RESUMO
OBJECTIVES: As ICUs are increasingly a site of end-of-life care, many have adopted end-of-life care resources. We sought to determine the association of such resources with outcomes of ICU patients. DESIGN: Retrospective cohort study. SETTING: Pennsylvania ICUs. PATIENTS: Medicare fee-for-service beneficiaries. INTERVENTIONS: Availability of any of one hospital-based resource (palliative care consultants) or four ICU-based resources (protocol for withdrawal of life-sustaining therapy, triggers for automated palliative care consultation, protocol for family meetings, and palliative care clinicians embedded in ICU rounds). MEASUREMENTS AND MAIN RESULTS: In mixed-effects regression analyses, admission to a hospital with end-of-life resources was not associated with mortality, length of stay, or treatment intensity (mechanical ventilation, hemodialysis, tracheostomy, gastrostomy, artificial nutrition, or cardiopulmonary resuscitation); however, it was associated with a higher likelihood of discharge to hospice (odds ratio, 1.58; 95% CI, 1.11-2.24), an effect that was driven by ICU-based resources (odds ratio, 1.37; 95% CI, 1.04-1.81) rather than hospital-based resources (odds ratio, 1.19; 95% CI, 0.83-1.71). Instrumental variable analysis using differential distance (defined as the additional travel distance beyond the hospital closest to a patient's home needed to reach a hospital with end-of-life resources) demonstrated that among those for whom differential distance would influence receipt of end-of-life resources, admission to a hospital with such resources was not associated with any outcome. CONCLUSIONS: ICU-based end-of-life care resources do not appear to change mortality but are associated with increased hospice utilization. Given that this finding was not confirmed by the instrumental variable analysis, future studies should attempt to verify this finding, and identify specific resources or processes of care that impact the care of ICU patients at the end of life.
Assuntos
Acessibilidade aos Serviços de Saúde , Unidades de Terapia Intensiva/organização & administração , Cuidados Paliativos , Adolescente , Adulto , Idoso , Protocolos Clínicos , Estudos de Coortes , Feminino , Hospitais para Doentes Terminais/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Pennsylvania/epidemiologia , Encaminhamento e Consulta , Estudos Retrospectivos , Suspensão de Tratamento , Adulto JovemRESUMO
AIM: Now considered a subspecialty of medicine and nursing, palliative care is a critical aspect of healthcare at the end of life. National and international healthcare agencies typically attribute its slow or haphazard growth in developing countries to various resource constraints. However, this study provides evidence of the substantial and widening gap between policy advocacy and patient choices in end-of-life care. It does so by establishing the incentives and risks that underlie decision-making by patients and providers against the relative scarcity of palliative care and hospices in these countries. METHODS: Jamaica offers an illustrative case. It shares the socioeconomic conditions and isolated provision of hospice and palliative care that remain prevalent in many developing countries. Empirical information was collected from all Jamaican hospices, along with agency and media reports, for comparative institutional analysis. RESULTS: Financial and infrastructural challenges hamper hospice expansion and integration into formal healthcare systems in developing countries. Yet, other equally vital considerations are too often neglected. These include the high transaction costs of decision-making, which account for limited hospice accessibility, affordability, and efficiency, particularly to underserved populations. Risk and payoff calculations by patients and their families as well as hospices and their providers lead to two strategic options in maximizing hospice value and/or minimizing transaction costs in end-of-life care. CONCLUSION: Policy formulation and advocacy for hospice and palliative care should match aggregate demand. The socio-cultural milieu of care is critical and should be equally considered. Otherwise, providing and expanding free or subsidized palliative care at the end-of-life stage can become cost-inefficient relative to robust family and grassroots community networks.
Assuntos
Redes Comunitárias/estatística & dados numéricos , Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Hospitais para Doentes Terminais/estatística & dados numéricos , Assistência Terminal/estatística & dados numéricos , Tomada de Decisões , Família , Hospitais para Doentes Terminais/economia , Humanos , Jamaica , Fatores SocioeconômicosRESUMO
AIDS: Hospice care relies on a variety of approaches to heal the mind and the soul, if not the body. While hospice care has been well developed in the United States and the United Kingdom, it has overlooked the crucial tool of psychiatry in responding to the mental health needs of dying residents. Many of the psychiatrist's roles are being handled by social workers, psychologists, and volunteers who are not trained to provide a deeper understanding of the complex picture of organic brain dysfunction, side effects of medical or psychiatric drugs, and psychiatric effects of opportunistic infections or cancers. Psychiatrists are trained to evaluate both the physical and psychiatric pieces of the whole patient picture, enabling a more precise understanding of the effects of dementia, grief, opportunistic infections, substance abuse, HIV treatment, and psychopharmacologic agents. The Psychiatrists Concerned About AIDS organization is working to overcome the exclusion of psychiatrists from acute and palliative care, and thus, resolve the split between psychiatry and hospice care.^ieng