Department of Medicine University of Toronto Ontario Canada.
ICES Toronto and Ottawa Ontario Canada.
J Am Heart Assoc. 2020 Mar 3;9(5):e013844. doi: 10.1161/JAHA.119.013844. Epub 2020 Feb 19.
Background Palliative care is associated with improved symptom control and quality of life in people with heart failure. There is conflicting evidence as to whether it is associated with a greater likelihood of death at home in this population. The objective of this study was to describe the delivery of newly initiated palliative care services in adults who die with heart failure and measure the association between receipt of palliative care and death at home compared with those who did not receive palliative care. Methods and Results We performed a population-based cohort study using linked health administrative data in Ontario, Canada of 74 986 community-dwelling adults with heart failure who died between 2010 and 2015. Seventy-five percent of community-dwelling adults with heart failure died in a hospital. Patients who received any palliative care were twice as likely to die at home compared with those who did not receive it (adjusted odds ratio 2.12 [95% CI, 2.03-2.20]; <0.01). Delivery of home-based palliative care had a higher association with death at home (adjusted odds ratio 11.88 [95% CI, 9.34-15.11]; <0.01), as did delivery during transitions of care between inpatient and outpatient care settings (adjusted odds ratio 8.12 [95% CI, 6.41-10.27]; <0.01). Palliative care was most commonly initiated late in the course of a person's disease (≤30 days before death, 45.2% of subjects) and led by nonspecialist palliative care physicians 61% of the time. Conclusions Most adults with heart failure die in a hospital. Providing palliative care near the end-of-life was associated with an increased likelihood of dying at home. These findings suggest that scaling existing palliative care programs to increase access may improve end-of-life care in people dying with chronic noncancer illness.
姑息治疗与心力衰竭患者症状控制和生活质量的改善有关。但对于它是否会增加心力衰竭患者在家中死亡的可能性，目前仍存在相互矛盾的证据。本研究的目的是描述新启动的姑息治疗服务在心力衰竭死亡患者中的实施情况，并衡量接受姑息治疗与未接受姑息治疗的患者在家中死亡的可能性之间的关联。
我们在加拿大安大略省进行了一项基于人群的队列研究，使用的是 2010 年至 2015 年间 74986 例居住在社区的心力衰竭死亡患者的健康行政数据进行关联分析。75%的居住在社区的心力衰竭患者死于医院。与未接受姑息治疗的患者相比，接受任何姑息治疗的患者在家中死亡的可能性是其两倍（调整后的优势比 2.12[95%置信区间，2.03-2.20]；<0.01）。家庭姑息治疗的实施与在家中死亡的相关性更高（调整后的优势比 11.88[95%置信区间，9.34-15.11]；<0.01），以及在住院和门诊治疗环境之间的治疗转换期间进行姑息治疗（调整后的优势比 8.12[95%置信区间，6.41-10.27]；<0.01）。姑息治疗最常开始于患者病程的晚期（≤死亡前 30 天，45.2%的患者），61%的时间由非专科姑息治疗医生发起。
大多数心力衰竭患者在医院死亡。在生命末期提供姑息治疗与在家中死亡的可能性增加有关。这些发现表明，扩大现有的姑息治疗计划以增加可及性可能会改善患有慢性非癌症疾病的临终患者的护理。
