The research was carried out among patients admitted into the wards at Lagos University Teaching Hospital, Idi-Araba. It was aimed at examining the pattern of admissions and needs assessment for palliative services among these patients in order to justify the need for the establishment of palliative care services in Lagos University Teaching Hospital Idi-Araba Lagos Nigeria
Sociodemographic Characteristics of Respondents
A total of 129 patients were interviewed for this study. Majority of the respondents were aged between 18–59 years, representing 83% of them. This was similar to the findings made by Ndiok and Ncama where this same age group represented 85.7% of their participants.9 The similarity could be attributed to the settings where recruiting of the respondents was done. This study, and their study were both conducted in Nigeria, and in teaching hospitals. Their mean age was 44.8 ± 14.5 years while this study’s finding was 38.77 ± 20.0 years.
This finding was, however, contrary to Robinson et al’s study (in New Zealand) who had majority of their participants being in the age range of 60–79 years (representing 54.3%).10 This may be because of the difference in their recruitment method. Although Robinson et al’s study was also a cross-sectional study, the least age for the recruited participants was 18 years and they all had the ability to understand and speak English.
In this study, more females were respondents, making the sex distribution to be 59% females and 41% males, and a ratio of 1.44:1. Most studies reviewed also had a similar pattern of more female respondents. Ndiok and Ncama, Robinson et al, and Agbodande et al (in Benin Republic) all had higher preponderance of females as 61.1%, 50.9% and 61% respectively in their studies as well.9,10,11 However, the study finding of Olden et al in New York, in relation to sex distribution was dissimilar.12 The female and male distribution was 46.44% and 53.56% respectively.
Pattern of Diseases Among Admitted Patients
In this study, several diseases were diagnosed in the respondents. For better collation and analysis, these diseases were further divided into different categories.
Pattern of Diseases Based on ICPC-2
The International Classification of Primary Care (ICPC) is the most widely used international classification for systematically capturing and ordering clinical information in Primary Care.13 It was developed and updated by the World Organization of Family Doctors’ (WONCA) International Classification Committee (WICC), and the most recent version is the ICPC-2 which was revised in 2015.13 The ICPC is divided into 17 chapters by body systems representing the localisation of the problem and/or disease. This makes it easy to use for healthcare providers.13
Based on ICPC-2 classification, in this study, Musculoskeletal-related diseases were observed to have the highest prevalence of 20.2%, and this was followed by the Blood, blood-forming organs and Immune mechanism-related diseases at 17.1%. The least observed were the Male genital-related and Psychologically-related diseases which were both 0.8% of the identified diseases in the respondents.
Contrary to the findings of this study, Ayankogbe et al reported in their study that General and unspecified illnesses had the highest prevalence of 23.1%, this was followed by Pregnancy, child-bearing and family planning-related illnesses at 13.9%.14 Their least recorded pattern of illnesses were CVDs (1.7%) and Psychological diseases (1.4%).14 Although this study, and Ayankogbe et al’s study were conducted in the same geographical area and with similar participants and sampling technique, the difference in the reported findings may be because Ayankogbe et al had private general/family practice clinics as their study sites as compared with this study which had a teaching hospital as its study site. Of note, however, is the similarity with this study, where psychological diseases were the least occurring in the geographical area.
Also, Gataa et al reported differences in the pattern of illnesses with highest prevalence as compared to this study.15 They reported Respiratory and Digestive illnesses to be of the highest prevalence at 43% and 10% respectively.15 Surprisingly, however, the diseases with least prevalence, as reported by Gataa and colleagues were similar to those reported in this study. They were Male genital-related and Psychologically-related diseases which were both 0.1% and 0.85% respectively. The differences in the pattern of illnesses with highest prevalence as compared with this study may be because of the sampling technique employed and the lifestyle of the recruited participants.
Pattern of Diseases Based on Clinical Assessment/ Provisional Diagnosis
In this study, Cancer was recorded as the highest occurring disease in the participants on admission, the prevalence was 27.9%; and this was followed by Trauma (having a prevalence of 17.8%); the least-occurring diseases were Appendicitis, Backpain, Biliary atresia, Diabetes, Seizures and Spinal cord compression, all had similar prevalence of 0.8% among the participants on admission.
In a comparative study by Nicholson et al, Cancer was also reported to be the highest occurring disease at 72% when the standard specialist care of palliative care was applied to their participants.16 The Bromley Care Coordination (BCC) which was being compared with, however, had 16% prevalence of cancerous diseases. The most prevalent disease in the standard care (cancer) as compared to this study may be because the study was conducted among individuals who needed palliative care, moreso, they were elderly individuals. The BCC findings, however, had lower cancerous cases possibly because it was a newly introduced innovative home care service, primarily for older people with palliative care needs who do not meet the criteria for referral to specialist palliative care.16
Also, Robinson et al and Agbodande et al reported higher cancer prevalence compared to non-cancer diseases in their studies, as 81.9% and 89.2% respectively.11,18 Robinson et al’s study was conducted in New Zealand, a country in Oceania continent among individuals aged 18 years and above; while Agbodande et al’s was in Benin, a West African country, just like the setting of this study, but with age distribution of 16–82 years, unlike this study with no age restriction in the recruited inpatient-participants.
In contrast to the findings of this study, Dinçer et al reported in their study that Cancer was of the third highest prevalence (23.4%), after Neurologic diseases (42.3%) and Chronic systemic diseases (41.4%).17 The least occurring disease that was reported by them was Infection (10.8%). The difference in their findings, and this study’s may be because of the difference in the settings of both studies, moreso, Dinçer et al recruited only geriatric participants, unlike this study which also recruited non-geriatric patients.
Pattern of Diseases Based on Category of Medical Condition.
In this study, most of the participants were eligible for palliative care. They represented 80.6% of the total participants. This is despite the fact that the recruited patients were general in-patients with numerous and diverse disease conditions. This further confirmed that palliative care arrangement in every tertiary health care facility cannot be over-emphasized. All the reviewed research results also buttressed this point.
Distribution of Palliative Care Domains of Patients
In this study, the four major domains of palliative care which include physical, psychological, social and spiritual domains were considered and several features were also considered under each major domain. Physical domain was the most occurring, with the highest feature being Pain and representing 94.6% (the least occurring feature was Constipation-7%), the next occurring domain was Spiritual (the highest feature was Suffering-88.4% and least feature was lost hope in God-0.8%). Social palliative domain had the least occurring domain at 63.6%. Agbondade et al reported findings that were similar to that of this study. The highest reported feature in their study was Pain which was seen in all their participants (100%), they also observed that the next occurring domain was Spiritual which represented 90.2% of the participants and the next occurring domain was Psychosocial which represented 73%.11 The similarity in the distribution of the domains may be related to the settings where the researches were conducted, both were done in West Africa. When compared to this study, Anderson et al’s findings were dissimilar. The highest domain of care that was recorded in their study was the Social domain which represented 37% of the results, this was then followed by other domains of care that trailed one another: Physical (15%), Psychological and Psychiatric (15%), and Spiritual, religious and existential domains (14%).18 The difference in reported findings with this study and Anderson et al’s may be because of the setting the research was conducted, it was conducted in the US, and the participants were not only patients on admission, like in this study, but they included patients, family/care givers and professionals.
Admission Characteristics among Patients
In this study, the patient admission characteristics put into consideration were: the caregiver advanced directive, preparation for home care/death, education about illness and stage of the disease. Most of the caregivers rendering care to participants in this study were the family members (83.7%), there was no previous advanced directive by most of the participants (65.9%), and most of them were not prepared for death/home care (72.1%). Although more than two-thirds of the participants knew about their illness (70.5%), the stage of the disease was mostly advanced (68.2%) in them. Several reviewed works had different admission characteristics of patients that they reported on. In this study, a sizeable number of the caregivers (83.7%) were the patients’ family members (relatives). This was the discovery made in other reviewed studies as the caregivers who were all relatives were spouse, children, sibling(s), daughter/son-in-law or parent(s). In the studies by Mercandes et al, Oğuz et al and Monsomboon et al, the family represented 100% of the caregivers.19,20,21 This confirmed the importance of the family in the role of care of an individual. In this study, most of the participants did not make provision for advanced directive, they constituted 65.9% of the participants. This was, however, contrary to the findings of Monsomboon et al who reported that 60.4% of their palliative care patients made previous advanced care plan, 4.9% also had living will, while 18.1% also had documented medical records.21 Monsomboon et al’s study was done in Thailand, and this may be the reason for the difference in the findings with this study. In this study, enquiries were made to find out the preparation of the participants for home care or death, majority of the participants (72.1%) did not have such plans. This finding was similar to that of Monsomboon and colleagues. They found out that 72.5% of the participants in their study had no plans for where they prefer to die, however, 15.9% preferred to die at home while 9.3% preferred the hospital.21 They also considered the caregivers, making enquiries about their preferred place of death for the patients they were taking care of. Majority of the participants had no plans (37.4%), the hospital was preferred in 36.3%, and 23.1% preferred the home.21 The findings may suggest that no one plans or prepares to die because no one wants to die. In this study, most of the participants were aware of their illness (70.5%). This was similar to the findings made by Mercadante et al who discovered that among the patients in their study on planned admission, 51.2% were completely aware of their disease while 39.0% were partially aware.19 However, of the patients on unplanned admission, 57.4% were completely aware, while 35.3% only had partial awareness.19 They went further to access the caregivers’ awareness status. The caregivers of patients on planned admission who were completely aware of their disease represented 86.2%, while 11.0% were only partially aware; the caregivers of patients of unplanned admission represented 83.8% while only 13.2% were partially aware of the disease condition of the patients they were taking care of.19 Only a minute number of caregivers (2.8% and 2.9% respectively) in both categories of patients had no awareness of the disease condition of the patients under their care. Monsomboon et al while studying the characteristics and factors associated with mortality in palliative patients also accessed the caregivers’ understanding about the palliative status of the patients they were taking care of.21 Majority of the participants (79.7%) were aware of the palliative status of the disease condition of the patients, while only 13.2% were not.21 Contrary to previous reported findings on patient’s awareness of the disease condition, Oğuz et al reported that 81.3% of the advanced cancer patients admitted to the palliative care unit had absent information about their disease, only 18.7% indicated presence of knowledge.20 Mercadante et al while describing the characteristics of patients who had unplanned admission in comparison to those with planned admission to an acute palliative care unit reported that most of the patients had their diseases in the advanced (metastatic) stage.19 The patients with unplanned admission had 82.4% of them with metastatic disease while 74.0% of those with planned admission had metastatic diseases.19 These findings look similar to that from this study where majority of the participants (68.2%) on admission had advanced stage of disease. This was also similar to the findings made by Oğuz et al who found out in their study in India, that 96.4% of the patients admitted to the palliative care unit already had metastasis.20 These findings may corroborate the fact that most patients present to health facilities in advanced stage of their diseases.