policy. Hospitals are supposedly unable to offer a ‘good’ death for patients, and dying there is thought to contradict patient choice, since patients are assumed to want to die at home. However, almost half of all deaths in England in 2015 occurred in hospital, and of these, nearly a third died within three days of admission. This thesis seeks to explore why these admissions are considered to be a problem and how they occur. Through a systematic review of UK literature I found that it cannot be stated that most patients want to die at home, because of the extent of missing data (preferences not asked, expressed, reported or absent). This finding challenges the justification that admissions are inappropriate because they contravene patient choice. Similarly inconclusive evidence about the undesirability, cost, and lack of need for patients to be in hospital were also found in a review of policy. Together with analysis of historical trends in hospital and hospice provision, it is apparent that attitudes towards end-of-life admissions reflect existing tensions about the role of hospital as an acute provider, and as a place of death. An analysis of interviews conducted with healthcare staff and next-of-kin involved in the admission of patients (case-patients) who died shortly after being admitted to Meadowbridge, a large English hospital explored these tensions further. I found that whilst hospital was not recognised as a place where ‘good’ deaths typically occurred, it was acknowledged as an emergency place of care. In this context, patients without obvious need for hospital care were nevertheless admitted to the hospital and the environment was subsequently recognised to offer distinct benefits. The need for emergency care reflected the difficulties of providing end-of-life care in the community. For dying to occur appropriately, home had to be adapted and care organised by healthcare staff. Both tasks were complicated by the unpredictability of dying, and family carers helped to absorb much of the uncertainty and support patients to die at home. Ambulance staff became involved when patients had care needs that exceeded care quickly and easily available in the community. When called to the case-patients, ambulance staff instituted familiar practices in transferring them to hospital. Hospital was recognised as a default place of care because ambulance staff struggled to facilitate alternative care and lacked sufficient professional authority to keep patients at home. The admissions of the case-patients represent the best attempts of staff to navigate the tangled practices of end-of-life care. These practices are the result of the actions of the staff, which in turn both constrained and enabled their action in providing care to patients. The term ‘inappropriate’ to describe admissions does not encompass these attempts, and moreover, devalued the significant care provided by healthcare staff in the community and hospital.