Volume 40, Issue 5 , Pages 704-714, November 2010
Comparing Noncancer and Cancer Deaths in Hong Kong: A Retrospective Review
Article Outline
- Abstract
- Introduction
- Methods
- Results
- Discussion
- Conclusion
- Disclosures and Acknowledgments
- References
- Copyright
Abstract
This retrospective study aimed to compare noncancer deaths with cancer deaths in the following: 1) utilization of the public health care system in the last six months of life; 2) end-of-life care received; and 3) documentation of the advance care planning (ACP) process. The following sample was recruited from the deaths in 2006 in four public hospitals for analysis: 656 noncancer deaths consisting of 239 deaths from chronic renal failure (CRF), 242 deaths from chronic obstructive pulmonary disease (COPD) and 175 deaths from congestive heart failure (CHF), and 183 cancer deaths. Only 1.4% of noncancer patients received palliative care, compared with 79.2% of cancer patients. As compared with cancer, the noncancer patients were older (79.1
±9.5 vs. 71.1±12.4 years, P<0.001) and had more comorbid conditions (2.3±1.4 vs. 1.6±1.4, P<0.001). Utilization of public health care was more intensive in noncancer patients, with more intensive care unit admissions, more ward admissions, more bed days occupied, and more clinic attendances. Within the last two weeks of life, the noncancer patients had more invasive interventions initiated, fewer symptoms documented, less analgesics and sedatives prescribed, less do-not-resuscitate orders in place, and more cardiopulomonary resuscitation performed. Dyspnea, edema, pain, and fatigue were among the most documented symptoms in both cancer and noncancer patients. A higher proportion of ACP discussions were first documented within three days before death in COPD and CHF patients as compared with CRF and cancer patients. There is a need to develop palliative care for noncancer patients in Hong Kong.
Key Words: Noncancer deaths, cancer deaths, palliative care, advance care planning, end-of-life care, Hong Kong
Introduction
Palliative care has been launched in Asia for several decades. However, most of the palliative care services are limited to cancer patients.1 Hong Kong has a population of 6.8 million. Cancer, as the leading cause of death, accounts for one-third of all deaths.2 Chronic noncancer diseases also are prevalent in Hong Kong, where the population is aging. In 2006, there were 37,415 deaths in Hong Kong, with heart diseases, chronic obstructive airway disease, and chronic renal failure (CRF) as the second, fifth, and seventh causes of death, respectively.2
Palliative care services have been developing in the public health care system of Hong Kong since early 1980s and now, a comprehensive range of inpatient, outpatient, day patient, and consultative services is in place, serving mainly advanced cancer patients.3 A local study of 494 cancer deaths in 2005 in four public hospitals showed that palliative care services covered 67.4% of cancer deaths and that 50.0% of cancer deaths occurred in palliative care units.4 When comparing cancer deaths with and without palliative care, results from our previous study suggested that palliative care had been impactful, as reflected by the proxy indicators of less utilization of acute care services in the last six months, less invasive interventions initiated in the last two weeks of life, more symptoms documented, more analgesics and sedatives prescribed and yet better mental alertness at 72 hours before death, more do-not-resuscitate (DNR) orders in place, and less cardiopulmonary resuscitation (CPR) performed.
Palliative care for noncancer patients is still in its infancy in Hong Kong as compared with that for cancer patients. This study aimed at a comparison of noncancer deaths with cancer deaths in 2006. Results of this study would shed light on the similarities and differences between cancer and noncancer deaths locally.
The objectives were to compare noncancer deaths with cancer deaths in the following: 1) the utilization profile of the public health care system and the treatment received in the last six months of life; 2) the end-of-life care received in terms of type of interventions initiated, analgesics given, CPR performed, and the DNR documented; and 3) the advance care planning (ACP) process.
Methods
This was a retrospective chart review. Patients who died from cancer and from noncancer diseases, namely CRF, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF), in four local public hospitals in 2006 were identified for analysis. Three hospitals were acute general hospitals with 600, 1000, and 1350 beds, and one was a convalescent hospital with 425 beds. All four hospitals admitted patients with a wide spectrum of medical diseases. All four hospitals provide specialist palliative care services, with 80 palliative care beds in total, comprising about 30% of those in Hong Kong. Apart from inpatient palliative care, all four palliative care units also provided home care and outpatient services. The hospitals were recruited from three different operational clusters among seven clusters in Hong Kong to increase the diversity of the samples.
Patient Selection
All deaths from cancer, CRF, COPD, and CHF in the four hospitals from January 1, 2006 to December 31, 2006 were retrieved from the electronic database of the Hospital Authority of Hong Kong. One in eight cancer deaths were recruited consecutively, whereas all noncancer deaths with the principle diagnoses of CRF, COPD, and CHF were included for analysis.
Data Collection
Data were collected in four parts by a set of standardized data collection sheets. Part I of the data sheets consisted of demographic data, including age, sex, residence before death episode, comorbid conditions, and the duration from presentation of disease to death. Part II consisted of data on utilization of health care services and the disease-specific treatments received in the last six months. Part III consisted of data confined to the last two weeks of life, including symptoms documented by the physician, prescription of analgesics and sedatives, interventions initiated, documentation of DNR order, performance of CPR, visit by chaplain, and documentation of events after death. Part IV consisted of data on documentation of ACP discussion, including that on disease-specific and general life-sustaining interventions. Disease-specific interventions included radiotherapy, chemotherapy, and surgery for cancer; dialysis for renal diseases; cardiac pacing, cardiac catheterization, stent insertion for cardiac diseases; and ventilation support (both invasive and noninvasive) and bronchoscopy for COPD. General items included CPR, transfusion of blood products, use of antibiotics and inotropics, nutrition and hydration through a nasogastric tube, percutaneous endoscopic gastrostomy and parental route, intensive care unit (ICU) care, and other diagnostic procedures including upper endoscopy. The interval from the first documentation of ACP to death and the persons involved were recorded.
There were two sources of data: 1) the electronic clinical database of the Hospital Authority and 2) the hard copy of the patient record. The former is a comprehensive electronic system that captures information of all patients under the Hospital Authority, including demographic data and summaries of clinical information of all admissions and ambulatory episodes, as well as the diagnoses, investigation results, medications prescribed, and the treatments or interventions provided. The latter contains the structured assessment of the patient on admission and the integrated documentation of the patient's clinical course during the hospital stay. After collecting available information from the electronic system, the hard copy of detailed patient record was reviewed to collect further information (such as full symptom documentation and ACP discussion with date and person involved). Cross-checking of data available from both sources also was performed to improve the accuracy of the data. In Hong Kong, the vast majority of the total patient population is under the public health care system.
Statistical Analysis
Descriptive statistics were used. SPSS 11.0 (SPSS, Inc., Chicago, IL) was used for statistical analysis. Comparison between groups was tested by one-way analysis of variance. All tests were two-tailed, and a P-value of <0.05 was considered statistically significant.
Ethical Considerations
The protocol complied with the latest version of the Declaration of Helsinki. Approval for research was granted by the Clinical Research Ethics Committee of the respective clusters of the Hospital Authority. Right of access to patients' records and electronic data were obtained from the clinical departments. All data were kept in a safe place by the investigators. Patients' data were kept confidential and anonymous for data analysis, interpretation, and publication.
Results
Baseline Characteristics
The number of cancer deaths identified and recruited for analysis was 183 (after one in eight sampling), whereas that of noncancer deaths was 656, including 239 CRF deaths, 242 COPD deaths, and 175 CHF deaths. The baseline characteristics are listed in Table 1. The noncancer patients were significantly older than the cancer patients (79.1±9.5 years vs. 71.1±12.4 years, P<0.001). The CHF group was the oldest among all (83.1±9.0 years); the COPD group had the highest male-to-female ratio of 3:1. The noncancer patients presented earlier compared with the cancer patients in terms of mean days before death (1446.5±1151.9 vs. 541.2±643.1 days, P<0.001).
Table 1. Baseline Characteristics
| Demographics | CRF (n=239) | COPD (n=242) | CHF (n=175) | Noncancer (n=656) | Cancer (n=183) | P-valuea |
|---|---|---|---|---|---|---|
| Mean (SD) age in years | 76.5 (10.4) | 78.8 (7.9) | 83.1 (9.0) | 79.1 (9.5) | 71.1 (12.4) | <0.001 |
| Male:female | 1.1:1 | 3:1 | 1:1 | 1.4:1 | 1.4:1 | NS |
| Old-age home resident, n (%) | 17 (7.1) | 56 (23) | 62 (35.4) | 135 (20.6) | 18 (9.8) | <0.001 |
| From presentation of disease to death in days, mean (SD) | 1218.8 (1081.8) | 1899.7 (1061.5) | 979.6 (1090.6) | 1446.5 (1151.9) | 541.2 (643.1) | <0.001 |
| Comorbid conditions | No. of patients (percent within group) | |||||
| CHF | 64 (26.8) | 24 (9.9) | NA | NA | 14 (7.7) | — |
| CRF | NA | 14 (5.8) | 60 (34.3) | NA | 10 (5.5) | — |
| COPD | 21 (8.8) | NA | 29 (16.6) | NA | 25 (13.7) | — |
| Diabetes mellitus | 123 (51.5) | 21 (8.7) | 61 (34.9) | 205 (31.3) | 43 (23.5) | 0.044 |
| Ischemic heart disease | 67 (28.0) | 37 (15.3) | 90 (51.4) | 194 (29.6) | 19 (10.4) | <0.001 |
| Cerebrovascular accident | 66 (27.6) | 25 (10.3) | 51 (29.1) | 142 (21.6) | 22 (12.0) | 0.003 |
| Psychiatric disease | 13 (5.4) | 17 (7.0) | 10 (5.7) | 40 (6.1) | 10 (5.5) | NS |
| Dementia | 32 (13.4) | 26 (10.7) | 36 (20.6) | 94 (14.3) | 9 (4.9) | <0.001 |
| Cancer | 14 (5.9) | 31 (12.8) | 10 (5.7) | 55 (8.4) | NA | — |
| Chronic liver disease | 8 (3.3) | 5 (2.1) | 3 (1.7) | 16 (2.4) | 15 (8.2) | <0.001 |
| Long-term deviceb | 14 (5.9) | 109 (45.0) | 26 (14.9) | 149 (22.7) | 21 (11.5) | <0.001 |
| Mean (SD) no. of comorbidities | 2.5 (1.4) | 1.8 (1.2) | 2.9 (1.4) | 2.3 (1.4) | 1.6 (1.4) | <0.001 |
aP-value refers to level of significance in comparing noncancer patients (n |
bLong-term device includes long-term oxygen therapy, noninvasive mechanical ventilation, Foley catheter, Ryle's tube for feeding, implantable cardiac devices. |
Comorbid conditions were more prevalent in noncancer patients than cancer patients (2.3±1.4 vs. 1.6±1.4, P<0.001), with the highest mean number in CHF patients (2.9±1.4) and lowest in cancer patients (1.6±1.4). Diabetes mellitus, ischemic heart disease, cerebrovascular accident, and dementia were more prevalent in the noncancer patients, whereas chronic liver disease was more prevalent in cancer. Overall, diabetes mellitus was the most prevalent comorbidity and present in near 30% of combined noncancer and cancer deaths. More noncancer patients were on long-term devices in the community, including long-term oxygen therapy, noninvasive ventilation, Ryle's tube, Foley's catheter, and implantable cardiac devices.
Last Six Months of Life
The health care utilization in the last six months of life is shown in Table 2. As compared with cancer patients, the noncancer patients had significantly more admissions to hospitals and ICUs, more clinic attendances, and a longer duration of hospital stay. Palliative care service covered 79.2% of cancer patients but only 1.4% of noncancer patients (P<0.001).
Table 2. Health Care Utilization and Disease-Specific Treatment Received in Last Six Months of Life
| Health Care Utilization/Disease Specific Treatment | CRF (n=239) | COPD (n=242) | CHF (n=175) | Noncancer (n=656) | Cancer (n=183) | P-valuea |
|---|---|---|---|---|---|---|
| Mean (SD) no. of clinic attendances | 4.8 (3.6) | 2.7 (2.9) | 3.4 (2.9) | 3.3 (3.3) | 3.0 (2.9) | <0.001 |
| Mean (SD) no. of AED visits | 2.9 (2.2) | 3.1 (2.4) | 2.9 (1.9) | 3.0 (2.2) | 2.9 (2.1) | NS |
| Mean (SD) no. of ward admissionsb | 4.0 (3.0) | 4.0 (3.0) | 3.6 (2.4) | 3.7 (2.7) | 3.2 (2.2) | 0.046 |
| Total duration of hospital stay in days (SD) | 36.7 (31.6) | 45.8 (41.3) | 40.0 (32.9) | 40.9 (36.0) | 28.5 (26.0) | <0.001 |
| Mean (SD) no. of ICU admissions | 0.2 (0.5) | 0.2 (1.0) | 0.2 (0.6) | 0.2 (0.8) | 0.04 (0.3) | <0.001 |
| Deaths in ICU (%) | 6 (2.5) | 5 (2.1) | 4 (2.3) | 15 (2.3) | 2 (1) | <0.001 |
| Patients received palliative care (%) | 1 (1.0) | 7 (3.6) | 1 (0.7) | 9 (1.4) | 145 (79.2) | <0.001 |
| Deaths in palliative care ward (%) | 0 (0.0) | 1 (0.5) | 0 (0.0) | 1 (0.2) | 116 (63.4) | <0.001 |
| Duration of death episode in days (SD) | 17.2 (24.1) | 20.7 (28.1) | 15.3 (16.0) | 18.0 (23.7) | 18.6 (18.1) | 0.208 |
| Disease-specific interventions | No. of patients (percent within group) | |||||
| Long-term oxygen therapy | 0 (0.0) | 102 (42.1) | 5 (2.9) | 107 (16.3) | 4 (2.2) | <0.001 |
| Noninvasive ventilation | 11 (4.6) | 110 (45.5) | 23 (13.1) | 144 (22.0) | 2 (1.1) | <0.001 |
| Invasive ventilation | 14 (5.9) | 24 (9.9) | 25 (14.3) | 63 (9.6) | 0 (0.0) | <0.001 |
| Dialysis | 68 (28.5) | 0 (0.0) | 5 (2.9) | 73 (11.1) | 0 (0.0) | <0.001 |
| Revision of dialysis access | 12 (5.0) | 0 (0.0) | 0 (0.0) | 12 (1.8) | 0 (0.0) | <0.001 |
| Cardioversion | 2 (0.8) | 0 (0.0) | 11 (6.3) | 13 (2.0) | 0 (0.0) | <0.001 |
| Cardiac surgery | 0 (0.0) | 0 (0.0) | 3 (1.7) | 3 (0.5) | 0 (0.0) | 0.01 |
| Implantable cardiac device | 2 (0.8) | 0 (0.0) | 6 (3.4) | 8 (1.2) | 1 (0.5) | 0.024 |
| Cancer surgery | 0 (0.0) | 2 (0.8) | 0 (0.0) | 2 (0.3) | 19 (10.4) | <0.001 |
| Chemotherapy | 1 (0.4) | 2 (0.8) | 0 (0.0) | 3 (0.5) | 28 (15.3) | <0.001 |
| Radiotherapy | 0 (0.0) | 3 (1.2) | 0 (0.0) | 3 (0.5) | 40 (21.9) | <0.001 |
aP-value refers to level of significance in comparing noncancer patients (n |
bWard admissions refer to admissions to wards other than ICU. |
The disease-specific treatments received by each disease group also are listed in Table 2. A total of 31.6% of patients in the noncancer group received either invasive (9.6%) or noninvasive (22.0%) ventilation. Use of ventilation was particularly prevalent in the COPD patients, with 9.9% of patients on invasive ventilation and 45.5% on noninvasive ventilation. The proportion of cancer patients who received any combination of cancer treatment (surgery, chemotherapy, or radiotherapy) was 40.4%.
The Death Episode (Last Two Weeks of Life)
The noncancer patients had more interventions initiated within the last two weeks of life as compared with cancer patients (mean 3.9±2.2 vs. 2.6±1.5, P<0.001), including central venous and arterial lines, Ryle's tube insertion, percutaneous endoscopic gastrostomy, Foley's catheter, invasive and noninvasive ventilation, inotropic infusion, dialysis, surgery, invasive cardiac interventions, and CPR (Table 3). Nearly 50% of COPD patients were initiated on either invasive or noninvasive ventilation. None of the cancer patients had tumor-targeted treatment initiated in the last two weeks of life.
Table 3. Interventions Initiated Within the Last Two Weeks of Life
| Interventions Initiated in Last 2 Weeks of Life | CRF (n=239) | COPD (n=242) | CHF (n=175) | Noncancer (n=656) | Cancer (n=183) | P-valuea |
|---|---|---|---|---|---|---|
| No. of patients (percent within group) | ||||||
| Intravenous/subcutaneous line | 184 (77.0) | 193 (79.8) | 123 (70.3) | 500 (76.2) | 133 (72.7) | NS |
| Oxygen | 180 (75.3) | 183 (75.6) | 147 (84.0) | 510 (77.7) | 121 (66.1) | 0.002 |
| Antibiotics | 131 (54.8) | 200 (82.6) | 100 (57.1) | 431 (65.7) | 97 (53.0) | 0.002 |
| Foley catheter | 98 (41.0) | 65 (26.9) | 77 (44.0) | 240 (36.6) | 42 (23.0) | 0.001 |
| Inotropic infusion | 59 (24.7) | 38 (15.7) | 63 (36.0) | 160 (24.4) | 5 (2.7) | <0.001 |
| Ryle's tube/PEG | 49 (20.5) | 57 (23.6) | 33 (18.9) | 139 (21.2) | 19 (10.4) | 0.001 |
| Noninvasive ventilation | 14 (5.9) | 93 (38.4) | 17 (9.7) | 124 (18.9) | 0 (0.0) | <0.001 |
| Invasive ventilation | 27 (11.3) | 25 (10.3) | 25 (14.3) | 77 (11.7) | 6 (3.3) | <0.001 |
| Transfusion | 54 (22.9) | 12 (5.0) | 18 (10.3) | 84 (12.8) | 25 (13.7) | NS |
| Dialysis | 40 (16.7) | 1 (0.4) | 2 (1.1) | 43 (6.6) | 1 (0.5) | <0.001 |
| Central venous/arterial line | 29 (12.2) | 18 (7.4) | 22 (12.6) | 69 (10.5) | 4 (2.2) | 0.005 |
| Total parenteral nutrition | 5 (2.1) | 0 (0.0) | 1 (0.6) | 6 (0.9) | 0 (0.0) | 0.023 |
| Invasive cardiac proceduresb | 10 (4.2) | 9 (3.7) | 18 (10.3) | 37 (5.6) | 3 (1.6) | <0.001 |
| Any surgery | 8 (3.3) | 2 (0.8) | 2 (1.1) | 12 (1.8) | 0 (0.0) | 0.022 |
| CPR | 28 (11.7) | 35 (14.5) | 37 (21.1) | 100 (15.2) | 8 (4.4) | <0.001 |
| Mean no. (SD) | 3.9 (2.5) | 3.9 (1.9) | 4.0 (2.1) | 3.9 (2.2) | 2.6 (1.5) | <0.001 |
aP-value refers to level of significance in comparing noncancer patients (n |
bInvasive cardiac procedures include pacemaker insertion, cardiac catheterization, electrical cardioversion, and endovascular stenting. |
More symptoms were documented in cancer patients as compared with noncancer patients (5.2±2.6 vs. 3.1±1.7, P<0.001) (Table 4). Most individual symptoms were more often documented in cancer, except for dyspnea and cough in COPD; edema in CHF; and pruritus in CRF. Irrespective of the underlying disease, dyspnea, edema, pain, and fatigue were among the most commonly documented symptoms.
Table 4. Symptoms Documented by Physician in the Last Two Weeks of Life
| Symptoms | CRF (n=239) | COPD (n=242) | CHF (n=175) | Noncancer (n=656) | Cancer (n=183) | P-valuea |
|---|---|---|---|---|---|---|
| No. of patients (percent within group) | ||||||
| Dyspnea | 127 (53.1) | 208 (86.0) | 144 (82.3) | 479 (73.0) | 107 (58.5) | <0.001 |
| Edema | 92 (38.5) | 55 (22.7) | 87 (49.7) | 234 (35.7) | 59 (32.2) | NS |
| Pain | 82 (34.3) | 66 (27.3) | 50 (28.6) | 198 (30.2) | 118 (64.5) | <0.001 |
| Cough | 43 (18.0) | 119 (49.2) | 32 (18.3) | 194 (29.6) | 43 (23.5) | NS |
| Fatigue | 68 (28.5) | 63 (26.0) | 33 (18.9) | 164 (25.0) | 117 (63.9) | <0.001 |
| Anorexia | 70 (29.3) | 39 (16.1) | 24 (13.7) | 133 (20.3) | 88 (48.1) | <0.001 |
| Bowel problem | 51 (21.3) | 35 (14.5) | 21 (12.0) | 107 (16.3) | 59 (32.2) | <0.001 |
| Confusion | 35 (14.6) | 45 (18.6) | 17 (9.7) | 97 (14.8) | 56 (30.6) | <0.001 |
| Nausea/vomiting | 45 (18.8) | 13 (5.4) | 11 (6.3) | 69 (10.5) | 51 (27.9) | <0.001 |
| Urinary problem | 25 (10.5) | 19 (7.9) | 15 (8.6) | 59 (9.0) | 31 (16.9) | 0.004 |
| Sores/wounds | 24 (10.0) | 10 (4.1) | 23 (13.1) | 57 (8.7) | 24 (13.1) | NS |
| Restlessness | 16 (6.7) | 6 (2.5) | 9 (5.1) | 31 (4.7) | 18 (9.8) | 0.013 |
| Oral problem | 6 (2.5) | 20 (8.3) | 5 (2.9) | 31 (4.7) | 23 (12.6) | <0.001 |
| Distended abdomen | 19 (7.9) | 7 (2.9) | 4 (2.3) | 30 (4.6) | 37 (20.2) | <0.001 |
| Cachexia | 4 (1.7) | 13 (5.4) | 3 (1.7) | 20 (3.0) | 38 (20.8) | <0.001 |
| Sleep problem | 8 (3.3) | 5 (2.1) | 3 (1.7) | 16 (2.4) | 30 (16.4) | <0.001 |
| Hemoptysis | 2 (0.8) | 10 (4.1) | 2 (1.1) | 14 (2.1) | 8 (4.4) | NS |
| Depressed mood | 4 (1.7) | 6 (2.5) | 4 (2.3) | 14 (2.1) | 15 (8.2) | <0.001 |
| Pruritus | 5 (2.1) | 1 (0.4) | 0 (0.0) | 6 (0.9) | 2 (1.1) | NS |
| Wish to hasten death | 0 (0.0) | 4 (1.7) | 1 (0.6) | 5 (0.8) | 5 (2.7) | 0.045 |
| Anxiety | 0 (0.0) | 3 (1.2) | 1 (0.6) | 4 (0.6) | 8 (4.4) | <0.001 |
| Suicidal ideation | 0 (0.0) | 2 (0.8) | 0 (0.0) | 2 (0.3) | 5 (2.7) | 0.007 |
| Request euthanasia | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 3 (1.6) | 0.010 |
| Mean no. | 3.1 (1.9) | 3.2 (1.6) | 2.9 (1.5) | 3.1 (1.7) | 5.2 (2.6) | <0.001 |
aP-value refers to level of significance in comparing noncancer patients (n |
In 58.5% of noncancer patients, no analgesic was prescribed (vs. 8.7% in cancer, P<0.001) (Fig. 1). Less noncancer patients were prescribed individual analgesics, including strong opioids.
Fig. 1.
Analgesics and sedatives prescribed in the last two weeks of life. P-value refers to level of significance in comparing noncancer patients (n
=656) and cancer patients (n=183). NSAID=nonsteroidal anti-inflammatory drug. Sedatives include benzodiapzepines and haloperidol.
The mean duration of the death episode in hospital was similar in noncancer and cancer, but with more noncancer deaths occurring in the ICU (Table 2). Among the cancer deaths, 63.4% occurred in palliative care units. The coexisting acute events contributory to death are listed in Table 5 and were more prevalent in noncancer than cancer patients (1.0±0.9 vs. 0.7±0.8, P<0.001). More than half of the COPD deaths (57.9%) were accompanied by pneumonia. The incidence of acute coronary syndrome in the CRF patients (15.9%) was similar to that of the CHF patients (16.0%).
Table 5. Coexisting Acute Events at Death
| Acute Events at Death | CRF (n=239) | COPD (n=242) | CHF (n=175) | Noncancer (n=656) | Cancer (n=183) | P-valuea |
|---|---|---|---|---|---|---|
| No. of patients (percent within group) | ||||||
| Pneumonia | 45 (18.8) | 140 (57.9) | 55 (31.4) | 240 (36.6) | 37 (20.2) | <0.001 |
| Septicemia | 16 (6.7) | 4 (1.7) | 8 (4.6) | 28 (4.3) | 8 (4.4) | NS |
| Other sepsis | 55 (23.0) | 6 (2.5) | 10 (5.7) | 71 (10.8) | 22 (12.0) | NS |
| Other organ failure | 36 (15.1) | 19 (7.9) | 29 (16.6) | 84 (12.8) | 31 (16.9) | NS |
| Acute coronary syndrome | 38 (15.9) | 12 (5.0) | 28 (16.0) | 78 (11.9) | 2 (1.1) | <0.001 |
| Arrhythmia | 18 (7.5) | 11 (4.5) | 25 (14.3) | 54 (8.2) | 6 (3.3) | 0.022 |
| Pneumothorax | 2 (0.8) | 10 (4.1) | 0 (0) | 12 (1.8) | 3 (1.6) | NS |
| Bone fracture | 3 (1.3) | 0 (0) | 0 (0) | 3 (0.5) | 2 (1.1) | NS |
| Gastrointestinal bleeding | 25 (10.5) | 9 (3.7) | 16 (9.1) | 50 (7.6) | 13 (7.1) | NS |
| Vascular insufficiencyb | 12 (5.0) | 2 (0.8) | 6 (3.4) | 20 (3.0) | 2 (1.1) | NS |
| Mean no. (SD) | 1.1 (1.0) | 0.9 (0.7) | 1.0 (0.9) | 1.0 (0.9) | 0.7 (0.8) | <0.001 |
| No. of patients (percent within group) | ||||||
| CPR performed | 28 (11.7) | 35 (14.5) | 37 (21.1) | 100 (15.2) | 8 (4.4) | <0.001 |
| DNR order in place | 214 (89.5) | 204 (84.3) | 140 (80.0) | 558 (85.1) | 175 (95.6) | |
aP-value refers to level of significance in comparing noncancer patients (n |
bVascular insufficiency includes deep vein thrombosis, gangrene, and acute stroke. |
As compared with cancer patients, noncancer patients had less DNR orders in place (85.1% vs. 95.6%, P<0.001) and more CPR performed (15.2% vs. 4.4%, P<0.001). More cancer patients were visited by a chaplain before death than noncancer patients (39.9% vs. 5.8%, P<0.001), and documentation of events after death, such as reactions of relatives, was identified in 69.9% of cancer deaths and 31.7% of noncancer deaths, respectively (P<0.001).
Advance Care Planning
Documentation of ACP or discussion of life-sustaining treatment was identified in 585 (89.2%) and 172 (94.0%) of noncancer and cancer patients (P=0.053), respectively (Fig. 2). The duration from documentation of first ACP discussion to death was widely dispersed, and the median days (interquartile range) were as follows: CRF 221 (50–666), COPD 23 (9–75), CHF 18 (7–56), cancer 56 (18–125), with the longest duration in CRF patients. Despite an earlier presentation of illness in COPD and CHF patients, the ACP discussion was first documented within three days before death in 26.9% and 35.7%, respectively, whereas that for CRF and cancer were 9.5% and 11.6%, respectively (P<0.001).
Fig. 2.
Cumulative percentage of patients with ACP documentation found in patients' record during the last six months of life in different disease groups.
CPR was discussed in 95% of all patients. The discussants involved in the noncancer and the cancer patients included patient (11.5% vs. 40.1%, P<0.001); spouse (19.3% vs. 27.9%, P=0.013); children (65.1% vs. 62.2%, no significant difference statistically [NS]); parents (0.5% vs. 0.6%, NS); and friends, distant relatives, and guardians (15.7% vs. 8.7%, P=0.022).
Discussion
Although palliative care has been launched in Asia for several decades, its coverage has not yet been extended from cancer patients to noncancer patients.1 This is the first study conducted in Asia to compare cancer and noncancer deaths. Our results show that patients who died from noncancer diseases, including CRF, CHF, and COPD, as compared with cancer deaths, were older, more dependent, and had more comorbid conditions. The noncancer patients presented earlier to the public health care system and had more intensive utilization of health care services in their last six months of life. More noncancer patients were dependent on long-term medical devices in the community and required institutionalized care. Palliative care coverage for noncancer was only 1.4%, contrasting with that of around 80% for cancer.
At the end of life, the noncancer patients had more interventions initiated and less symptoms documented. Symptoms of dyspnea, pain, edema, and fatigue were among the most common ones in both noncancer and cancer. Fewer noncancer patients were prescribed analgesics and sedatives during the death episode. More COPD and CHF patients had the ACP discussion first documented within three days before death. A DNR order was less documented in the noncancer patients, and more CPR was performed.
We had chosen patients who died from CRF, COPD, and CHF as they were a group of major noncancer deaths in Hong Kong. With regard to the deaths from CRF, COPD, and CHF, the noncancer patients analyzed in our study constituted around 11%, 15%, and 10% of respective deaths in all hospitals in the Hospital Authority. Our noncancer patients, aside from being older than the cancer patients, also had more comorbid conditions. Diabetes mellitus was most prevalent among all patients. Diseases related to atherosclerosis such as ischemic heart disease and cerebrovascular accident; and dementia as related to old age and other major organ failure were common in the noncancer deaths. Patients who died from CHF were oldest, had the highest number of comorbid conditions, and had the highest proportion of old-age home residents among all disease groups. In patients with CRF, acute coronary syndrome in the dying phase was as prevalent as that of CHF patients. Cardiac events are well known as among the most common causes of death in CRF.5
These results reflect the composite picture of coexisting diseases and morbidities in patients with debilitating chronic diseases, and in turn, the complex demands on the health care system, and the formal and the informal caregivers. Hong Kong has an aging population, and chronic diseases are prevalent. By the year 2031, one in four citizens will be above 65 years of age.6 Three-quarters of people above age 65 suffer from one or more chronic diseases,7 the prevalence of which is more than five times higher than in an individual of age 20 years. The utilization of hospital beds increases with the age of patients in Hong Kong,6 and in the Hospital Authority, patients over 65 years of age constituted one-third of patients admitted and accounted for 46.5% of all bed days occupied in the public hospitals.8
Another plausible reason for the more intensive health care utilization in noncancer patients is the less predictable disease trajectory in noncancer diseases, which can be more protracted and often interrupted by acute or even life-threatening exacerbations.9 The reversibility of these exacerbations or deterioration episodes for noncancer patients could be difficult to predict; these patients might receive or require simultaneous “active” and “palliative” interventions. It is, therefore, possible that a life prolongation approach may be continued till the final days of life, with more invasive interventions implemented and more CPR performed, as in our study.
The proxy indicators that were used to reflect the end of life in this study included interventions or treatment initiated within the last two weeks of life, symptoms documented, analgesics and sedatives prescribed, the mental alertness, which in turn reflected the ability to communicate, the DNR order in place, and CPR performed. Our results showed that more invasive interventions were initiated in noncancer than cancer patients in last two weeks of life. The palliative role of a specific intervention is affected by the stage of the disease and functional status of the individual patient, and the best evidence available at that time. For example, noninvasive ventilation could be burdensome to a dying patient, but it could also, in appropriate selected cases, be used for relief of dyspnea when the benefit outweighs the burden. In our study, up to 38.4% of the COPD patients were initiated on noninvasive ventilation within two weeks before death, and this occurred in around 6% of CRF and 10% of CHF patients. However, it would not be possible for us to evaluate the palliative intent and the outcome in a retrospective design. Overall, around 30% of our noncancer patients were initiated on any type of ventilation, while three-quarters of them were documented to be dyspneic by doctors. However, medications that could palliate dyspnea at end of life, including morphine and sedatives, were less prescribed in noncancer patients than in cancer patients.
A systematic review showed that symptom prevalence in patients with noncancer end-stage diseases, including acquired immunodeficiency syndrome, heart disease, COPD, and renal disease, was similar to that of cancer, with pain, breathlessness, and fatigue present in more than 50% of all patients.10 However, as this was a retrospective study, the symptoms could not represent those as reported by patients prospectively, or include those symptoms that might be missed if not specifically looked for. In a prospective study on end-stage renal disease in Hong Kong, patients reported more than nine symptoms on average when given a standard list of 23 symptoms for reporting.11 As we had to depend on the documentation in our study, the symptoms retrieved would not be as complete as those in a prospective study.
In our study, despite the variances in the documentation rate among different disease groups, the top symptoms documented were remarkably similar, with dyspnea, edema, pain, and fatigue common to all disease groups. These findings suggested that noncancer patients also had similar needs for symptom relief as cancer patients. However, fewer symptoms were documented in the noncancer patients. As this occurred against the background that noncancer patients received more invasive interventions than cancer patients, lower symptom detection was plausible.
Symptoms related to psychological distress were also more documented in cancer patients, including anxiety, depressed mood, wish to hasten death, suicidal ideation, and request for euthanasia. Far more cancer patients were visited by a chaplain before death, and there was more documentation of the scene and family's reaction after death in cancer deaths. These findings suggested the attention to the psychosocial and spiritual needs by the palliative care team providing care to most cancer deaths.
In preparing for a better dying process, the ACP process has the merits of empowering patient's autonomy, reducing unnecessary or futile treatments when dying, reducing the family's burden in making difficult medical decisions, and in promoting mutual understanding among the family members.12 In Hong Kong, the Hospital Authority has been promoting the use of a DNR form since 1996 and issued guidelines on withholding and withdrawing life-sustaining treatment in the terminally ill in 2002.13 This promulgation has contributed to the relatively high rate of DNR documentation in our study, but the rate was even higher among the cancer patients. Furthermore, it is a common practice in palliative care in Hong Kong to involve patients as discussants in CPR and DNR decisions when feasible and appropriate. In our study, this occurred in 40.1% of cancer patients as compared with 11.5% of noncancer patients. However, advance directives are not enacted by law in Hong Kong, and the concept is not familiar to the local population. Such discussions on life-sustaining treatments would be documented in the patient's record to facilitate appropriate care.13 Among all disease groups, the CRF patients had ACP discussion first documented significantly earlier than the others. This was likely because of the local clinical practice that patients with Stage 4 or 5 kidney disease were commonly referred to renal physicians for assessment of potential risks and benefits from long-term dialysis. Those CRF patients who were initiated on dialysis or were referred earlier would contribute to the longer duration from ACP discussion to death. However, more than one-quarter of COPD patients and more than one-third of CHF patients had the ACP discussion first documented within three days before death. This could be because of the presence of relapsing acute deteriorations in the respective disease trajectories, the availability of various treatments for “reversing” the critical clinical states, and the use of the more aggressive treatments till the late stage of life, as shown in our study.
More patients and their spouses were documented to be involved in the ACP discussion in the cancer group, whereas children were equally involved in both cancer and noncancer patient discussions. In the Chinese culture, family plays an important role and often functions as a unit in medical decision making.13, 14 It is the local experience that children of patients may have concern, out of filial piety, about the distress their parents may incur; yet, there are patients who would like to exercise their autonomy and be directly involved in the discussion. When discussions are conducted and first documented within last three days of life, as is the case in about one-quarter of our noncancer patients, lucid discussion with patients would be limited by their impaired mental capacity at end of life.
The coverage of palliative care for cancer deaths as found in this study had expanded as compared with the cancer deaths in the same hospitals the year before.4 The palliative care coverage for cancer patients increased from 67.4% to about 79.2%, and the percentage of cancer patients who died in palliative care units increased from 50.0% to 63.4%. The same set of proxy indicators was used to explore the impact of palliative care on cancer deaths. Results from this study showed the same pattern of differences, but the comparison was conducted between noncancer deaths and cancer deaths. The less predictable nature of noncancer diseases as compared with cancer might explain some of the differences. However, the high percentage of palliative care coverage in the cancer group also could contribute to the difference, as patients with noncancer diseases have been shown to have similar needs as cancer patients at the end of life. The symptom profiles of cancer and noncancer patients showed similarities from our results and from other studies.10 Local studies also showed that COPD and cancer patients shared similar quality-of-life concerns.15 CRF patients with or without dialysis had impaired quality of life and overlapping symptom burdens.11
Palliative care for noncancer patients is now developing in various places around the world but with highly variable access and coverage. In the United States, 58.7% of the hospice admissions in 2007 were noncancer patients.16 In the United Kingdom, noncancer diagnosis accounted for 7.2% of all hospice admissions from 2006 to 2007, ranging from 0% to 38% among individual units.17 In another survey conducted in Ireland, only 24% of specialist palliative care services provided care for noncancer patients in some way, and among all who received palliative care, a noncancer diagnosis only constituted 7.21% in 2004.18 To meet the increasing palliative care needs, there is a projected increase in demand for the palliative medicine specialist work force, notably in training of specialists and in providing care for noncancer patients.19 Although it would be impossible for the limited number of specialist palliative care teams to meet the vast needs, the integrated care pathway for the dying is now implemented in the United Kingdom to improve end-of-life care in nonpalliative care settings, for both cancer and noncancer.20
In Hong Kong, palliative care for noncancer patients is limited to a few local programs for CRF and COPD, with the collaboration of specialists from palliative care and other respective specialties. Results of our study illustrated the challenges as stipulated and projected by local health authorities,6, 7 namely, an aging population with multiple chronic diseases, functional dependency, and high utilization of public health care services. The palliative care needs of our noncancer patients were considerable, and yet they received more aggressive interventions at the end of life. It is imperative to develop palliative care for noncancer patients in Asia to address the inequity in access and the unmet needs at present and in the future. In view of the enormous needs, the model of delivery of palliative care and the interfacing with respective specialties remain to be explored. Measures to improve the ACP process could avoid unwanted or unnecessary invasive interventions at the end of life.
Limitations
Because this was a retrospective study, there were limitations in accurately assessing the outcome measure in symptom management and the contents of the ACP discussions. As the results were obtained from four local hospitals in three operational clusters, one may not be able to generalize the results to other public hospitals in Hong Kong or other countries.
Conclusion
Our noncancer patients, as compared with cancer patients, were older, more dependent, had more comorbid conditions, and were more demanding on the public health care system in the last six months of their lives. The noncancer patients also, at end of life, had more coexisting acute events, more invasive interventions initiated, fewer symptoms documented, less analgesics and sedatives prescribed, less DNR orders in place, and more CPR performed. Noncancer patients and their spouses were less involved in ACP discussions, and a considerable proportion of COPD and CHF patients had the ACP discussion first documented within three days before death.
Palliative care was delivered to only 1.4% of noncancer patients, in contrast to the nearly 80% of cancer patients. There is an imperative need to further develop palliative care for noncancer patients in Hong Kong. The impact of palliative care, measures for improvement of the ACP process, and implementation of an end-of-life clinical pathway for noncancer patients remain to be explored.
Disclosures and Acknowledgments
The authors thank the Society for the Promotion of Hospice Care for funding this study. The funder was not involved in the conduct of the study or development of the submission. The authors declare no conflicts of interest.
References
- . The Asia Pacific Hospice Palliative Care Network: a network for individuals and organizations. J Pain Symptom Manage. 2002;24:128–133
- . Department of Health, The Government of the Hong Kong Special Administrative Region. Vital statistics. 2008. Available from http://www.chp.gov.hk/data.asp?lang=en&cat=4&dns_sumID=380&id=27&pid=10&ppidAccessed April 13, 2009
- . Two decades of palliative care. Hong Kong Med J. 2002;8:465–466
- . The impact of palliative care on cancer deaths in Hong Kong: a retrospective study of 494 cancer deaths. Palliat Med. 2007;21:425–433
- . Changing patterns of renal replacement therapy. In: Chambers EJ, Germain M, Brown E editor. Supportive care for the renal patient. Oxford, UK: Oxford University Press; 2004;p. 1–13
- Health and Medical Development Advisory Committee, The Government of Hong Kong Special Administrative Region. Building a healthy tomorrow. Discussion paper on the future service delivery model for our health care system. July 2005. Available from http://www.fhb.gov.hk/hmdac/english/papers/files/hmdac_paper.pdf. Accessed April 15, 2009.
- . The Government of Hong Kong Special Administrative Region. Survey on socio-demographic, health and economic profiles of older people and the soon to be old people 2000. Hong Kong, ROC: The Government of Hong Kong Special Administrative Region; 2000;
- Hospital Authority Hong Kong. Statistics report 2006-2007. March 2007. Available from http://www.ha.org.hk/visitor/ha_visitor_index.asp?Content_ID=136136&;%20Dimension=100&Lang=ENG. Accessed April 15, 2009.
- . Illness trajectories and palliative care. Br Med J. 2005;330:1007–1011
- . A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006;31:58–69
- Symptom palliation and quality of life in end-stage renal disease: a study of 179 patients on dialysis and palliative care. Palliat Med. 2009;23:111–119
- Reconceptualizing advance care planning from the patient's perspective. Arch Intern Med. 1998;158:879–884
- Working group on Clinical Ethics, Hospital Authority Clinical Ethics Committee, Hospital Authority of Hong Kong. Guidelines on life-sustaining treatment in the terminally ill. April 2002. Available from http://www.ha.org.hk/visitor/ha_visitor_index.asp?Parent_ID=110&Content_ID=363&Dimension=100. Accessed April 14, 2009.
- . Sharing death and dying: advance directives, autonomy and the family. Bioethics. 2004;18:87–103
- Assessing quality of life of patients with advanced chronic obstructive pulmonary disease in the end of life. J Palliat Care. 2005;21:180–187
- National Hospice and Palliative Care Organization. NHPCO facts and figures: Hospice care in America. October 2008. Available from http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and-figures_2008.pdf. Accessed April 14, 2009.
- The National Council for Palliative Care. National survey of patient activity data for specialist palliative care services. MDS full report for year 2006-2007. December 2007. Available from http://www.ncpc.org.uk/download/mds/MDS_Full_Report_ 0607part.pdf. Accessed April 15, 2009.
- . Survey of specialist palliative care services for noncancer patients in Ireland and perceived barriers. Palliat Med. 2008;22:77–83
- NHS Workforce Review Team, NHS South Central, National Health Services. NHS work force summary palliative medicine. June 19, 2008. Available from http://www.wrt.nhs.uk/index.php/component/docman/doc_view/73-palliative-medicine?tmpl=component&format=raw. Accessed April 15, 2009.
- LCP Central Team, The Marie Curie Palliative Care Institute Liverpool. LCP non-cancer briefing paper. July 2008. Available from http://www.mcpcil.org.uk/files/LCPNon-CancerBriefingPaper-Julyprintablepdf.pdf. Accessed April 15, 2009.
PII: S0885-3924(10)00497-5
doi:10.1016/j.jpainsymman.2010.02.023
© 2010 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Volume 40, Issue 5 , Pages 704-714, November 2010
